BRIEF

Launching a University Tablet Initiative:

Recommendations from Stanford
Universitys iPad Implementation

Jenn Stringer, Director, Academic Technology Services, New York University

April 2012

Brian Tobin, Instructional Technology Manager, Stanford University School of Medicine

Stanford University School of Medicine has been distributing iPads to incoming

students since 2010 and to a subset of clinical students since 2011, with the goals
of exploring paperless course content delivery and mobile access to information in
clinical environments.

While student adoption of the tablet varied, a large proportion of students preferred

it to laptops and paper for taking notes and reviewing materials after class.

Early survey data suggests that iPads are perceived as effective in clinical situations

for accessing frequently used library materials, organizing PDF documentation and
readings, using apps for clinical calculators and quick reference, and educating patients.

Early planning, training, and support services were key to the success of the

tablet initiative.

Overview

Form factor optimized for use while either

In 2006, the Horizon Report listed mobile

phones as an emerging factor that will be
important to deliver educational content
to learners whenever and wherever they
need it. Since then, screens have become
larger, devices more powerful, and iPads and
Android tablets have emerged as dominant
mobile platforms. The 2012 higher education edition of the Horizon Report lists tablet
computing as one of the technologies with
a time-to-adoption horizon of one year
or less. As educational institutions consider
how to truly enable and support anytime,
anywhere learning, we need to address two
key questions:
1. How should schools plan for and support
mobile learning?
2. H
 ow can we ease the transition from classroom-based to mobile learning?
Similar to many other schools, Stanford
University previously piloted mobile initiatives
with Palm Pilots, iPods, audience response
systems, and other emerging technologies.
However, the Spring 2010 launch of the iPad
offered the first availability of a mobile technology that met the feature requirements
important for medical education:

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sitting or standing

Drawing and annotation capability

Vivid high-resolution display for medical

imaging

Fast Wi-Fi for media and content access

In Autumn quarter 2010, all 91 incoming MD

and Master of Medicine students at Stanford
University School of Medicine received an iPad
and PDF annotation software for use in their
curriculum. Key goals of the initiative were to
move towards a paperless model of content
delivery; facilitate use of educational content
and information in courses and labs; and explore
the opportunities and challenges of standardizing mobile device use across the curriculum.
The rationale for this project included the
following factors:
Student readiness: Our students already

have considerable familiarity and facility

with educational technologies, and this
creates new opportunities for efficient,
mobile, and innovative learning.

Preparing

students for using digital

devices in clinical medicine: Mobile devices
such as iPads provide students an opportunity for just-in-time, evidence-based
practice utilizing Lane Medical Librarys

2012 EDUCAUSE. CC by-nc-nd.

digital library of knowledge, including clinical search tools, licensed content such as
journal articles, image and specialty databases, online tutorials, and e-books.
The flexibility of iPad technology: The iPad

allows students to view and annotate course

content electronically, facilitating advance
preparation as well as in-class note-taking
in a highly portable, sharable, and searchable format.

Going green: Replacing printed syllabi

with PDFs is in line with the Sustainable

Stanford initiative, which aims to build
sustainable practices into every aspect of
campus life. An average first-year medical
student receives over 3,500 pages of printed
syllabus materials.

The Li Ka Shing Center (LKSC) for Learning

and Knowledge (http://lksc.stanford.edu):

Our new education building provides a
technology-enhanced test bed with its
newly designed learning spaces, automated
video capture, and high-bandwidth wireless
throughout the facility.

