1. Online CKD education program for health-care
professionals
Roberto Tapia-Conyer1
, Hector J. Gallardo-Rinco´n1
, Guillermo Garcı´a-Garcı´a2
,
Rodrigo Saucedo-Martı´nez1
, Librado De la Torre-Campos2
and Karina Renoirte-Lopez2
1
Instituto Carlos Slim de la Salud, Mexico, DF, Mexico and 2
Hospital Civil de Guadalajara ‘‘Fray Antonio Alcalde’’, Division of Nephrology,
University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
Online learning has become an increasingly popular
approach to medical education. We describe the first
E-learning Diploma to be offered to primary health-care
professionals in Mexico that provides comprehensive training
in the detection and treatment of chronic non-communicable
diseases. The Diploma is divided into five consecutive
modules. Each module includes workshops, case discussions,
and selected readings that include elements of integrated
prevention and early detection, changes in lifestyle, clinical
care, and adequate use of technology. Between 1 March 2010
and February 2011, 844 students from eight states were
enrolled. Three hundred sixty-two students were accredited
from the course, with an average score of 9.6 out of 10; 19%
of the students scored 10. The main reasons for not finishing
the course were poor compliance and lack of motivation.
The E-Learning Diploma offers a valuable educational tool for
training health-care professionals in the detection and
treatment of chronic kidney disease and other chronic
non-communicable diseases.
Kidney International Supplements (2013) 3, 174–177; doi:10.1038/kisup.2013.8
KEYWORDS: chronic non-communicable diseases; E-learning;
internet education
INTRODUCTION
Chronic non-communicable diseases (CNCDs), such as
obesity, diabetes mellitus, hypertension, and chronic kidney
disease (CKD), have become a major public health problem
in the Mexican population. Diabetes mellitus is present in as
many as 14% of adult Mexicans, and 72% are overweight or
obese.1,2
The incidence of kidney failure has increased
dramatically in parallel with these risk factors3
and currently
is among the 11 leading causes of death in the adult
population.4
It has been estimated that 8% of the adult
Mexican population has an estimated glomerular filtration
rate o60 ml/min.5
Early CKD detection and intervention
retards or may prevent progression of CKD to end-stage renal
disease. However, specialized human resources are scarce and
there are only B700 nephrologists in Mexico to look after
this growing population (Consejo Mexicano de Nefrologia,
unpublished data). Recent studies have shown that family-
practice physicians who had undergone comprehensive
training increased their clinical competence in the manage-
ment of patients with diabetic nephropathy, and achieved
better preservation of patients’ kidney function.6
Thus,
there are good grounds to train other health professionals,
such as nurses and primary-care physicians, to diagnose
and treat CKD.
E-learning has become an increasingly popular approach
to medical education. The introduction of the World Wide
Web in 1991 facilitated the use of the Internet, and its
potential as an instructional tool was quickly recognized.
Among its advantages, Internet-based education allows
students to participate at a time and place convenient to
them, facilitates instructional methods that might be difficult
in other formats, and has the potential to tailor instruction to
the individual’s learning needs.7
The key steps in developing
an effective E-learning platform have been elegantly described
by Cook and Dupras.8
The Carlos Slim Health Institute is a nonprofit organiza-
tion established by the Carlos Slim Foundation to contribute
to the generation of sustained health initiatives that aim to
have a profound impact on the people in Mexico and Latin
America. Its mission is the design, development, evaluation,
and upscaling of integrated models of health care. It
has a specific focus on the United Nations Millennium
meeting report http://www.kidney-international.org
& 2013 International Society of Nephrology
Correspondence: Guillermo Garcia-Garcia, Hospital Civil de Guadalajara
‘‘Fray Antonio Alcalde’’, Division of Nephrology, Hospital 278, PO Box 2-70,
Guadalajara, Jalisco 44280, Mexico. E-mail: ggarcia1952@gmail.com
174 Kidney International Supplements (2013) 3, 174–177

2. Development Goals 4 and 5 (maternal and child health); the
epidemiology of the critical burden of CNCDs; the genera-
tion of knowledge (research and its translation into public
health policies); and the strengthening of human capital
through E-learning platforms for health professionals and
community health-care workers.
