Enhanced capture of healthcare-related harms and injuries in the 11th revision of the International Classification of Diseases (ICD-11).

The World Health Organization (WHO) plans to submit the 11th revision of the International Classification of Diseases (ICD) to the World Health Assembly in 2018. The WHO is working toward a revised classification system that has an enhanced ability to capture health concepts in a manner that reflects current scientific evidence and that is compatible with contemporary information systems. In this paper, we present recommendations made to the WHO by the ICD revision's Quality and Safety Topic Advisory Group (Q&S TAG) for a new conceptual approach to capturing healthcare-related harms and injuries in ICD-coded data. The Q&S TAG has grouped causes of healthcare-related harm and injuries into four categories that relate to the source of the event: (a) medications and substances, (b) procedures, (c) devices and (d) other aspects of care. Under the proposed multiple coding approach, one of these sources of harm must be coded as part of a cluster of three codes to depict, respectively, a healthcare activity as a 'source' of harm, a 'mode or mechanism' of harm and a consequence of the event summarized by these codes (i.e. injury or harm). Use of this framework depends on the implementation of a new and potentially powerful code-clustering mechanism in ICD-11. This new framework for coding healthcare-related harm has great potential to improve the clinical detail of adverse event descriptions, and the overall quality of coded health data.

Essays on pricing of risk and international linkage of Russian stock market

Last two decades have seen a rapid change in the global economic and financial situation; the economic conditions in many small and large underdeveloped countries started to improve and they became recognized as emerging markets. This led to growth in the amounts of global investments in these countries, partly spurred by expectations of higher returns, favorable risk-return opportunities, and better diversification alternatives to global investors. This process, however, has not been without problems and it has emphasized the need for more information on these markets. In particular, the liberalization of financial markets around the world, globalization of trade and companies, recent formation of economic and regional blocks, and the rapid development of underdeveloped countries during the last two decades have brought a major challenge to the financial world and researchers alike. This doctoral dissertation studies one of the largest emerging markets, namely Russia. The motivation why the Russian equity market is worth investigating includes, among other factors, its sheer size, rapid and robust economic growth since the turn of the millennium, future prospect for international investors, and a number of important major financial reforms implemented since the early 1990s. Another interesting feature of the Russian economy, which gives motivation to study Russian market, is Russia’s 1998 financial crisis, considered as one of the worst crisis in recent times, affecting both developed and developing economies. Therefore, special attention has been paid to Russia’s 1998 financial crisis throughout this dissertation. This thesis covers the period from the birth of the modern Russian financial markets to the present day, Special attention is given to the international linkage and the 1998 financial crisis. This study first identifies the risks associated with Russian market and then deals with their pricing issues. Finally some insights about portfolio construction within Russian market are presented. The first research paper of this dissertation considers the linkage of the Russian equity market to the world equity market by examining the international transmission of the Russia’s 1998 financial crisis utilizing the GARCH-BEKK model proposed by Engle and Kroner. Empirical results shows evidence of direct linkage between the Russian equity market and the world market both in regards of returns and volatility. However, the weakness of the linkage suggests that the Russian equity market was only partially integrated into the world market, even though the contagion can be clearly seen during the time of the crisis period. The second and the third paper, co-authored with Mika Vaihekoski, investigate whether global, local and currency risks are priced in the Russian stock market from a US investors’ point of view. Furthermore, the dynamics of these sources of risk are studied, i.e., whether the prices of the global and local risk factors are constant or time-varying over time. We utilize the multivariate GARCH-M framework of De Santis and Gérard (1998). Similar to them we find price of global market risk to be time-varying. Currency risk also found to be priced and highly time varying in the Russian market. Moreover, our results suggest that the Russian market is partially segmented and local risk is also priced in the market. The model also implies that the biggest impact on the US market risk premium is coming from the world risk component whereas the Russian risk premium is on average caused mostly by the local and currency components. The purpose of the fourth paper is to look at the relationship between the stock and the bond market of Russia. The objective is to examine whether the correlations between two classes of assets are time varying by using multivariate conditional volatility models. The Constant Conditional Correlation model by Bollerslev (1990), the Dynamic Conditional Correlation model by Engle (2002), and an asymmetric version of the Dynamic Conditional Correlation model by Cappiello et al. (2006) are used in the analysis. The empirical results do not support the assumption of constant conditional correlation and there was clear evidence of time varying correlations between the Russian stocks and bond market and both asset markets exhibit positive asymmetries. The implications of the results in this dissertation are useful for both companies and international investors who are interested in investing in Russia. Our results give useful insights to those involved in minimising or managing financial risk exposures, such as, portfolio managers, international investors, risk analysts and financial researchers. When portfolio managers aim to optimize the risk-return relationship, the results indicate that at least in the case of Russia, one should account for the local market as well as currency risk when calculating the key inputs for the optimization. In addition, the pricing of exchange rate risk implies that exchange rate exposure is partly non-diversifiable and investors are compensated for bearing the risk. Likewise, international transmission of stock market volatility can profoundly influence corporate capital budgeting decisions, investors’ investment decisions, and other business cycle variables. Finally, the weak integration of the Russian market and low correlations between Russian stock and bond market offers good opportunities to the international investors to diversify their portfolios.