Preparation

Immediately after determining the iPad was

viable for our initiative, we created the iPad
Implementation Team. This team met at least
monthly throughout the initiative to set the
mission for the initiative, review progress, and
address any concerns. The Implementation
Team consisted of leadership in the School of
Medicine from the Office of Medical Education,
Student Affairs, Educational Technology, Lane
Medical Library, Networking and Security, and
the Service Desk.
We sent an announcement to students
explaining exactly what they would get: a
Wi-Fi iPad, case, and iAnnotate PDF annotation software. The iPads remained the property
of Stanford School of Medicine, and students
signed an agreement that outlined the policies that they were required to comply with
regarding the iPad and professional behavior.
We developed a website that contained general
information about the initiative, training materials, and links to all of the appropriate policies
(see http://med.stanford.edu/estudent/). We
also announced the initiative to faculty and
confirmed that all the faculty-authored course
readers would be available to students as PDFs
with bookmarks to enhance navigation.
We handed out iPads to students during
orientation week and offered a team of staff
to answer questions. Students completed a
checklist of steps to agree to the iPad study
agreement, retrieved and applied their app

redemption code, registered the iPad for wireless, and in the most recent year registered
for the Mobile Device Management system to
set up e-mail/calendar and security. To ensure
students were ready to use the iPads on the first
day of class, we offered group training sessions
on iOS basics as well as how to specifically use
iOS to take notes using iAnnotate.

Initial Use

Given that we had just a few months to prepare,

our initial goals were to offer students wellorganized PDFs of all course readers, lecture
slides, and readings as well as access to iPadfriendly videos of all lectures. Our training and
support for both students and faculty revolved
around how to transition from a paper-centric
curriculum toward iAnnotate and PDF documents for a note-taking and studying platform.
From the start, a sizeable portion of students
were able to use iPads to draw on, hand-label,
and add text notes to their course materials. We
also frequently witnessed students using the
iPad to watch lecture videos while studying or
while running on treadmills in the student gym.

Data Collection

We made it a priority to collect useful data

throughout the initiative. We surveyed students
each quarter to collect data on their perceptions of the implementation as well as to learn
how they used their iPads. We took attendance
in class to count the number of iPads and
computers in use. Our staff also kept track of the
number of office-hours attendees and support
requests. We analyzed the logs of our student
printers and surveyed students regarding their
preference for having a printed syllabus. To
gain information about the types of materials
students wanted to print, we also tracked the
types of print jobs sent to the student printer.
During clinical pilots, we collected surveys
during and at the end of each month.
Student Acceptance and Use Survey results
indicate that the majority of students used their
iPads as a learning aid and that their experience
using the new technology has been positive. We
also found that frequency of use varied across
courses and from student to student. (See
Figure 1.)
At the end of the first quarter, Fall 2010, 78%
of students rated the iPad experience positively
overall, and in all courses, more than 50% of the
students rated the iPad positively for studying
and note-taking. Despite differences of opinion
across courses, 52% of students indicated that
the iPad was helpful for their learning, with 23%
indicating that they found it unhelpful. Students
also stated that they used the iPad in class for

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Figure 1. Student Responses about iPad Value for Learning*

* Bars represent ratings for individual courses. Black squares indicate the average rating ( SEM) across all courses.

reviewing course materials (73%) and looking up

unfamiliar terms (63%). Approximately 50% of
students reported that they use the iPad regularly
for note-taking and accessing course content,
and this matches our observations in class.
In survey comments, students who valued the
iPad as a learning tool said that it was useful for
drawing, organizing materials, searching the full
text of course content, digital ink note-taking
(drawing), and magnifying images and figures.
They also appreciated its portability. Students have
also commented that they appreciated becoming
acclimated to the new technology because they
expect that portable devices will be increasingly
in use in clinics. As one student wrote:
I have been really trying to incorporate the
iPad into my daily educational activities
because it is extremely convenient to take it
everywhere and have all of the course material in a small, compact location. I am also
someone who learns best with diagrams and
pictures, so it was really great to be able to
zoom in and out of figures in the notes and
PowerPoint presentations while studying and
having them show up in clear, crisp definition.

