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Competency Framework Specifications

 

 

 

 

 

 

 

 

 

Version: 0 .7 .6 1
Date:     October 1 7 , 2011
Authors: Valerie Smothers
Author email: vsmothers@jhmi.edu

 


Version History

 

Version No.

Date

Changed By

Changes Made

0.1

2008-07-17

Valerie Smothers

Initial draft

0.2

2009-10-06

Valerie Smothers

Added lom to replace/supplement framework title and identifier, renamed CompetencyDefinitions CompetencyObjects, made category and references subelements fo CompetencyObject, added XtensibleInfo, added CompetencyMap subelements.

0.3

2009-12-23

Valerie Smothers

Removed Competency objects (will be a separate spec) and competency map; put relation at the root.

0.4

2010-03-25

Valerie Smothers

Required elements form lom and eliminated any overlap. Required URI identifier. Changes to non-hierarchical relationships. Changed structure of relations to be 1 to 1 rather than 1 to many.

0.41

2010-05-06

Valerie Smothers

Further simplified relations. Eliminated references.

0.5

2010-07-28

Valerie Smothers

Added SupportingInformation element.


0.6

2011-07-14

Valerie Smothers

Added Includes element. Remove the use of broader/narrower than for relations of framework to top competency objects
Allow competency object broader than competency framework.
Allow framework includes framework.
If using ' broader than ' , the broader thing must be a competency object
Made Relations optional.
Updated graphics.
 

0.61

2011-09-06

Valerie Smothers

Added language forbidding hierarchical conflicts. Changed format, added examples for supporting information. Added XtensibleInfo container.

0.62

2011-10-10

Valerie Smothers

Added note about hierarchical conflicts with examples, modified definition of includes element, added recommended metadata description.

0.7

2011-10-17

Valerie Smothers

Added status, replaces, and replacedBy elements.

 


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1          Acknowledgements

 

The MedBiquitous Consortium wishes to acknowledge the help of  the MedBiquitous Competencies Working Group members, invited experts, and other individuals that contributed to the creation of this document, including:

 

  • Rosalyn Scott, M.D., Department of Veterans Affairs, Co-Chair
  • Tim Willet, M.D., CRI Critical Care Education Network, Co-Chair

 

  • Susan Albright, Tufts University
  • Mary Pat Aust, American Association of Critical-Care Nurses
  • Theresa Barrett, New Jersey Academy of Family Physicians
  • Chris Candler, M.D., Association of American Medical Colleges
  • Allan Cumming, M.D., University of Edinburgh
  • Tom Doyle, METI
  • Rachel Ellaway, Ph.D., Northern Ontario School of Medicine
  • Maria Esquela, Advanced Informatics
  • Vladmir Goodkovsky, University of Virginia
  • Simon Grant, Ph.D., Jisc Cetis
  • David Hadden, TheraSim
  • David Hananel, METI
  • Ted Hanss, University of Michigan
  • Ronald Harden, M.D., IVIMEDS
  • Sean Hilton, M.D., St. George’s University of London
  • Matt Lewis, Outcomes, Inc.
  • Michael Mintzer, M.D., Department of Veterans Affairs
  • David Price, M.D., American Board of Family Medicine
  • Carla Pugh, M.D, Northwestern University
  • Doris Quinn, Vanderbilt University
  • Isarin Sathitruangsak, Tufts University
  • Valerie Smothers, MedBiquitous
  • Lesley Southgate, M.D., St. George's University of London
  • David Stern, M.D., University of Michigan
  • Lana Vukovljak, American Association of Diabetes Educators
  • Jeff Williamson, American Medical Informatics Association
  • Nabil Zary, Karolinska Institute

 

Specification authors also received technical guidance from members of the MedBiquitous Technical Steering Committee.

  • Joel Farrell , IBM, Technical Steering Committee Chair
  • James Fiore, American Board of Surgery
  • Andrew Rabin, CECity
  • Dan Rehak, Learning Technologies Architect

This specification would not be possible without the previous work of Claude Ostyn, in particular the Proposal for a Simple Reusable Competency Map. Claude paved the way for this specification and others related to advanced uses of learning technologies. For access to Claude’s work, visit: http://www.ostyn.com/resources.htm

 

 


2          Documentation Conventions

This document uses the following conventions:

Convention

Description

Bold Text

When used with an XML element name, indicates that the element contains sub-elements.

Italics

When used in an XML element description, an attribute of the XML element.