Among the Institute’s initiatives, the Casalud model
consists of strengthening the health-care services in
governmental primary-care settings through three core
pillars: (1) improvement of quality of care and infrastruc-
ture through the development of guidelines for physicians
and patients, and the assured provision of technological
equipment and connectivity; (2) strengthening of human
resources, both professional and community health
workers, through the implementation of an E-learning
course accredited by the National Academy of Medicine,
as well as tailored workshops; and (3) patient empower-
ment through the use of mobile technologies to
improve lifestyle and achieve control of diabetes and
hypertension.
We describe the first E-learning course to be offered to
health professionals in Mexico that provides comprehensive
training in the detection and treatment of CNCDs.
DESIGN
The E-learning Diploma is offered through an online
platform that enables health professionals and community
health workers to acquire up-to-date health information in
CNCDs. It is an effective and reliable platform that can be
used as a training, educational, and information tool. The
Diploma is structured in core modules with a multi-
disciplinary approach, including clinical, community, and
human development content. Instruction is provided by
experts using You Tube-type lectures synchronized with
presentations and support material. In addition, users can
interact with these virtual professors and resolve any
questions they might have regarding the video lessons.
Finally, through the platform students can answer online
surveys and study reports. Thus, the E-learning platform
offers much more in the way of resource materials beyond the
mere videos; it is a powerful teaching tool that combines the
flexibility of online educational information and learning
with continuous interactions with health experts. The
platform has been widely tested in different settings in order
to secure a flexible, user-friendly yet structured course, and
the Diploma is accredited by the National Academy of
Medicine.
The platform is continuously available, thus enabling a
large of number of participants from various geographical
areas to be trained simultaneously. Access is restricted to
health professionals and community health workers who
work at the Casalud health units, and each of them has an
individualized plan so that they can study at their own pace.
Each video-lesson is evaluated and graded automatically and
the student coursework can be monitored online by the
coordinators who have premium access to customized
reports of their activity. The Diploma covers the different
aspects of overweight and obesity, type II diabetes mellitus,
hypertension, dyslipidemia, and CKD.
The course is divided into five consecutive modules
(Figure 1), presented in video lessons that last an average of
20 min each. Each course comprises workshops, case
discussions, and selected readings. Each section includes
elements of integrated prevention and early detection,
changes in lifestyle, clinical care, and adequate use of
technology. Lessons consist of: (a) introduction; (b) pre-
sentation of the most relevant and practical information,
including graphics, tables, algorithms, practical examples,
and additional readings; (c) review of prevention and
early detection strategies and integrated medical care; and
(d) conclusions and take-home remarks.
The CKD course includes 25 sessions, including epide-
miology, risk factors, definition and classification; complica-
tions; risk factor modification; interventions to retard CKD
progression; timely nephrological referral; healthy lifestyle
and self-care recommendations; team work and patient
empowerment.
PLATFORM OPERATION
Experts run each of the lessons. The platform synchronizes
the speaker’s lesson with a PowerPoint presentation on two
different screens. Participants can either view both screens or
choose between them at any point of the lesson. In addition,
there is a small library on the computer screen for each of the
lessons where participants can access additional teaching
materials such as guidelines, self-care manuals, academic
articles, and a complete list of activities and procedures for a
comprehensive integrated practice evaluation. Through the
premium access, coordinators can view the number of times
the participant has accessed the course, the grades for each of
the lessons, and the number of practical exercises he or she
has completed.
STUDENT PROFILE
The student must be a health-care professional–primary-care
physician, nurse, nutritionist, or social worker, with the
ability to work both individually and in collaboration, and
possessing basic computer skills.
Casalud model
5 Sessions
Type II DM
Arterial
Hypertension
25 Sessions 23 Sessions
Obesity and
Dyslipidemia
Chronic Kidney
Disease
24 Sessions 25 Sessions
Human Development 8 Sessions
Figure 1 | E-learning Diploma for the prevention and
integrated care of chronic non-communicable diseases.
