‘Learning from home’: role of e-learning methodologies and tools during novel coronavirus pandemic outbreak

ABSTRACT Background During the crucial time of coronavirus pandemic, education is being remodelled: opening the doors of electronic learning (e-learning). The review emphasises on the various e-learning methods that can be used in the current scenario. Methods The review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on databases, namely, PubMed, Google Scholar and Cochrane. Out of 1524 identified articles, after the process of screening and based on the eligibility criteria, 45 full-text articles were reviewed. Results Though there are many caveats on the path of successful implementation this is the right time that we step towards e-learning. The article discusses the methods and tools in e-learning that can modify the traditional ways of content delivery, record maintenance, assessment and feedback. Conclusion During the period of ‘planet arrest’, when the whole world is locked down with the motive of social distancing, let us stay connected with e-learning.


INTRODUCTION
Novel coronavirus pandemic outbreak in 2020 is a world-shattering event affecting all domains of lives. 1 In order to curtail the spread, lockdown across the globe is being implemented. With the closure of educational institutions, the students face doldrums in their academic activities. In these trying times, technology comes to the fore, transforming teaching and learning into a novel experience.
Electronic (e)-learning is the most convenient tool that is being used reliably transcending geographical frontiers and time zones. E-learning is defined as any educational intervention that is mediated electronically via the internet. 2 Education technology firms are going to be uplifted in the wake of the coronavirus outbreak. Organisations and institutions are at present keenly interested in offering blended mode of learning to facilitate better education and for accreditation purposes. 3 Moreover, e-learning is befitting to the colleges with greater annual intake of undergraduates, owing to its capability to address large group learners at a single point. It is high time that medical teachers learn and orient themselves in the realm of e-learning. The process of e-learning enhances self-motivation of the current smart generation and offer learners control over content, learning sequence, allows the learner to work at their own pace, provides opportunity to build on their previous experience and offers a problem-centric learning environment. Thus, e-learning offers increased learner autonomy and self-direction, thus fulfiling the adult learning principles. 4 Taking all these facts into consideration, probably, Information Communication Technology (ICT) will facilitate to temporarily fill the present gap in education, by enhancing the learner's knowledge, keep automated records of individual student activities, evaluate them and track their academic performance for a specified period of time.
With this perspective in mind, the current review aimed to explore the available e-learning modalities that can be employed to foster medical education. This review may serve as a resource material to a beginner and an update to regular users of e-learning.

METHODS
We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations as depicted in the PRISMA flow diagram 5 (figure 1).
We searched PubMed, Google Scholar and Cochrane from the year 2000 to March 2020 for all published articles on e-learning in education.

Search strategy
The search was conducted using the following, Medical Search Headings (MeSH) terms and keywords, namely, 'Online learning', 'Medical education', 'E-learning', employing Boolean operators like AND, OR.

Inclusion criteria
All original and review articles fulfiling the following eligibility criteria were included in the study: (i) e-learning methods and tools enabling the teaching learning process and (ii) articles published in peer review journals in English from 2000 until March 2020. posters, conference abstracts or discussion papers; (ii) articles not published in peer review journals; and (iii) no full-text available.

Screening
Two authors independently extracted relevant information by using standard proforma and one author reviewed the data. The research question was taken into consideration during the process of screening the data. The research question framed was, 'What are the available e-learning tools and methods that can be used to facilitate medical education during the current coronavirus pandemic period?' Of the initial 1524 identified references, 858 records were obtained after removing the duplicate works and based on the availability of full texts. References were then randomly distributed for abstract screening among the two researchers. If there was any in-sufficiency in the information provided, the article was taken up for the next level of full-text screening. After examining the full texts of 666 articles, 45 eligible fulltext articles were retained and considered. Conflicts that arose during the selection process and extraction were discussed until a consensus was achieved. Further discussions were carried out on, how to categorise the data and an outline was planned.

