DESCRIPTIVE ARTICLE

Diffusion of Innovations: Smartphones and Wireless

Anatomy Learning Resources
Robert B. Trelease*
Department of Pathology and Laboratory Medicine, UCLA Center for the Health Sciences,
Los Angeles, California

The author has previously reported on principles of diffusion of innovations, the proc-
esses by which new technologies become popularly adopted, specifically in relation to
anatomy and education. In presentations on adopting handheld computers [personal digi-
tal assistants (PDAs)] and personal media players for health sciences education, particular
attention has been directed to the anticipated integration of PDA functions into popular
cellular telephones. However, limited distribution of early ‘‘smartphones’’ (e.g., Palm
Treo and Blackberry) has provided few potential users for anatomical learning resources.
In contrast, iPod media players have been self-adopted by millions of students, and ‘‘pod-
casting’’ has become a popular medium for distributing educational media content. The
recently introduced Apple iPhone has combined smartphone and higher resolution media
player capabilities. The author successfully tested the iPhone and the ‘‘work alike’’ iPod
touch wireless media player with text-based ‘‘flashcard’’ resources, existing PDF educa-
tional documents, 3D clinical imaging data, lecture ‘‘podcasts,’’ and clinical procedure
video. These touch-interfaced, mobile computing devices represent just the first of a new
generation providing practical, scalable wireless Web access with enhanced multimedia
capabilities. With widespread student self-adoption of such new personal technology,
educators can look forward to increasing portability of well-designed, multiplatform ‘‘learn
anywhere’’ resources. Anat Sci Ed 1:233–239, 2008. © 2008 American Association of Anatomists.

Key words: anatomical informatics; diffusion of innovations; handheld computers;

cellular telephones; gross anatomy; medical education

INTRODUCTION daily learning tasks, from lectures and laboratories to

As studied by social and behavioral scientists, diffusion of
innovations (DOI) is the complex process by which new tech-
nologies become incorporated into daily use (Rogers, 2004).
A good example of diffusion from the mid-1990s, familiar to
most anatomists, is the progressive, pervasive adoption of the
personal computer (PC), multimedia, and the World Wide
Web for anatomical informatics and educational use. In most
disciplines, PCs have become essential tools for accomplishing
*Correspondence to: Dr. Robert B. Trelease, Department of
Pathology and Laboratory Medicine, UCLA Center for the Health
Sciences, Los Angeles, CA 90095, USA. E-mail: trelease@ucla.edu
Received 14 August 2008; Revised 21 October 2008; Accepted 10
November 2008.
Published online 3 December 2008 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ase.58
© 2008 American Association of Anatomists
‘‘remote learning.’’
DOI can thus be transformative of group behaviors and
practices in sciences and education, and modern anatomists
can benefit from understanding it and proactively learning
how to apply new evolving technologies. In DOI terms
(Trelease, 2006), conscientious innovators become ‘‘early
adopters’’ of promising new technologies, in order to commu-
nicate their appropriate uses, relative advantages, and other
implementation information needed for adoption by potential
users. This article concerns the diffusion of a new kind of
personal technology for anatomical education.
In the past several years, handheld, ‘‘wearable,’’ or mobile
personal computing devices have become potential comple-
ments to the use of PCs in education. In 2000, for example,
the UCLA School of Medicine implemented a ‘‘personal digi-
tal assistant’’ (PDA) requirement for third- and fourth-year
medical students, to provide learning resources and patient
encounter tracking for clerkship rotations (UCLA Health Sci-
ences, 2008). While supporting these efforts, the author has
explored and reported on the diffusion of PDAs and more
recent personal media players (e.g., the iPod) into anatomy