Monospaced type

Sample XML tags, code, schema, or portion thereof.

 

The document uses graphics generated by Altova XML Spy® software, which uses the following graphical conventions.

address-example_schemadiagram.png


3          Conformance

To be a conformant instance of the MedBiquitous Curriculum Report specification, an XML document shall:

  • Shall validate against the Curriculum Report XML Schema available at: http://ns.medbiq.org/#curriculum_report
  • Shall conform to any additional requirements stated in this specification.
  • May include elements not defined in this document only by using the XtensibleInfo container element defined in the section XtensibleInfo.

4          Common Data Types

Most of the elements and attributes in MedBiquitous XML documents use the data types defined by the W3C XML schema definition. In some cases MedBiquitous creates its own datatypes as part of its best practices or to meet a specific requirement. Commonly used datatypes are described below.

4.1       IdentifierType

Many of the elements in Competency Framework use the IdentifierType datatype, which allows competency framework developers to indicate the catalog or source of the identifier along with the identifier. This two-part approach facilitates the exchange of competency frameworks across systems by preventing identifier duplication. Competency references may reference MedBiquitous Competency Objects [ Competency Objects ], IEEE Reusable Competency Definitions [ IEEE RCD ], or external competency frameworks.

 

 

Elements using the IdentifierType have Catalog and Entry subelements, which are described in the table that follows.

IdentiferType Subelements

Element

Description

Required

Multiplicity

Datatype

Catalog

Catalog indicates the identification or cataloguing scheme for the entry. URIs may be used in many cases and are required for MedBiquitous Competency Objects and MedBiquitous Competency Frameworks. In others, organizations may wish to use an internal cataloguing scheme.

Required

1

Non-null string

Entry

Entry is the value of the identifier within the cataloguing scheme specified by the Catalog element.

Required

1

Non-null string

 

The following example shows an identifier for a competency definition that uses a URI cataloging schema.

<Identifier>

<Catalog>URI</Catalog>

<Entry>http://www.medschool.edu/competencies/kp87t</Entry>

</Identifier>

 

The next example shows an identifier for a competency definition that uses a local cataloguing schema.

<Identifier>

<Catalog>Medschool University</Catalog>

<Entry>2005.10.87</Entry>

</Identifier>

 


5          Introduction

This document describes MedBiquitous Competency Frameworks specification in detail. It is intended for use by anyone who wants to develop tools or implement electronic systems for linking competencies to educational and performance data and resources. The status of the document is indicated at the bottom of the page; draft documents are subject to review and approval through the MedBiquitous and ANSI standards development processes (see http://www.medbiq.org/working_groups/consortium_process/MedBiquitousANSIProcess.pdf ).

The use of outcome and competency frameworks is a growing part of healthcare education and maintenance of certification. Many nations or states have accreditation frameworks for health professions schools and programs as well as requirements to demonstrate lifelong learning and competency in medical specialties/subspecialties .  Currently, there is no standard way to represent these competencies in healthcare, and therefore no easy way to import/export competencies across systems. Once competencies are expressed in a common format, they can be used as the backbone of education and performance management systems, enabling the following:

  • Learners and educators able to search for learning resources addressing a particular competency
  • Educators able to determine where specific competencies are addressed in a curriculum
  • Boards and hospitals able to track and manage competency data for the professional.
  • Administrators are able to map one competency framework to another.

The objective of the specification is to provide a consistent format and data structure for defining a competency framework. This, combined with other existing and emerging specifications, enables educational resources and activities to be tied to a competency framework.

The standard allows extensions so that data beyond the core set identified in this document may be communicated to other organizations. This specification is intended to work in concert with other specifications.

 

 

 


6          Other Standards, Specifications, or Schema Referenced

 

This standard references:

  • ANSI/MEDBIQ LO.10.1-2008, Healthcare Learning Object Metadata [ Healthcare LOM ]
    Healthcare LOM provides the format for identifiers and metadata about the competency framework.
     
  • Competency Object [ Competency Object ]
    Competency Framework may reference individual statements of expectation using a MedBiquitous defined format or the IEEE Reusable Competency Definition.
     
  • 1484.12.3-2005, IEEE Standard for Learning Technology-Extensible Markup Language (XML) Schema Definition Language Binding for Learning Object Metadata  [ LOM ]
    Healthcare LOM extends the IEEE LOM standard.
     
  • 1484.20.1-2007 - IEEE Standard for Learning Technology-Data Model for Reusable Competency Definitions [ IEEE RCD ]
    Competency Framework may reference individual statements of expectation using a MedBiquitous defined format or the IEEE Reusable Competency Definition.
     