The state of research and development in Australia: implications for future development

The scale of research and development (R&D), and other technological activities, and the way in which the available resources are managed and organized at the enterprise and national level contribute to the rate of technological change in a country. A well organized national innovation system can be a powerful engine of progress, whereas a lack of interaction between institutions results in the slowing down of technological change, thereby diminishing its contribution to economic growth and welfare. The research object of this thesis is Australia’s national innovation system and the state of R&D in Australia. In order to establish an overall picture of the situation and to be able to make recommendations for future development, the general level of R&D activity and the main performers and funders of R&D within the system are analyzed. The framework policies supporting R&D and prevalent dynamics between different actors and sectors are of specific interest of the research. The findings reveal that the Australian culture is not a culture of research and innovation and that the main challenge is building a coherent system with strong domestic and international linkages.

Health and reproduction of red mullet, Mullus barbatus, in the western Mediterranean Sea

The reproductive and general health of exploited fish stocks is an essential element of sustainable and profitable fisheries. The main purpose of this study was to assess the relationships between reproduction and two important parameters of fish health (parasitism and energy reserves) in female specimens of red mullet, Mullus barbatus, from the western Mediterranean Sea. We present new data for this species on (i) the prevalence and intensity of infection by metazoan parasites; (ii) the total lipid content in muscle and gonads as a measure of condition and (iii) fecundity and egg quality as a measure of their reproductive capacity. The results show that M. barbatus is a batch spawner with an income breeding strategy, an asynchronous development of oocytes and indeterminate fecundity. The results also indicate that the three most abundant and prevalent parasites significantly affect the condition and reproduction of M. barbatus. Specifically, the digenean, Opecoeloides furcatus, causes a reduction in the female"s energy reserves, while the nematodes, Hysterothylacium fabri and H. aduncum, produce a rise in egg production but impair egg quality. These implications of the relationships between parasitism, fish health and fish reproduction should be taken into consideration in the assessment and management of exploited species

Etiology and epidemiology of Pythium root rot in hydroponic crops: current knowledge and perspectives

The etiology and epidemiology of Pythium root rot in hydroponically-grown crops are reviewed with emphasis on knowledge and concepts considered important for managing the disease in commercial greenhouses. Pythium root rot continually threatens the productivity of numerous kinds of crops in hydroponic systems around the world including cucumber, tomato, sweet pepper, spinach, lettuce, nasturtium, arugula, rose, and chrysanthemum. Principal causal agents include Pythium aphanidermatum, Pythium dissotocum, members of Pythium group F, and Pythium ultimum var. ultimum. Perspectives are given of sources of initial inoculum of Pythium spp. in hydroponic systems, of infection and colonization of roots by the pathogens, symptom development and inoculum production in host roots, and inoculum dispersal in nutrient solutions. Recent findings that a specific elicitor produced by P. aphanidermatum may trigger necrosis (browning) of the roots and the transition from biotrophic to necrotrophic infection are considered. Effects on root rot epidemics of host factors (disease susceptibility, phenological growth stage, root exudates and phenolic substances), the root environment (rooting media, concentrations of dissolved oxygen and phenolic substances in the nutrient solution, microbial communities and temperature) and human interferences (cropping practices and control measures) are reviewed. Recent findings on predisposition of roots to Pythium attack by environmental stress factors are highlighted. The commonly minor impact on epidemics of measures to disinfest nutrient solution as it recirculates outside the crop is contrasted with the impact of treatments that suppress Pythium in the roots and root zone of the crop. New discoveries that infection of roots by P. aphanidermatum markedly slows the increase in leaf area and whole-plant carbon gain without significant effect on the efficiency of photosynthesis per unit area of leaf are noted. The platform of knowledge and understanding of the etiology and epidemiology of root rot, and its effects on the physiology of the whole plant, are discussed in relation to new research directions and development of better practices to manage the disease in hydroponic crops. Focus is on methods and technologies for tracking Pythium and root rot, and on developing, integrating, and optimizing treatments to suppress the pathogen in the root zone and progress of root rot.