Anatomical Sciences Education NOVEMBER 2008 Anat Sci Ed 1:233-239 (2008)

and health sciences education (Trelease, 2006). Attention has
been consistently directed to the anticipated integration of
more powerful operating systems and handheld computer
functions into the cellular telephones that most current stu-
dents carry. However, limited self-adoption of such first-gen-
eration ‘‘smartphones’’ (e.g., Palm Treo and Blackberry; Wiki-
pedia, 2008) has provided few potential users for basic health
sciences learning resources. In contrast, with the widespread
popular adoption of the iPod media player by people of all
ages, ‘‘podcasting’’ has become a successful portable medium
for distributing lectures, images, and video-based content to
students and other public users.
With the 2007 introduction of the Apple iPhone smart-
phone and the iPod touch wireless media player, enhanced
touch-screen graphics display capabilities, communications,
and wireless World Wide Web access have been added to the
iPod’s basic media player functions. The purpose of this arti-
cle is to assess the capabilities of these new mobile devices
for displaying anatomical images and for running different
kinds of Web-based educational applications. Special atten-
tion is paid to aspects of DOI that will affect student adop-
tion and create new opportunities for distributing educational
resources for use outside of conventional academic settings.
METHODS AND PROCEDURES
All software development focused on producing learning
resources usable on Windows and Macintosh PCs and mobile
devices, although the specific programs were hosted on Apple
Macintosh computers running OS X 10.41, a version of the
Unix operating system. As described later, the programs used
(or functional equivalents) are available in dominant Win-
dows versions, and so these methods and procedures are not
restricted to one platform.
The iPhone smartphone, although it runs an ‘‘embedded’’
version of the OS X (BSD Unix) operating system, can be
used with Windows or Macintosh PC systems, exchanging
data via direct USB (universal serial bus) connection and
through ‘‘synchronization’’ with Apple iTunes software. Inde-
pendently, iPhone Web connections are made via cellular tele-
phone data network or via wireless ethernet (WiFi) using the
built-in Safari Web browser. The WiFi-enabled iPod touch
can be viewed as an iPhone ‘‘work alike,’’ having almost
identical multimedia display and programming capabilities,
without the cellular telephone functions. The most important
common features include a 320 3 480 pixels (‘‘half-VGA’’),
24-bit color touch screen display, stereo sound output
through earphones, and 8–16 gigabytes of internal storage
(random access memory). Users interact with programs by
touching on-screen buttons, entering text on a displayed key-
board, and employing fingertip gestures to pan and to zoom
images.
Anatomical images were processed with Osirix (Osirix,
2008) and Adobe Photoshop (Adobe Systems Incorporated,
San Jose, CA) for use in Web documents and iPhoto (iPod)
format image libraries. Consistent with ‘‘Web 2.0’’ design
practices supporting multiple platforms (e.g., PC or mobile;
Castro, 2007), information pages were programmed in eX-
tensible Hypertext Markup Language (XHTML) code with
cascading style sheets (CSS) using Adobe DreamWeaver. Pro-
duction versions of all Internet resources were hosted on pub-
lic servers using Apache HTTP Server software. All content
was tested on an 8-GB Apple iPhone and a 16-GB iPod
234
touch, via PC (iTunes) synchronization, cellular telephone
(GMRS-EDGE), institutional and personal (home) Wi-Fi network
connections. Web pages and other multimedia content were also
tested with the iPhone software simulator from the Apple iPhone
Software Development Kit running on a MacBook.
Several types of anatomical education media were
exported or reprogrammed for use on the iPhone. A variety
of anatomy lecture notes in Adobe Acrobat portable docu-
ment format (PDF) were directly loaded and reviewed from
existing course support Web sites. The previously reported
iNatomy limb muscles flashcard resource (Trelease, 2006)
was converted from its original HTML-subset source code
(for the iPod Notes Reader) to XHTML with CSS customized
for the screen dimensions (320 3 480 pixels) of the iPhone
Web browser.
In a prior article in this journal (Trelease and Rosset,
2008), the authors described a method for transforming clini-
cal imaging (DICOM) data into anatomical virtual reality
learning objects for PC use. Several of these CT and MR
datasets were converted into iPhone-compatible image array
data. We then tested how well different anatomical structures
could be displayed, particularly, whether the 3D image arrays
could be used like interactive QuickTime VR movies. Finally,
we tested ‘‘virtual microscope slide’’ use of existing histology
images from an existing Web-based archive.
Existing full-screen digital lecture videos and a commercial
laparoscopic cholecystectomy training video were converted
to iPhone MPEG4 format with QuickTime Professional soft-
ware. The resulting files were imported into an iTunes video
library for synchronization with (loading onto) the iPhone
and iPod touch. Videos were also loaded onto a Web server,
where they could be directly accessed from appropriate
HTML page links.
Finally, two entirely new educational flashcard applica-
tions, specifically formatted for iPhone display and using
touch-screen links, were created with XTHML coding and
JPEG images. These included a set of flashcards for learning
cranial nerve facts, as well a new type of application for
‘‘just-in-time’’ review of anatomical facts for structurally
related disease diagnoses encountered by third- and fourth-
year medical students on their required surgical clerkship
rotations. These applications were accessed via a secured
Web server, as well as directly from iPod touch memory, with
files that had been stored onboard using a secured network
file transfer (SSH) utility.
RESULTS
The author’s existing iNatomy limb muscle ‘‘flashcard’’
resource was readily translated from onboard iPod Notes
Reader ‘‘HTML’’ format to XHTML for Web-based access
(see Fig. 1). On touch activation, hyperlinks on the starting
(index) page jumped directly to successive link menus for
upper and lower extremities, and from the latter to pages for
individual limb compartments. Navigation between higher
level, compartment menus, and muscle information was very
rapid. This new application was tested and openly distributed
on a public Web server (iNatomy Limb Muscles, 2008). Web
page access logs were used to track public downloads.
Volume-mapped head CT image data for virtual reality-
type displays were exported as no-compression JPEG images
by Osirix, then loaded into iPhoto libraries. These libraries
were then included for loading with other images during
Trelease
Figure 1.
Screen capture images of four successive screens of the iNatomy limb muscles flashcard application running on an iPod touch with the Safari Web browser, down-
loaded from a public Web site. Hyperlinks, in blue, are selected by tapping on them with a finger. Pages can be scrolled up or down with a touch-and-slide gesture.
Clockwise from upper left: (1) Starting menu; (2) the selected upper limb menu; (3) the selected flexor compartment menu; (4) the selected pronator teres informa-
tion displayed at the top, with other muscles in the compartment, below. This display is virtually identical to that on an iPhone.