At the end of the first quarter, however, it

was also clear that a portion of the class did
not perceive the iPad as useful for note-taking.
In survey comments, these students identified a number of challenges. Some found the
on-screen keyboard more difficult to use than a
physical keyboard. Faculty noticed that students
who tried to type on the keyboard kept their
heads down rather than making eye contact
with lecturers. The stylus was not precise
enough to make fine annotations and required
zooming in and zooming out in order to draw
detail. The autopredict feature sometimes misinterpreted medical terms, which also led to
inaccuracies while typing. The annotation software lacked an eraser function and sometimes
crashed when students were working with large
files. Some students found it difficult to download, store, and transfer content to and from
the iPad because connecting and moving files
around is not as easy as with a USB stick or hard
drive. One student commented on these technical challenges, I feel I miss information trying
to zoom in/out to take notes with the stylus, and
the touchscreen keypad is difficult to type with
because of the large number of errors made.

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Figure 2. Observed Classroom Usage of iPads*

* Dots represent individual data points, and lines represent the regression line for each course.

As part of our initial evaluation, we also

observed iPad usage in class. Headcounts
of iPad use were collected during lectures
throughout the first two quarters of the year
(see Figure 2). This allowed us to gain a better
sense of how often iPads were being used for
lectures, to establish whether differences in
iPad use may exist across different courses,
and to monitor whether iPad use in lectures
changed over time.
The data collected showed that students
did have different patterns of iPad usage
from course to course. The Surg203A and
Surg203B Human Anatomy courses consistently showed the highest proportion of iPad
use. (However, it is important to note that
only 3 out of 10 Surg203B Human Anatomy
sessions had observation data.) We suspect
this is due to the fact that anatomy faculty
provide students with coloring bookstyle
lectures slides (notes with gaps learning
approach) and draw on top of slides in a way
that makes it very easy for students to follow

along and annotate on the iPad. It also appears

that iPad use in lecture declined as the first
quarter progressed. This trend continued
in Winter 2011, but may have leveled off as
students determined whether they found the
iPad useful or not for a particular class. One
factor that likely contributed to the apparent
decline in iPad usage from Autumn 2010 to
Winter 2011 is the change in policy around
printed materials. Printed syllabi were not
made available to students in Autumn 2010,
while in Winter 2011 students were given the
option to order printed syllabi, if desired (see
below for more discussion). We plan to further
explore these course-based differences and
other usage trends with questions in student
focus groups.

iPad Versus Paper and Laptops

The initial survey results show that 50% of

students identified the iPad as their preferred
learning aid during lectures (see Figure 3),
although laptops and paper are still popular
methods for accessing course content in class.

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One noted limitation in iPad technology was the

inability to access Flash-based content, including
interactive slides in histology and demonstration videos in the Practice of Medicine course.
The Learning Strategies Office reached out
to students who found that the iPad did not
work to their satisfaction as a replacement for
paper study materials. Those students were
provided printed copies of the syllabus and
offered additional study resources. Based upon
our observations and the Autumn 2010 quarter
survey data, we realized that paper materials
would continue to be an important resource for
some students. All students were offered the
option of ordering a printed syllabus for Winter
2011 courses, but fewer than 50% of students
requested one.

Printing

Prior to the 20102011 academic year,

Stanford had provided every student with
printed copies of the course syllabi/readers. In
previous years we had never provided students
with printed lecture slides, but students could
download slides and print them on their own

printer or on the free student printer provided

by the Stanford Medical Student Association.
Autumn 2010 survey data showed that:
31% of students had printed one or more of

the whole course readers; an additional 13%

printed part of a reader

28% of students printed lecture slides

77% of students printed journal articles

(either monthly, weekly, or daily)

83% had utilized LKSC 4th floor printer to

print some course materials

Student printer logs from mid-October to midNovember showed there were 3,006 total print
jobs. Of these print jobs:
83.0% (2,496) were 19 pages in length
16.5% (497) were 1099 pages in length
0.4% (13) were reader-length (100+ pages

in length)

For Winter 2011 and Spring 2011 quarters, we

offered students the option of ordering printed
course readers at no cost. Table 1 shows the
statistics on students who opted for a copy.