  • XHTML™ 1.0 The Extensible HyperText Markup Language (Second Edition) [ XHTML ]
    XHTML provides the format for supporting information embedded in the competency framework.

 

 

 


7          Terminology

Much of the terminology in this area is ill-defined or ambiguous, often employed differently (and sometimes interchangeably) by different professionals [ Harden 1 ]  To ensure clarity and consistency we provide working definitions of the terminology we use in the context of this paper:

  • Competence – possession of sufficient and necessary knowledge, skill and attitude by an individual to allow her to safely and effectively perform a specific job.
  • Competency – a statement describing a specific ability, or set of abilities, requiring specific knowledge, skill and/or attitude.  Competencies are used to set performance standards that must be met [ Albanese 1 ]
  • Competency Framework – an organized and structured representation of a set of interrelated and purposeful competency objects.
  • Competency Object – an umbrella term used by the CWG to describe any abstract statement of learning or performance expectations, and information related to the statement.  Statements can be learning outcomes, competencies per se, learning objectives, professional roles, topics, classifications/collections, etc.  The Competency Object may include additional data to expand on or support the statement.  The Object is abstract in the sense that it does not inherently contain information about connections of the statement to individuals or events or other objects.
  • Learning Objective – the intended aggregate learner endpoint for an activity, typically directly linked to the means by which it is to be achieved.  Learning objectives may be derived from competencies or learning outcomes.
  • Learning Outcome – the intended aggregate learner endpoint for a program, typically independent of the means by which the outcome is achieved.  Used to identify, define and communicate the skills and qualities graduates should have [ Harden 2 ]
  • Learning Object – a digital resource used to support learning.
  • Performance – a demonstration of practice, such as patient care. Can be used as evidence of one or more competencies.

 


8          Competency Framework Schema Grammar

The following sections explain the Competency Framework Schema grammar. Values in bold under XML Tags column indicate that the element has sub-elements.

All the elements having sub-elements will be defined in separate sections. All elements without sub-elements will be defined within the appropriate element sections that use them.

8.1       CompetencyFramework

CompetencyFramework is the root element. It contains subelements that describe a set of related competency definitions as well as the relationships among those competency definitions, if applicable. CompetencyFramework must occur once within a competency framework document.

 

CompetencyFramework Element Information

Element

Description

Required

Multiplicity

Datatype

CompetencyFramework

CompetencyFramework is the root element. It describes a set of related competency definitions and their relationships.

Required

1

Container

 

lom

lom is the subelement of CompetencyFramework. It contains subelements that define title, publisher, and other descriptive information about this competency framework.

The lom element is defined in the Healthcare Learning Object Metadata standard defined by MedBiquitous. Please see the Healthcare Learning Object Metadata Specifications and Description document for more information on the sub-elements of lom.

The following elements within  lom are required in a competency framework:

identifier

Defines a unique identifier for the competency framework. For competency frameworks, identifiers must be in the form of a URI.

title

Defines the title for this competency framework in one or more languages.

The following elements within lom are recommended in a competency framework:

general: description

A short description of the competency framework.

lifecycle: role and lifecycle: entity

Use the role and entity elements within the lifecycle element to indicate the publisher of the competency framework. Role may have a value of publisher, and the corresponding entity element may include a vcard reference to the publisher.

educational: context

The educational environment for which the competency framework is intended. The MedBiquitous vocabulary for educational context is recommended.

rights: copyrightAndOtherRestrictions

This element indicates whther or not copyright or other restrictions exist on the competency framework. Valid values are yes and no.

rights: description

The description element within rights provides a brief description of the copyright or other constraints on the competency framework. The description may include a link to a license.

healthcareMetadata: healthcareEducation:targetAudience: profession

The health profession for which this competency framework is intended.

For more information on these elements, see [ LOM ] and [ Healthcare LOM ].

Required

1

Container

For more information, see  [ Healthcare LOM ] and [ LOM ].

Status

Status is a subelement of CompetencyFramework. It describes the status of the competency framework. Valid values are Active and Retired. The default value is Active.

Optional

0 or 1

Restricted

replaces

Replaces is a subelement of CompetencyFramework. Replaces is defined by the Dublin Core Metadata Initiative . It indicates a related competency framework that is supplanted, displaced, or superseded by the described framework .

Implementers must use a URI to represent the related framework.