DISCUSSION
In the past decade, call for competency-based medical education, changes in the societal expectations, rapidly developing healthcare environment were the driving factors for the implementation of e-learning in medical education. 6 In India, e-learning had been maximally used for literature search, and utility of e-learning for other purposes was in a nascent stage. 7 Yet, in the current period of indefinite lockdown, e-learning is growing viral; starting from schools, colleges, institutions, and universities wide across the globe. This indirectly has opened new avenues for engaging the students and has exposed many e-learning tools, beyond the tip of the iceberg. The graduate attributes, dictated by the Medical Council of India, could be effectively attained with learnercentred, technology-driven, self-paced e-learning. This review article is formulated in CAPS format (Current state of knowledge, Area of interest, Potential Impact of Knowledge Suggestions from experts), with the intention of unveiling the e-learning tools, that could be effectively used for the teaching and learning from home. 8 Prerequisites for e-learning E-learning is a two-way process requiring an earnest effort from both the learner and the faculty. The requisites are as follows: 9 i. Highly motivated, self-directed and self-regulated learner with basic knowledge on ICT ii. Trained and motivated faculty iii. Learning materials which can be non-interactive (documents, PowerPoint presentations, video or audio files, developed in accordance with the learning objectives) or interactive e-lessons (web-based training where there is provision for questions and feedback, links to online resources) iv. A good learning atmosphere with adequate internet facilities v. Technology or tools from a basic email account to the availability of learning management system (LMS). 10 Table 1 highlights the various advantages and challenges in e-learning. Table 2 shows the various e-learning methods and tools that can be used to replace the traditional way of learning.

Synchronous and asynchronous e-learning
Synchronous e-learning refers to real-time learning and it requires the learner and teacher to be online at same time at different locations. This facilitates the learners to be the participants in a group where active interaction occurs in a synchronous way rather than isolated communication. 11 Benefits of synchronous e-learning include, instant feedback, motivate interaction, socialism and emotional support. 12 Videoconferencing, instant messaging and chats are examples for synchronous modes and complement with face-to-face meetings. Synchronous learning is preferred in discussion of less complicated issues and planning.
Asynchronous e-learning refers to offline e-learning where instructor and learner need not be online at the same time. It offers flexibility for the learners to access the documents and reading materials at any time, send messages to teachers or peers. It gives time for the learner to understand and refine their thought process. emails, discussion forums and blogs are examples for asynchronous e-learning modes. For reflecting on complex issues and where synchronous meetings are not feasible due to practical and technical difficulties asynchronous mode is preferable. 13 In the present situation, a hybrid model that employs both synchronous and asynchronous mode of e-learning can be beneficial for the students. These two modes complement each other and motley of these will help the students to learn from different activities.

E-learning methodologies and relevant e-learning tools For content delivery and student participation
The traditional way of content delivery includes, lecture classes, practical sessions, and reading with reference books. Mostly these are teacher-centric methods where information flows in one direction. E-learning can facilitate content delivery through the collaboration platforms which are highly student-centric.

Non-interactive/linear methods
There is linear presentation of the content in a sequence. It is useful to teach static processes, where the content is delivered in predetermined linear manner, in multimedia format. The simplest way of delivering the content is by using audio and video to create sound or video files and that can be uploaded in the official websites or LMS after editing using sound-editing tools. The process of delivery of audio/video recorded content in digital format is called as podcasting. These documents can then be accessed by students through mobiles, desktops, laptops, etc. 14-16   17 It is also found that e-books are preferred for quick searches and for concise reading purposes. 16 18 Interactive methods/collaborative learning It is a kind of social learning where learners share knowledge and perform tasks in a collaborative manner and that may be aided by a facilitator. It may be a synchronous mode or asynchronous mode of content delivery. Virtual classrooms offer adaptable learning environment favouring synchronous form of learning, with provision for online chat rooms promoting high interactivity among the learners.

Social media
Social media play a major role in enhancing e-learning and also highly embraced by the medical students. 19 20 They are employed to access, exchange and collaborate ideas or information. YouTube, 21 22 Facebook, WhatsApp, 23 and Twitter 24 are the widely used social media by the current generation. Of these, Facebook and YouTube are widely evaluated educational tools for learning. Though these social media can be employed to facilitate learning but they are not exempted from disadvantages and risks of addiction, cyber-bullying, contrasting effects on academic performance, maintenance of privacy, integrity and security issues. 23 Virtual classrooms

Webinars
Webinar is a web-based seminar which helps to offer a presentation, lecture or seminar using videoconferencing software. People are connected using virtual platforms and can interact synchronously in real-time. Many studies employing webinars are observed to be effective in disseminating knowledge and skills. 26 27 Group discussions In Discussion forums, there is asynchronous communication between the participants. Google groups offer the advantages of asynchronous learning through discussion boards/forums that can be used by the participants for private or public view modes. Wikis are formed as a result of collaborative work, which is open for editing by the readers. 28

Journals/diaries
Blog is an online journal created by one individual but turns out to be a public domain, encouraging comments from the readers. Free Open Access Medical education (FOAM) is an online platform for sharing free information accessed by medical professionals and other learners. This helps to accelerate the research to practice. These include blogs, podcasts, tweets, videos and other web-based media. Blogs form a core part of FOAM. These are the online journals or diaries in which the web pages are modified frequently with dated entries maintained by authors and used personally or for public view. This platform helps for reflection and peer interaction. 28 E-learning tools used in collaborative learning include websites and applications for discussion boards (Usenet, Quora, Google groups), blogging (WordPress, Blogger), networking (Facebook, Twitter, LinkedIn, Google) and wikis (Wikipedia).