Figure 3. Preference among Learning Aids*

* Bars represent ratings for individual courses. Black squares indicate the average rating ( SEM) across all courses.

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Table 1. Student Choices for Printed Materials, by Term and Course

Winter 2011

Spring 2011

IMM205, Immunology: 52 (57%)

INDE203, Practice of Medicine: 27 (33%)

INDE202, Practice of Medicine: 21 (23%)

INDE221, Human Health and Disease: 53 (60%)

INDE220, Human Health and Disease: 44 (48%)

NBIO206, Neurobiology: 39 (48%)
SURG203B, Human Anatomy: 33 (36%) slides only, no syllabus/reader

These statistics show that many students found

the digital copies to be sufficient for their learning
needs. Anecdotally, weve heard that fewer students
in 20112012 are requesting printed readers,
suggesting that they might be finding digital
options even more functional this year.

Support and Training

We provided a variety of options for

supporting and training users, including handson large-group training sessions during official
orientation time or just before class; office hours
and phone support; web-based YouTube videos
for just-in-time training (http://med.stanford
.edu/estudent/support/tutorial_videos.html);
and a website and PDFs for other documentation. We tracked use of these resources and
found that:
23% of students attended office hours or

made drop-in appointments

38% of students attended an Autumn 2010

workshop on using iAnnotate to draw on

anatomy lecture slides

8% of students attended a Winter 2011 Show-

and-Tell session discussing favorite apps

Based upon general hit data on YouTube

videos, we estimate that only a small percentage
(<20%) of students used training videos.
These data suggest that although students were
engaged with the iAnnotate workshop at the beginning of the quarter, the following quarter they were
not as interested in attending a show-and-tell of
other apps that might be useful. Because students
havein conversation with staffexpressed interest
in learning about more apps, the question remains
how to more actively engage students in exploring
new uses for their iPads.
AppleCare was purchased in order to cover the
potential need for increased technical support
for iPads. AppleCare offers an extended service
warranty, as well as hands-on and phone support
and tutorials. As of March 2011, three iPads broke
or malfunctioned and two students received free
replacements through AppleCare.
In order to support clerkship studentsthose
who are in clinical training and rotate at various
hospital sites across the Bay Areawe placed an

emphasis on providing face-to-face training for

students on the very first day of their clerkship.
We covered both the basics of how to use the iPad
(settings, interface, etc.), as well as higher-level
principles such as how to interact professionally
with patients while using a mobile device, and we
demonstrated useful library resources and Apps.

Observed Use of Peripherals

Stylus use is high in courses where drawing

or writing is helpful. We would recommend that
other institutions provide students with a stylus
along with the iPad, given that the majority of
students wanted one and it makes freehand
drawings and annotation possible. Most students
preferred the BoxWave brand stylus and others
with narrow and firm rounded tips. Students and
faculty expressed desire for a more precise stylus
such as those on pressure-sensitive screens like
Windows tablet computers. Unfortunately, this
level of precision is not possible with the iPads
current capacitive screen.
Most students during 20102011 using an
iPad in class did not carry an external keyboard
and instead typed directly on the iPad screen.
In 20112012, weve observed more students
using external keyboards or the new cases
that include a small bluetooth keyboard
inside. We believe that students who forego
the keyboard generally find the on-screen
keyboard good enough; want to go as lightweight as possible; or do not want to pay an
added cost for a keyboard.