For more information, see [ DCTerms ].

 

 

Any, no child elements permitted.

For more information , see [ DCTerms ].

isReplacedBy

isReplacedBy is a subelement of CompetencyFramework. isReplacedBy is defined by the Dublin Core Metadata Initiative. It indicates a related competency framework that supplants, displaces, or supersedes the described framework .

Implementers must use a URI to represent the related framework.

For more information, see [ DCTerms ].

 

 

Any, no child elements permitted.

For more information, see [ DCTerms ].

SupportingInformation

SupportingInformation is the subelement of CompetencyFramework. It contains subelements that include or link to supporting information, such as descriptions of the rationale for developing the framework and its intended use. See section SupportingInformation for more information.

Optional

0 or more

Container

Includes

Includes is the subelement of CompetencyFramework. It contains subelements that uniquely identify competencies included in this competency framework. All competencies included in the framework must be referenced using the Includes element, including any competency object or framework referenced in a relations element. .

Required

1 or more

IdentifierType

See section IdentifierType for more information.

Relation

Relations is the subelement of CompetencyFramework. . It contains subelements that define a relationship between two components of a framework. See section Relation for more information.

Optional

0 or more

 

Container

XtensibleInfo

XtensibleInfo contains sub-elements defined by the organization implementing the schema. See section XtensibleInfo for more information.

Optional

0 or 1

Container

 

Example:

 

<CompetencyFramework>

<lom:lom>

. . .

</lom:lom>

<SupportingInformation>

. . .

</SupportingInformation>

<Includes>

. . .

</Includes>

<Includes>

. . .

</Includes>

<Includes>

. . .

</Includes>

<Relation>

. . .

</Relation>

<Relation>

. . .

</Relation>

<Relation>

. . .

</Relation>

 

8.2       SupportingInformation

SupportingInformation includes or links to supporting information, such as descriptions of the rationale for developing the framework and its intended use.


SupportingInformation Element Information

Element

Description

Required

Multiplicity

Datatype

SupportingInformation

SupportingInformation is the subelement of CompetencyFramework. It contains subelements that include or link to supporting information, such as descriptions of the rationale for developing the framework and its intended use.

Optional

0 or more

Container

Link

Link is the subelement of SupportingInformation. It provides a URL or URI reference to a supporting resource, such as a pdf or html file describing the purpose of the framework in detail.

Link must contain a valid URI.

Either Link or xhtml:div is required

0 or 1

Restricted

xhtml:div

A div element is a mixed type element referenced from XHTML. The div element can include a mix of text and XHTML tags as specified by the XHTML schema.

Either Link or xhtml:div is required

0 or 1

Container

For more information, see [ XHTML ].

The following example provides a link:

<SupportingInformation>

<Link>http://www.scottishdoctor.org/resources/scottishdoctor3.doc</Link>

</SupportingInformation>

 

The following example shows the use of XHTML:

<SupportingInformation>

<xhtml:div>

<xhtml:h2>The Scottish  Deans Medical Curriculum Group (SDMCG)</xhtml:h2>

<xhtml:p>Following the publication of &lsquo;Tomorrow&rsquo;s  Doctors&rsquo; by the UK General Medical Council (GMC) in 1993, the five Scottish  Medical Schools (Universities of Aberdeen, Dundee, Edinburgh, Glasgow and St  Andrews) had a series of meetings to discuss the implications of the  recommendations. As a result of these discussions, the Scottish Deans&rsquo; Medical  Curriculum Group (SDMCG) was set up in 1999. The purpose of the SDMCG is to  discuss and where necessary coordinate the development, delivery and evaluation  of their undergraduate curricula and to ensure that the graduates from each  school are of an equivalent standard. </xhtml:p>

<xhtml:p>The Group comprises two members from each  School, one of whom is the Teaching Dean or equivalent. The Group also has as  members a medical education IT expert, an educationalist, who also acts as the  Project Officer, a Post Graduate Dean and an administrator. The activities of  the Group are funded by the five Schools, with earlier support coming from NHS  Education for Scotland. The SDMCG reports to the Board for Academic Medicine in  Scotland.</xhtml:p>

<xhtml:p>The Scottish Doctor publications have been the most  visible results of the SDMCG&rsquo;s activities. Other projects include ones on  standard setting, student portfolios, learning in acute care, communication  skills and anatomy and some of these projects are ongoing. There is also a  standing IT/informatics subgroup (The Medical Education Informatics Group). The  SDMCG has proved a valuable forum for the Schools to discuss national issues  such as Government or NHS consultation documents or guidance from specialty  groupings about undergraduate medical curricular content. The Group has  recently appointed a Senior University Teacher in Law, Ethics and Risk  Management. The holder of this post, which is funded by the Medical and Dental  Defence Union of Scotland, works with all five Schools on their continuing  development of this important curricular theme.</xhtml:p>

</xhtml:div>

</SupportingInformation>

 

8.3       Relation

Relation defines a relationship between two components of a framework.