Massive Open Online Courses (MOOC)
These are online courses which offer unlimited access through the web, favouring unlimited participation. They can be accessed through smartphones and other digital devices. Coursera, EdX and SWAYAM, NPTEL from India are some of the platforms offering MOOCs. They are encompassed with course materials. Interactive courses with social media discussion forums have shown high course completion rates. 29

Simulations
The digital simulation technologies have emerged providing medical knowledge to students through virtual laboratories, 30 virtual microscopy and virtual patients. Learners can see and interact with the simulated representations of real-life scenario. Virtual patients are computerised representations of clinical conditions used in medical education to teach clinical reasoning skills and has shown to enhance the student learning experience. 31 32

Interactive whiteboards and PowerPoint presentations
There are many tools that may make online collaboration interactive, such as Prezi, which help to make highly interactive PowerPoint presentations in the online lectures. Similarly, interactive whiteboard tools like Liveboard, Explain Everything bring convenience and flexibility in learning and also increase the level of engagement of students and teachers. 33 34 Record maintenance E-portfolio These are owned by the learners and represent dynamic digital workspaces where they capture their ideas, access their work collection, reflect on their learning process, share it, set goals, seek feedback. In short, it represents the showcase of their learning and achievements over time. Poole et al in 2018 has discussed in detail the various roles of e-portfolios, the challenges and opportunities in implementation in education. 35 However, training in the integration of e-portfolio in regular teaching-learning process may augment the learning process. 36 It can also be employed as formative method of assessment. 37 E-portfolio is more apt and beneficial for postgraduates who require documentation of their day to day activity. So it is important for documentation or tracking the student's progress in the learning process.