Faculty Acceptance

The short implementation time frame hindered

our ability to communicate with faculty, involve
them in the process, and get their input regarding
the initiative. Ideally, we would have held faculty
development sessions regarding mobile devices
in Spring 2010. To involve all faculty and set the
stage for a full evaluation, an iPad Summit was
organized. The summit brought together faculty
and staff from across the curriculum, as well as a
wide range of learning and technology experts. The
primary purpose of the summit was to begin developing a formal evaluation plan for assessing the
impact of tablet technology on student learning.
Working groups considered ways to assess how

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the iPad is being used currently, to imagine how

the iPads might be used in more innovative ways
going forward, and to discuss how those changes
should be monitored and assessed. While some
quantitative measures had already been collected,
including survey data, tracking of how paper materials are used, and observations of iPad use in class
(results shown above), many other opportunities
still remain. Similarly, it was agreed that rigorous
qualitative evaluation might also yield important insights on the impact of tablet technology
on teaching and learning. It was proposed that a
group of researchers develop a plan of inquiry that
might include ethnography and in-depth interviews
detailing tracking of patterns of use.

Technical Infrastructure

The primary technical hurdle that we encountered in the rollout of the iPads to the new students
was engineering our 802.11n wireless network to
accommodate a larger number of wireless devices,
particularly in the classroom setting. The combination of the number of devices in a room (often
three devices per personlaptop, smartphone, and
iPad) and the simultaneous downloading of 1020
MB course content files by the students caused
severe degradation of wireless performance. We
were forced to make a number of adjustments
to the wireless network infrastructure, including
augmenting the coverage in the classrooms to
focus on client density to support the new network
trends. Wireless performance has significantly
improved from the initial deployment. However,
limitations still exist due to wireless networking
being a shared medium and the limited performance capabilities of the iPad 802.11n wireless
radios. We have recently redesigned our wireless network architecture to successfully address
a number of these issues. We also encouraged
students to download content at home before
class, but we still see a number of students downloading right before class.

Content Licensing

It is worth noting that some e-books are only

available for individual purchase licensing, and
the interface and usability of e-books is still in
need of improvement. Digital versions of textbooks have been licensed at an extremely high
cost, with some roughly at $1,200 for a single
text per year. The cost for providing institutional
licenses to textbooks will require additional
budget support.
The library licenses campus-wide and remote
(anytime, anywhere) access to web-based
digital resources with IP-based access controls.
The library does not license content packaged
for personal devices or limited platforms. The
personal nature of the iPad device does limit

licensing options for non-Stanford-produced

content or content that is licensed regardless
of device used. The library licenses and lobbies
with publishers for web access combined with
mobile access whenever possible, however.

Mobile Applications and Interfaces

EdTech offers annual minigrants to encourage

development and evaluation of innovative learning technologies. For the 20102011
proposals, we encouraged submissions that
addressed mobile technologies and interfaces.
Twelve out of 27 proposals focused on mobile
development (six proposals for clinical learning,
and six proposals for graduate or MD courses).
Although some students sought new ways
to use the iPad and explored all its features,
our survey data showed that students rarely
experimented with applications other than
what Stanford provided. Many students were
not aware that word processing applications,
double-speed video players, and a variety of
apps related to course content are available
for download. It may be the case that students
lack of awareness of these other features of the
iPad decreased its perceived usefulness. Going
forward, we plan to provide more resources
and training to students on additional applications that mught be helpful for their learning.
We plan to encourage use of Stanfords internal
MedApps medical application review website
to help medical students find the most relevant
and useful mobile applications.
Data presented earlier in this brief showed that
clinical and course faculty have many good ideas
for creating mobile learning applications. Given the
wide variety of mobile devices on the market, it is
essential that we support development of mobile
apps that work across all platforms. Most mobile
apps are references to information and content
formatted for mobile display interfaces. Few apps
take advantage of features such as multitouch,
accelerometer/gyroscope/inclinometer, camera,
microphone, or GPS. For these reasons, we are
encouraging most mobile developers to focus on
building mobile web applications. For example,
Sakai learning management system (CourseWork
at Stanford) and Moodle both offer mobile CSS
that turns any course and content into mobileaccessible systems. Mobile CSS toolkits such as
iUi (http://med.stanford.edu/irt/teaching/iui.html)
allow anyone who knows basic web HTML to
create websites formatted specifically for mobile.
Lane Medical Library is also discovering and
creating access (e.g. cataloging and categorizing mobile interfaces as distinct from mobile
applications) to highly relevant mobile content
for the first year medical students and for all
of our users across the continuum of learning.