Organizational mechanisms and conditions of individuals for knowledge sharing in post-acquisition integration

The challenges of knowledge sharing after cross-border acquisitions are widely recognised. The study took a new view to the subject by applying a two-level framework provided by the knowledge governance approach. The purpose of the study was to investigate the effects of organizational mechanisms on the conditions of individuals for knowledge sharing in post-acquisition integration context. Qualitative research methods were used in this case study. Individual interviews were performed within an international firm after a recent cross-border acquisition. The results showed that integrators, the rotation of the personnel from the acquiring firm and visits and meetings enhance the conditions at the individual level for knowledge sharing after the acquisition. Respectively, strategic change, matrix structure and foreign HRM practices challenge the conditions at the individual level for knowledge sharing in the early post-acquisition integration phase. The findings are supported by the prior research on knowledge management in acquisitions. In particular, the study enlightens how organizational level actions influence the conditions of individuals for knowledge sharing. The study suggests that organizations should adjust organizational mechanisms to support the conditions of individuals, in order to promote knowledge sharing in the early phase of the integration.

Internationalization of small and medium-sized enterprises and impact of institutions on international entrepreneurship in emerging economies: the case of Russia

The doctoral study presents a comprehensive analysis of the impact of the institutional environment on the internationalization-based growth strategic choices of small and mediumsized enterprises (SMEs) in emerging economies. In responding to the calls for more research on institutions and international entrepreneurship, this dissertation extends the linkages between the two to the context of emerging economies. The study presents a comprehensive analysis of institutional challenges and their impact on the internationalization of SMEs in emerging economies, particularly in Russia. The research contributes to the adoption of the institution-based view in international entrepreneurship. The dissertation is presented through five research papers. Based on primary and secondary data, the study categorizes the possible sources of institutional influences on internationalization and empirically tests their impact by applying a method triangulation research design. The result of the conducted research is a proposed theoretical model of the institutional impact on the internationalization of SMEs in emerging economies. The model is specifically focused on the growth stage of the entrepreneurial process and considers only its internationalization facet. The research identifies and provides empirical support for the existence of a positive influence of a transparent and supportive regulatory environment, an institutionalized pool of general business knowledge, and collectivistic value orientation on the proclivity of SMEs to internationalize. A level of appreciation of entrepreneurial initiatives in home country and a greater positive institutional gap provide a positive impact on the international performance of SMEs. The research provides contextualized knowledge of the institutional impact on the internationalization of SMEs in Russia. The obtained results present theoretical value in terms of showing how the environmental conditions effect the entrepreneurial internationalization-based growth in emerging economies, providing the methodological insights into the measurement of the institutional effects, and empirically contextualizing the linkage between institutions and internationalization in the Russian business environment. The research also provides value for the business and policy making stakeholders by identifying ways of utilizing the conditions in the external institutional environment.

Exploring the Impact of Mental Health Education on Adolescents’ Perceptions About Mental Health and Mental Illness. Improving community health

The purpose of this study was to explore perceptions of mental health and mental illness as well as the perceptions towards people with mental illness among adolescents, and further to examine the impact that a mental health educational intervention has on these perceptions. The review of the literature revealed a small number of publications on mental health educational interventions among adolescents which aimed at increasing knowledge and affecting attitudes towards mental illness with positive results. Fifty nine pupils (13-16 years old) from two randomly selected secondary schools around Athens, Greece, participated in this study. These schools were randomly selected as the experimental group (n=28) which participated in the mental health educational intervention, and the comparison group (n=31), which did not receive any intervention. Data were collected using individual interviews with open-ended questions, drawings and a questionnaire (Opinions about Mental Illness - O.M.I. scale). The participants described mental health and mental illness before and after the intervention, using the same expressions for both terms. Among the experimental group, changes were seen within the same expressions after the intervention, although some descriptions did not change. However, after the intervention, participants in the experimental group did not confuse mental health with mental illness and they also included specific diagnostic examples or stated that mental illness can happen to anyone and it can be managed. Moreover, they expressed positive attitudes towards mentally ill people, which they had not done before the intervention. The analysis of the drawings before the intervention showed that mentally ill persons were drawn similarly in both groups. After the intervention, the drawings of the participants in the experimental group changed, including fewer negative elements, while the drawings of the comparison group did not change. Regarding the results on the O.M.I. scale, it was found that the score on the Social Discrimination factor significantly decreased from pre-test to post-test in both study groups. The experimental group had higher levels on Social Discrimination at pre-test compared to the comparison group, but this difference was not significant at post-test. No significant changes were found for the Social Restriction factor for either study group. Scores of the Social Care and Social Integration factors increased significantly only in the intervention group. Overall, the results of this study indicate that the mental health educational intervention had a positive impact on the perceptions about mental health and mental illness among adolescents, and (mental) health professionals can use these results for implementing similar interventions and further research.