iTunes synchronization. Each set of data was loaded as an
individual Photos library (e.g., head CT1). Individual images
were displayed full screen by the built-in iPhone/touch Photos
software in portrait or landscape viewing format, and the dis-
played anatomical objects would appear to rotate when the
forward and backward display buttons were tapped. Further-
more, structural image captions could be displayed, and indi-
vidual frames could be ‘‘zoomed’’ to higher magnification and
panned using simple finger touch gestures (see Fig. 2). How-
ever, because the iPhone operating system did not provide a

Anatomical Sciences Education NOVEMBER 2008 235

full QuickTime or QuickTime Player environment, ‘‘virtual
anatomy objects’’ could not be smoothly rotated with a fin-
gertip gesture, as they would be moved with a mouse on a
PC using QuickTime VR.
Previously archived microscopic images from a UCLA
medical histology Web site were also easily accessed and
loaded via wireless connection. Individual images could also
be zoomed and panned using simple finger-touch gestures.
Depending on the original graphic resolution of each histol-
ogy file, images could easily be zoomed to magnifications
high enough to display individual pixels, the equivalent of a
few hundred diameters magnification. While the speed of
wireless network loading of Web-based image files was com-
parable to that of a PC, cellular network loading was very
slow and frequently erratic.
Existing MPEG-4 video podcasts of embryology lectures
were easily and rapidly exported as new media files (m4v) for
the higher (480 3 320 pixels) iPhone resolution for iTunes
synchronization (see Fig. 3). On playback, slide graphics and
text as small as 18 points could be read easily from the
iPhone or iPod screen held at normal viewing distances (less
than an arm’s length). Similarly exported instructional video
of laparoscopic cholecystectomy was graphically sharp and
played back smoothly in landscape (horizontal) display mode.
All narrative audio was very clearly heard on playback
through the supplied earphones (earbuds).
Finally, the two new hyperlinked, image-containing, flash-
card-like resources were easy to program with XHTML with
CSS customized for iPhone screen dimensions. Both of these
applications were loaded on secured private Web servers
and successfully tested as part of a continuing development
process.
The first of these, a cranial nerves learning guide, included
a labeled diagram of the nerves on the ventral brainstem and
brain, as well as popular mnemonics and essential functional
information for each nerve (see Fig. 4). As with the previ-
ously discussed Limb Muscles flash cards, menus and individ-
ual hyperlinks provided quick navigation between index and
subject menus, explanatory text and images.
The second learning resource was an entirely new dis-
ease/diagnosis oriented review program for surgical anatomy,
intended for use by upper-division medical students on their
surgical clerkship rotations. This latter program employed
clinically oriented anatomy illustrations with hyperlink
menus and navigation controls, outlines of basic anatomy
for specific clinical diagnoses, problems, or procedures (e.g.,
cecum and appendix for appendectomy). There were discrete
vascular notes for arteries, veins, and lymphatics, and
functional, clinical correlate ‘‘pearls’’ for specific diagnoses
for each structure. A version of the surgical anatomy learning
resources is currently being tested in practice on a secured
server at the David Geffen School of Medicine at UCLA.
DISCUSSION
As an exercise in applied anatomical informatics, this DOI
project demonstrated that text-based anatomical information,
clinical imaging data, histological images, and educational
videos could be easily transferred to and practically used on
the iPhone and iPod touch. These educational multimedia
resources could be directly loaded from a PC to iPhone via
the normal iTunes software synchronization process, or they
could be accessed via wireless connection to Web servers.
236
Although the Safari browser was capable of using standard