Kidney International Supplements (2013) 3, 174–177 175
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3. ADMISSION AND PERMANENCE REQUIREMENTS
The Diploma is restricted to health professionals who work in
Casalud units and it is offered free of charge. Governmental
state health authorities propose the candidates. Their place of
work must meet the minimum requirements, including
direct patient care, access to a computer from anywhere (with
Intel Pentium II processor or greater, internet connection and
speakers), and must commit to a minimum of 6 h per week
to the coursework. Lessons are ordered sequentially and
students must complete all of them. The whole Diploma is
designed to run over 3 months, although some flexibility was
allowed in the pilot study: The minimum grade that needs to
be achieved in order to receive the Diploma is 8.0. In the
event that a student fails to achieve a pass mark in a given
module, he or she is allowed to take that section again. If he
or she fails again, they are dismissed from the course. There is
no penalty for dropping out.
ACCREDITATION
The E-learning platform allows the registration of the
number of hours accessed to the course and evaluation
results. The National Academy of Medicine and the General
Practice National Regulatory Committee accredit the pro-
gram. Once the user successfully completes the whole course,
and has approved the online, multiple-choice question
evaluation tests, a certificate is issued automatically by the
platform and students can print it themselves.
RESULTS
Between 1 March 2010 and February 2011, 844 primary
health-care physicians from eight Mexican states were
enrolled in a pilot study (Table 1). In total 362 (44%)
students accredited the course, with an average score of 9.6.
19% of the students scored 10.0. The main reasons for not
finishing the course were poor compliance and lack of
motivation; only one participant actually failed the course.
The average time required to take the course was 160 days
(range 82–346 days). During this period 21,965 web hits and
72,722 video reproductions were recorded.
DISCUSSION
E-learning has become an increasingly popular approach to
medical education. Online learning programs for diabetes,
dyslipidemia, and hypertension have led to improved knowl-
edge of treatment guidelines9–11
and complications.12
Although
there is a wide selection of renal resources on the web,13
none
meets the criteria of computer-assisted instruction in which
computers play a central role in the means of information
delivery and provide direct interaction with the learner (in
contrast to the use of computer applications such as Power-
Point), and to some extent replace the human instructor.7
In a recent review of internet-based learning in the health
professional publications, among 201 studies none of the
topics were related to CKD.7
Our E-learning Diploma is
among the first that includes the education of primary
health-care physicians and other health professionals on CKD
detection and prevention as a part of a comprehensive course
on chronic non-communicable diseases. The large number of
participants who did not finish the course was probably due
in part to poor student selection by the local state health
authorities, the complexity of the course, and lack of
motivation. However, it is encouraging that among those
who completed the course, only one failed to pass it. A
significant number of participants did not complete the
course on time. This was probably because of its complexity.
To facilitate the acquisition of the Diploma and because of
the variable knowledge base of the participants, the course
has now been divided and restructured into three levels
of complexity: (a) essential (basic); (b) intermediate; and
(c) integral (advanced).
Our report has a number of limitations. Although the
system allows the grading of the content and quality of the
lessons, the participants’ satisfaction with the course was not
evaluated. Additionally, no pre-test was done to assess their
clinical knowledge on CNCDs. We have made the necessary
adjustments to overcome these limitations.
In conclusion, the E-Learning Diploma offers what we
believe is a valuable alternative educational tool for the
training of health-care professionals in the detection and
treatment of CKD and other CNCDs.
DISCLOSURE
The study was financed by the Carlos Slim Institute of Health. The
faculty received a nominal fee for their services.
ACKNOWLEDGMENTS
Publication of this article was supported in part by the National
Health and Medical Research Council of Australia through an
Australia Fellowship Award (511081: theme Chronic Disease in High
Risk Populations) to Dr Wendy Hoy, School of Medicine, the
University of Queensland, and the National Institutes of Health—
NIDDK DK079709, NCRR RR026138, and NIMHD MD000182.
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Table 1 | Results of 844 participants enrolled in the pilot
study
n (%)
Enrolled students (n) 844
Participating states (n) 8
Did not finish the course (%) 472 (56)
Finished the course (%) 362 (44)
Average scoring 9.6
Average days needed to finish the course (n) 160
Web hits (n) 21,965
Video reproductions (n) 72,722
176 Kidney International Supplements (2013) 3, 174–177
meeting report R Tapia-Conyer et al.: Online education for health-care professionals

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