Quality of radiotherapy care by development of e-feedback knowledge

The aim of this three phase study was to develop quality of radiotherapy care by the e-Feedback knowledge of radiotherapy -intervention (e-Re-Know). In Phase I, the purpose was to describe the quality of radiotherapy care and its deficits experienced by cancer patients. Based on the deficits in patient education in Phase II, the purpose was to describe cancer patients’ e-knowledge expectations in radiotherapy. In Phase III, the purpose was to develop and evaluate the outcomes of the e-Re-Know among breast cancer patients. The ultimate aim was to develop radiotherapy care to support patients’ empowerment with patient e-education. In Phase I (2004-2005), the descriptive design was used, and 134 radiotherapy patients evaluated their experiences by Good Nursing Care Scale for Patients (GNCS-P) in the middle of RT period. In Phase II (2006-2008), the descriptive longitudinal design was used and 100 radiotherapy patients’ e-knowledge expectations of RT were evaluated using open-ended questionnaire developed for this study before commencing first RT, in the middle of the treatment, and concluding RT period. In Phase III, firstly (2009-2010), the e-Re-Know intervention, i.e. knowledge test and feedback, was developed in terms of empowering knowledge and implemented with e-feedback approach based on literature and expert reviews. Secondly (2011-2014), the randomized controlled study was used to evaluate the e-Re-Know. Breast cancer patients randomized to either the intervention group (n=65) receiving the e-Re-Know by e-mail before commencing first RT and standard education or the control group (n=63) receiving standard education. The data were collected before commencing first RT, concluding last RT and 3 months after last RT using RT Knowledge Test, Spielberger’s State Trait Inventory (STAI) and Functional Assessment of Cancer Therapy - Breast (FACT-B) –instruments. Data were analyzed using statistical methods and content analysis. The study showed radiotherapy patients experienced quality of care high. However, there were deficits in patient education. Furthermore, radiotherapy patients’ multidimensional e-knowledge expectations through Internet covered mainly bio-physiological and functional knowledge. Thus, the e-Re-Know was developed and evaluated. The study showed when breast cancer patients’ carried out the e-Re-Know their knowledge of side effects self-care was significantly increased and quality of life (QOL) significantly improved in line with decrease in anxiety from time before radiotherapy period to three months after. In addition, the e-Re-Know has potential to have positive effects on anxiety and QOL, regardless of patient characteristics or knowledge level. The results support the theory of empowering patient education suggesting that empowerment can be supported by confirming patients’ understanding of own knowledge level. In summary, the e-Feedback knowledge of radiotherapy (e-Re-Know) intervention can be recommended in development of quality of radiotherapy care experienced by breast cancer patients. Further research is needed to assess and develop patient-centred quality of care by patient education among cancer patients.

Application and development of numerical methods for the modelling of innovative gas cooled fission reactors