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The beta version of a mobile interface to Lanes

digital content was released in December (http://
lane.stanford.edu/m).

Broader Effects

The project has accomplished much of what we

intended at the outset. It has provided students
with a device that has been adopted by many
as their primary note-taking and studying device
and has changed the way many of them access
and organize their course materials. This project
has also prompted the School of Medicine to put
greater focus on the educational use of mobile
devices and the development of mobile content.
In the creation of the Implementation Team, we
unified a network of individuals from a variety of
departments and groups to get a full perspective and address the support and adoption of
mobile devices and content across the school.
Future use of tablet computing in medical
education is likely to further exploit their
capabilities as consumption devices (push
technologies, e-textbooks, and news readers).
Hardware such as front- and high-definition
rear-facing video cameras should significantly
increase tablets capacity to be used as media
production and communication devices. These
cameras also allow opportunities for augmented
reality tools to be used as guides in labs and
classrooms. We see use for applications that
allow for groups of tablet users to connect
their devices for collaborative work as well. For
instance, synchronous creation of mind maps,
texts, and drawings could be used to enhance
existing small-group clinical reasoning sessions
for medical students.
Beyond the device changing over time, we are
interested in how tablet use from current adopters
will change as they transition through a second
year of courses and into clerkships. We are already
seeing enthusiasm and momentum building for
exploring more innovative uses of the iPad as a
tool to enhance patient care at the bedside. The
Stanford anesthesia department developed an iPad
application to provide clinically useful educational
modules, tutorials, videos, podcasts, and cognitive
aids to help facilitate learning at the point of care.
The application includes videos providing demonstrations and instructions for clinical procedures
and is structured in a format specifically designed
to be accessed on the iPad. It is exciting to see
faculty engaged in early planning as they prepare
for a cadre of students who will be expecting to
take full advantage of their iPads during clinical practice. Being able to pilot test promising

innovations in advance and share best practices

across the curriculum will be important in ensuring
that tablet technology is effectively incorporated
into the students clerkship experience.

Key Lessons Learned

A robust wireless infrastructure is key to

success.

Students

found web-based
extremely helpful on the iPad.

resources

The iPad is an advantageous platform to

organize documents for easy retrieval.

PDF files continue to be the easiest way

to produce and distribute content to users.

Many students found the iPad suitable for

in-class note-taking, although a physical

keyboard is preferred.

Training for students should be integrated

into orientation and courses, as well as made

available through just-in-time videos.

Programs need to offer early faculty support

and guidance on using the iPad for teaching

and learning.

The AppleCare program was accessed for

a very small percentage of support issues

and may not be cost-effective for large
implementations.

Apples Volume Purchase Program allows for

discounted purchase of apps at a discount

and makes it easy to distribute redemption
codes to initiative participants.

Device Profiles, a feature of iOS, make it easy

for schools to prepopulate e-mail and password settings and add hyperlinks to materials
or resources. Mobile device management
solutions offer powerful additional features
to manage participants personal devices.

For Further Exploration

Horizon Report: 2012 Higher Education Edition

http://net.educause.edu/ir/library/pdf/
HR2012.pdf

Stanfords

eStudent Initiative
http://med.stanford.edu/estudent

Website

University of California, Irvines iMedEd site

http://www.imeded.uci.edu/

Seton Hill University gives iPads to all students

http://www.setonhill.edu/ipad/

Stanford Anesthesia Informatics and Media Lab

http://aim.stanford.edu/

The EDUCAUSE Learning Initiative (ELI) is where teaching and learning professionals come to learn, lead, collaborate,
and share in the context of an international forum. Members benefit from the expansive emerging technology research
and development that takes place collaboratively across institutions. To learn more about ELI, visit educause.edu/eli.

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