PC-formatted HTML and JavaScript-based Web pages, the
best performance was obtained with pages designed specifi-
cally for iPhone screen display dimensions. And although
conventional, PC page-formatted text documents (e.g., Acro-
bat PDF) could also be read on the iPhone by using touch-
based zooming and panning, the most practical readable
designs used flash-card-like ‘‘chunking’’ of text into relatively
small blocks.
The new learning resources described herein were primar-
ily designed for Web-based usage, with XHTML and CSS
coding techniques recommended by Apple for ‘‘program-like’’
Web 2.0 functions (Apple, 2008). These programming con-
ventions are compatible with those recommended for other
mobile devices (PDAs) and cell phones (Castro, 2007), allow-
ing well-designed XHTML Web pages to display appropri-
ately on PCs, as well as on smaller graphics displays with
fewer available fonts. In that regard, the most practical devel-
opment of new learning content for the iPhone and for newer
types of smartphones can take advantage of existing Web
page content and images programmed in XHTML with CSS
style sheets formatted for mobile devices. Sound educational
resources can thus migrate from PCs to smartphones.
Self-contained programs can also be created for the iPhone
and iPod touch with the Objective C language, using the
iPhone Software Development Kit. As this paper was first
being written (July 2008), Apple released version 2.0 of the
iPhone operating system and the first commercially developed
programs, including a free medical imaging viewer and a pro-
prietary set of Netter image anatomy and neuroanatomy
flashcards. While C programs can deliver greater interactivity
and multimedia capabilities, they require greater time and
effort for academic developers than the previously discussed
XHTML applications. Furthermore, such C programs would
not be usable as-is on different manufacturers’ smartphones,
although commercial publishers might develop additional ver-
sions for selected popular devices.
Having to learn to use new technology can provide a bar-
rier or impediment to DOI with new types of learning resour-
ces. Conversely, educational resources developed for smart-
phones can take advantage of the fact that cellular telephones
have become almost universally self-adopted by most post-
secondary students (Salaway and Borrison, 2007; Diamonduras
et al., 2007). Furthermore, most students also own media play-
ers. All these mobile devices are most frequently carried daily
and are integrated with students’ personal activities, providing
great potential for extramural and intramural access to appro-
priately designed educational resources. Convergence of smart-
phone and wireless media player capabilities, as shown by the
iPhone and iPod touch, increases the number of potential stu-
dent users, although discrete media players may decline in
popularity.
The author is not asserting that the iPhone will become a
widely student-owned, universally distributed device available
for education uses. It is, however, reasonable to expect that
student users will begin adopting a variety of manufacturers’
new smartphones with enhanced Web browser and standar-
dized multimedia file capabilities, reducing the need to carry
separate devices for communications and media playback. A
2006 survey showed that U.S. users replace their cell phones
on the average of about 18 months (J.D. Power and Associ-
ates, 2006), and this period may decrease somewhat in the
future. Nokia, Samsung, and LG have recently released their
next generations of competing smartphones with touch
Trelease
Figure 2.
Three different frames from playback of serial images from a volume-mapped CT imaging study, originally configured as a QuickTime ‘‘virtual reality learning
object’’ (Trelease and Rosset, 2008). Left: tapping the left arrow button rotates the apparent head object and pops up structural labels. Middle: a finger spreading
gesture on the touch screen ‘‘zooms’’ the image to a higher magnification. Right: the magnified image is panned with a wiping motion of the fingertip.