Relation Element Information

Element

Description

Required

Multiplicity

Datatype

Relation

Relation is the subelement of Relations. It contains subelements that define a relationship between two components of a framework. The following types of relationships are allowed:

  • A competency may be broader than another competency.
  • Conversely, a competency may be narrower than another competency.
  • A competency may be broader than an external framework.
  • Conversely, an external framework may be narrower than a competency.
  • A competency may be related to another competency.
  • A competency may be related to an external framework.

 

No other relationships may be defined. Cyclical references are forbidden as are any references that result in a hierarchical conflict. For more information, see the note about hierarchical conflict following this section.

Optional

0 or more

Container

Reference1

Reference1 is the subelement of Relation. It identifies a single competency with a relationship to the componentspecified in Reference2.

Required

1

Container

Relationship

Relationship is a subelement of Relation. It defines the nature of the relationship between the components of the framework specified inReference1 and Reference2. Valid values are: broader than, narrower than, related to.

Broader than and narrower than are converse relationships. If Component1 is broader than Component2, Component2 must be narrower than Component1. The converse relationship does not need to be explicitly encoded; it should be understood based on the nature of the relationship between the two components.

Related to may be used for any relationship that is non-hierarchical.

Required

1

Restricted

Reference2

Reference2 is the subelement of Relation. It identifies the component that has a relationship to the component specified in Reference1.

Required

1

Container

 

Example:

< Relation >

< Reference1 >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency123 </ Entry >

</ Reference1 >

< Relationship > broader than </ Relationship >

< Reference2 >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency234 </ Entry >

</ Reference2 >

</ Relation >


Note about Hierarchical Conflict

The ability to define relations to external competency objects and frameworks provides a great deal of flexibility in defining a competency framework, but it also has the potential to lead to confusion. This standard explicitly forbids any relations that result in a hierarchical conflict, as in the example below.

Framework A has no external references.

Framework B incorporates Framework A. Competency object B3 is broader than Framework A.

Framework C incorporates a competency from framework A and all of Framework B, saying that competency object A1 is broader than Framework B. This is a hierarchical conflict since Framework B explicitly defines Framework A, and therefore all of its competency objects, including A1, as narrower than competency object B3, which is a part of framework B. The resulting string of relations look like this:

The hierarchical relation shown in red clearly conflicts with the hierarchical relation shown in green.

8.4       XtensibleInfo

The XtensibleInfo element contains sub-elements defined by the organization implementing the schema. It extends the currently defined schema. Elements listed in XtensibleInfo may be candidates for inclusion in a revision of this standard. We encourage submission of these ideas to the MedBiquitous. You may submit suggestions to info@medbiq.org .

XtensibleInfo is a sub-element of CompetencyFramework.

 

 


9          Appendix : Hierarchical Conflicts

The Competency Framework Specifications forbids cyclical references and any references that result in a hierarchical conflict within the relation element. This section illustrates what is meant by hierarchical conflict.

 

 

 


10    Sample XML Document s (update)

 

<?xml version="1.0" encoding="UTF-8"?>

< CompetencyFramework xmlns =" http://ns.medbiq.org/competencyframework/v1/ " xmlns:lom =" http://ltsc.ieee.org/xsd/LOM " xmlns:hx =" http://ns.medbiq.org/lom/extend/v1/ " xmlns:xsi =" http://www.w3.org/2001/XMLSchema-instance " xsi:schemaLocation =" http://ns.medbiq.org/competencyframework/v1/ competencyframework.xsd http://ltsc.ieee.org/xsd/LOM http://ns.medbiq.org/lom/healthcarelom.xsd http://ns.medbiq.org/lom/extend/v1/ http://ns.medbiq.org/lom/healthcare/healthcaremetadata.xsd ">