E-assessment
This is commonly called as digital assessment or computer-based assessment. The various forms of e-assessment tools employed are Google forms (create forms with hyperlinks, images and videos, can be used to create quiz also); Poll everywhere (a realtime polling app); Socrative.com (a free web-based service for an immediate view of understanding level of students); Kahoot (free class quiz game); Quizalize; Triventy (helps for making group surveys and quiz games) and many other applications. E-assessment can be used to evaluate knowledge, performance, behaviour or attitude.
For remote purpose multiple-choice questions (MCQs), true/ false, matching questions and predetermined short answer questions are the options for assessing the knowledge. Of these MCQs are commonly used. 38 39 Objective Structured Clinical Exams (OSCE) or virtual patient cases can be used to assess performance and based on their discussions and proceedings on the discussion forum behaviour or attitude assessment can be done. After the process of assessments are completed, spreadsheets are supported that help to keep the track of grades of all students and intimate them. Individuals can see their marks and the overall performance of their class. Further real-time communication technology will facilitate to conduct viva voce online or perform clinical examinations that can be observed by the examiner. Also, many proctored online exam platforms are available that can be considered for E-assessment like Mettl, Eklavvya with use of artificial intelligence. Platforms like Gradescope, Google classroom aid in grading the scanned answer sheets.
E-assessment tools always have a provision of instant feedback, which enhances the learner engagement and retention. It also helps the facilitators to plan appropriate remedial measures. 40 However, the integrity of the assessment tools may be enhanced by creating questions of higher-order type, using varied type of questions, shuffling the order of questions and choices and restricting the testing window period.
Though these e-tools can be efficiently used for formative assessment but their usage for summative assessment is under debate. Practically, the adult learning principles are difficult to thread into online summative assessments. Moreover, whether these e-assessment grades are accepted by the medical bodies and universities is doubtful due to issues like fairness, validity, and authentic depiction of learning process. 41 E-feedback E-platforms offer provision for both providing and obtaining feedback in the teaching-learning encounter. Tools like Google forms, survey monkey are widely used for obtaining feedback from the students over the fruitfulness of academic sessions. Meanwhile, formative e-assessments through Google forms offer advantages over providing instant feedback for wrong answers, thereby enriching the learning experience.
Digital badges represent an electronic mode of certification of accomplishment, may appear as an icon or logo, and accessed from curriculum vitae of the learners, e-portfolio, LMS and also may be placed in the social media. They help the learners to identify their strengths and areas of improvement. 25 Integrated learning environment for e-learning: learning management system There are many modes of e-content delivery. Yet there is a common tool that integrates all the above-mentioned categories like content delivery, student participation, record maintenance, assessment and feedback into a common platform called the learning management system.
Digital learning management systems (LMS): Many colleges and institutions are adapting the LMS to systematically implement and manage e-learning. It can be a proprietary software (closed source) or open-source software or developed by the ICT department of self-institution. The closed source software can be easily installed but offers less flexibility when compared with the open-source and self-developed platforms. The opensource software is those whose codes are available for anybody to access and modify through open collaborations. They are free of cost and offers greater flexibility. The disadvantage is that it offers no official support, security and warranty.
This software administers trains, delivers the content and keeps automated track of all details. Literature search indicates that LMS is widely used for undergraduate training 42 43 in medical fields and helps to offer a structured-blended curriculum. LMS help in content delivery through sharing of PowerPoint presentations, PDFs and other contents. It helps in student participation via, discussions, chats, messages. It keeps the track of individual student progress and assignments submitted and student evaluation is done through quizzes and other assessments. The advantage of using LMS is that it can incorporate contents in various formats like video, audio, text, pictures and others. The contents can be accessed remotely and properly documented. The major disadvantage is that implementation requires good in-house built technology infrastructure by the institution.
The various resources and tools available in market are Blackboard, Century Tech, ClassDojo (Connects teachers with parents and students), Edmodo, EkStep (Open learning platform), Google Classroom, Moodle (Globally supported open learning Platform), Schoology and Skooler (converts Microsoft Office software into education platform).
These LMS require instructors and Learners to be registered for the phase to gain access. Based on the assigned roles (teacher/ student/mentor), participants can make use of the variety of tools and services designed by the instructor or technologist.
Facing the constraints ► Online Faculty development programs on e-learning to sensitise the faculty and overcome the resistance from them. ► In area of no connectivity, it is wise to run an LMS on local area network (LAN) in the client-server architecture or offline. ► Adopting institutional strategies for improvising the infrastructure may serve the dual-purpose of supporting the e-learning process and also help in meeting the accreditation standards. 44 ► Integrity of assessment may be improved by multiple tests, with higher-order questions restricting the testing window, so that available time can be used only for answering and not searching. 45 Future scope: mobile learning, telemedicine Mobile phones especially smartphones are now of pivotal importance in everyone's life. Mobile learning will further enhance the digital trend communication between instructor and learner. With the mobile networks covering larger areas, the advantages offered by mobile learning includes convenience, accessibility, low expenditure and self-assessment making learning comparatively easy. 46 m-learning offers an enjoyable learning experience to the learners. 47 Another mobile device gaining popularity in the current trend is the Personal Digital Assistants (PDA). These are handheld devices with features of computation, faxing and networking. In simple terms, these are handheld laptops or pocket personal computer. Literature search indicates that they are being used by physicians and health professionals for patient healthcare and computing purposes 48 but their role in learning is not yet properly defined. Successful implementation of m-learning is an upcoming digital trend that needs collaboration between the individual profession and technology.
Development of e-learning models ADDIE model is widely employed for developing the e-learning models. 49

CONCLUSION
During the current coronavirus pandemic outbreak, where there is indefinite lockdown imposed worldwide, implementing and execution of e-learning strategy is really a challenging task. In the current scenario, when stringent safety measures are being adopted like social distancing, large group learning such as lectures are possible only through e-learning. Despite the practical and technical difficulties that can be encountered, this is high time to open the door for e-learning technology for social connectivity amidst the social distancing to break the chain of coronavirus spread and make learning an enjoyable experience for the millennial generation.

Main messages
► E-learning is a convenient way to continue the teaching learning process during the coronavirus pandemic outbreak and beyond. ► Learning management system (LMS) can integrate content delivery, record maintenance, assessment and feedback processes. ► Though many barriers and challenges are in the way of successful implementation of E-learning but the need of the hour is to step forward with e-learning technology.

Current research questions
► What are the available e-learning tools and methods that can be used to facilitate medical education during the current COVID pandemic period? ► What are the important motivating factors for e-learning? ► How can the process of e-learning, enhanced and made appealing to the students?