Figure 3.
Two types of educational video displayed on an iPhone. Top: screen shot of a slide from a cardiovascular development lecture podcast. Original font sizes greater
than 18 points are easily read on exported PowerPoint slides. Bottom: screen shot of a frame from a converted commercial digital video showing a laparoscopic
cholecystectomy.
Figure 4.
Three frames from a Web-based flashcard application for learning the cranial nerves. Left: the starting menu, showing hyperlinks for individual cranial nerves, a dia-
gram, and popular mnemonics. Middle: a simply labeled color diagram showing the gross connections of the cranial nerves on the ventral brainstem and brain.
Right: example of the ‘‘top’’ information page for the trigeminal nerve, with links to specific course, ganglia, and nuclei subpages. These images were captured from
the iPhone simulator software.
screens and advanced media features, and Google and T-mo-
bile have produced the G1 smartphone, based on the Android
(embedded Linux) operating system. Thus, the ongoing adop-
tion of new, higher performance personal technology can be
expected to equip a new generation of students with
advanced mobile Web and multimedia playback capabilities.
In fact, as this article was being revised, the David Geffen
School of Medicine was considering allowing third- and
fourth-year students to use iPhones in 2009, in compliance
with the previously discussed PDA requirement (UCLA
Health Sciences, 2008).
The author is also not specifically proposing that smart-
phones will become an appropriate, chosen platform for pri-
mary instruction in anatomical sciences at health sciences
schools. However, given that multiple educational media
types can be effectively used on these mobile devices, they
can be readily integrated with existing PC-based learning
environments, such as Web-based course resources. Indeed, a
blended or multimodal approach (in educational psychology
terms) has been promoted for efficient medical education
(Ruiz et al., 2006). In a similar context, Ward and Walker
(2008) have demonstrated that a majority of successful veteri-
nary students use multiple methods to learn anatomy, and
mobile learning resources may thus make a considerable con-
238
tributions to student learning outside the immediate class-
room or laboratory settings. Furthermore, depending on the
educational domain (e.g., community college anatomy
instruction), some institutions may find it quite feasible to
replace conventional lectures with podcasts and other high-
quality digital media that can be distributed to smartphones
and media players.
No specific claims are made here for the educational effi-
cacy of media and other resources distributed on iPhones,
other smartphones, and wireless media players. While some
educators may feel that podcasting is just ‘‘a recent revival of
the moribund art of lecture taping,’’ others have argued that
it enhances the preclinical educational experience (Pilarski
et al, 2008). Indeed, effective use of podcasting and smart-
phone technology will depend on the skills of educational
developers and appropriate integration with other learning
resources within specific instructional programs. However, it
is worth noting that the rapid evolution of computer applica-
tions has lead to widespread adoption of such new technolo-
gies without a priori formal educational assessment. While
this does not obviate the need for assessment of new technol-
ogy, it does indicate that educational innovations can be
widely adopted if they are readily embraced and demanded
by the current ‘‘net generation’’ students (Kennedy et al.,
Trelease
2008). As consumer information technology continues to
evolve, future work should continue to focus on the most
educationally sound ways to implement new learning resour-
ces for students’ personal computing devices.
ACKNOWLEDGMENT
The author thanks Dr. Wojciech Pawlina for his good advice
and support for this work.
NOTE ON CONTRIBUTOR
ROBERT B. TRELEASE, Ph.D., is a professor in the Division
of Integrative Anatomy, Department of Pathology and Labo-
ratory Medicine, as well as associate director of the Instruc-
tional Design and Technology Unit, Dean’s Office, David
Geffen School of Medicine at UCLA, Los Angeles, California.
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