< lom:lom >

< lom:general >

< lom:identifier >

< lom:catalog > URI </ lom:catalog >

< lom:entry > http://www.example.org/framework1 </ lom:entry >

</ lom:identifier >

< lom:title >

< lom:string language =" en "> The Competent Physician </ lom:string >

</ lom:title >

< lom:description >

< lom:string language =" en "> The Competent Physician describes the knowledge, skills, and abilities a physician should have. </ lom:string >

</ lom:description >

</ lom:general >

< lom:lifeCycle >

< lom:version >

< lom:string > 1.0 </ lom:string >

</ lom:version >

< lom:contribute >

< lom:entity > Association of Worldwide Physicians </ lom:entity >

< lom:role >

< lom:source > LOMv1.0 </ lom:source >

< lom:value > publisher </ lom:value >

</ lom:role >

</ lom:contribute >

</ lom:lifeCycle >

< lom:educational >

< lom:context >

< lom:source > HEALTHCARE_LOMv1 </ lom:source >

< lom:value > undergraduate professional education </ lom:value >

</ lom:context >

</ lom:educational >

< lom:rights >

< lom:copyrightAndOtherRestrictions >

< lom:source > LOMv1.0 </ lom:source >

< lom:value > yes </ lom:value >

</ lom:copyrightAndOtherRestrictions >

< lom:description >

< lom:string language =" en "> Creative Commons Attribution 3.0 Unported license, http://creativecommons.org/licenses/by/3.0/ </ lom:string >

</ lom:description >

</ lom:rights >

< hx:healthcareMetadata >

< hx:healthcareEducation >

< hx:targetAudience >

< hx:profession >

< lom:string language =" en "> physician </ lom:string >

</ hx:profession >

</ hx:targetAudience >

</ hx:healthcareEducation >

</ hx:healthcareMetadata >

</ lom:lom >

< Includes >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency1 </ Entry >

</ Includes >

< Includes >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency2 </ Entry >

</ Includes >

< Includes >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency3 </ Entry >

</ Includes >

< Relation >

< Reference1 >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency1 </ Entry >

</ Reference1 >

< Relationship > broader than </ Relationship >

< Reference2 >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency3 </ Entry >

</ Reference2 >

</ Relation >

< Relation >

< Reference1 >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency1 </ Entry >

</ Reference1 >

< Relationship > broader than </ Relationship >

< Reference2 >

< Catalog > URI </ Catalog >

< Entry > http://www.example.org/competency2 </ Entry >

</ Reference2 >

</ Relation >

</ CompetencyFramework >

 


11    References

 

Albanese 1
Albanese MA, Mejicano G, Mullan P, Kokotailo P and Gruppen L.  Defining characteristics of educational competencies.  Medical Education 2008; 42(3):248-55.

Competency Object
MedBiquitous Competency Object Specifications and description Document. MedBiquitous Website. http://www.medbiq.org/sites/default/files/CompetencyObjectSpecification.pdf . Accessed June 16, 2011.

DC Terms
DCMI Metadata Terms. Dublin Core Metadata UInitiative Website. http://dublincore.org/documents/dcmi-terms/#terms-replaces . Accessed October 17, 2011.

Harden 1
Harden RM.  Learning outcomes and instructional objectives: is there a difference?  Medical Teacher 2002; 24(2):151-5.

Harden 2
Harden RM, Crosby JR, Davis MH and Friedman M.  AMEE Guide No. 14: Outcome-based education: Part 5 – From competency to meta-competency: a model for the specification of learning outcomes.  Medical Teacher 1999; 21(6):546-52.

Healthcare LOM
ANSI/MEDBIQ LO.10.1-2008, Healthcare Learning Object Metadata, MedBiquitous Website.
http://www.medbiq.org/std_specs/standards/index.html#HCLOM . Accessed June 1, 2011.

IEEE RCD
1484.20.1-2007 - IEEE Standard for Learning Technology-Data Model for Reusable Competency Definitions, IEEE Standards Association Website.
http://standards.ieee.org/findstds/standard/1484.20.1-2007.html. Downloaded October 21 , 2009.

LOM
"IEEE Standard for Learning Technology-Extensible Markup Language (XML) Schema Definition Language Binding for Learning Object Metadata," IEEE Std 1484.12.3-2005 , vol., no., pp.0_1-46, 2005
doi: 10.1109/IEEESTD.2005.97889
URL:  
http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=1532505&isnumber=32693

XHTML
XHTML™ 1.0 The Extensible HyperText Markup Language (Second Edition), W3C website.
http://www.w3.org/TR/2002/REC-xhtml1-20020801. Accessed September 6 , 2011.