Innovative gas cooled reactors, such as the pebble bed reactor (PBR) and the gas cooled fast reactor (GFR) offer higher efficiency and new application areas for nuclear energy. Numerical methods were applied and developed to analyse the specific features of these reactor types with fully three dimensional calculation models. In the first part of this thesis, discrete element method (DEM) was used for a physically realistic modelling of the packing of fuel pebbles in PBR geometries and methods were developed for utilising the DEM results in subsequent reactor physics and thermal-hydraulics calculations. In the second part, the flow and heat transfer for a single gas cooled fuel rod of a GFR were investigated with computational fluid dynamics (CFD) methods. An in-house DEM implementation was validated and used for packing simulations, in which the effect of several parameters on the resulting average packing density was investigated. The restitution coefficient was found out to have the most significant effect. The results can be utilised in further work to obtain a pebble bed with a specific packing density. The packing structures of selected pebble beds were also analysed in detail and local variations in the packing density were observed, which should be taken into account especially in the reactor core thermal-hydraulic analyses. Two open source DEM codes were used to produce stochastic pebble bed configurations to add realism and improve the accuracy of criticality calculations performed with the Monte Carlo reactor physics code Serpent. Russian ASTRA criticality experiments were calculated. Pebble beds corresponding to the experimental specifications within measurement uncertainties were produced in DEM simulations and successfully exported into the subsequent reactor physics analysis. With the developed approach, two typical issues in Monte Carlo reactor physics calculations of pebble bed geometries were avoided. A novel method was developed and implemented as a MATLAB code to calculate porosities in the cells of a CFD calculation mesh constructed over a pebble bed obtained from DEM simulations. The code was further developed to distribute power and temperature data accurately between discrete based reactor physics and continuum based thermal-hydraulics models to enable coupled reactor core calculations. The developed method was also found useful for analysing sphere packings in general. CFD calculations were performed to investigate the pressure losses and heat transfer in three dimensional air cooled smooth and rib roughened rod geometries, housed inside a hexagonal flow channel representing a sub-channel of a single fuel rod of a GFR. The CFD geometry represented the test section of the L-STAR experimental facility at Karlsruhe Institute of Technology and the calculation results were compared to the corresponding experimental results. Knowledge was gained of the adequacy of various turbulence models and of the modelling requirements and issues related to the specific application. The obtained pressure loss results were in a relatively good agreement with the experimental data. Heat transfer in the smooth rod geometry was somewhat under predicted, which can partly be explained by unaccounted heat losses and uncertainties. In the rib roughened geometry heat transfer was severely under predicted by the used realisable k − epsilon turbulence model. An additional calculation with a v2 − f turbulence model showed significant improvement in the heat transfer results, which is most likely due to the better performance of the model in separated flow problems. Further investigations are suggested before using CFD to make conclusions of the heat transfer performance of rib roughened GFR fuel rod geometries. It is suggested that the viewpoints of numerical modelling are included in the planning of experiments to ease the challenging model construction and simulations and to avoid introducing additional sources of uncertainties. To facilitate the use of advanced calculation approaches, multi-physical aspects in experiments should also be considered and documented in a reasonable detail.

Highlights of the 3rd International Conference on High Pressure Bioscience and Biotechnology

The 3rd International Conference on High Pressure Bioscience and Biotechnology was held in the city of Rio de Janeiro from September 27 to September 30, 2004. The meeting, promoted by the International Association of High Pressure Bioscience and Biotechnology (IAHPBB), congregated top scientists and researchers from all over the world. In common, they shared the use of hydrostatic pressure for research, technical development, or industrial applications. The meeting consisted of invited lectures, contributed papers and a well-attended poster session. Very exciting discussions were held inside and outside the sessions, and the goals of discussing state-of-the-art data and establishing working collaborations and co-operations were fully attained.

Challenges in the research and development of new human vaccines

The field of vaccinology was born from the observations by the fathers of vaccination, Edward Jenner and Louis Pasteur, that a permanent, positive change in the way our bodies respond to life-threatening infectious diseases can be obtained by specific challenge with the inactivated infectious agent performed in a controlled manner, avoiding the development of clinical disease upon exposure to the virulent pathogen. Many of the vaccines still in use today were developed on an empirical basis, essentially following the paradigm established by Pasteur, “isolate, inactivate, and inject” the disease-causing microorganism, and are capable of eliciting uniform, long-term immune memory responses that constitute the key to their proven efficacy. However, vaccines for pathogens considered as priority targets of public health concern are still lacking. The literature tends to focus more often on vaccine research problems associated with specific pathogens, but it is increasingly clear that there are common bottlenecks in vaccine research, which need to be solved in order to advance the development of the field as a whole. As part of a group of articles, the objective of the present report is to pinpoint these bottlenecks, exploring the literature for common problems and solutions in vaccine research applied to different situations. Our goal is to stimulate brainstorming among specialists of different fields related to vaccine research and development. Here, we briefly summarize the topics we intend to deal with in this discussion.

Knowledge governance, innovation and development

This paper aims to be a very preliminary effort to contribute to a better understanding of the interaction among innovation, competition and intellectual property policies from an evolutionary-developmental perspective. As such, it seeks to build a more coherent framework within which the discussions of both institution building and policy design for development can proceed. In order to accomplish that, the paper introduces the concept of "Knowledge Governance" as an alternative analytical and policy-oriented approach, and suggests that from a public policy/public interest perspective, and within an evolutionary framework, it is a better way to address the problems concerning the production, appropriability and diffusion of knowledge. In doing so, it also intends contribute to broaden the ongoing discussions on the "New Developmentalism".

Development and Effect Analysis of the Asteri Consultative Auditing Process - Safety and Security Management in Educational Institutions

The Finnish legislation requires for a safe and secure learning environment. However, the comprehensive, risk based safety and security management (SSM) and the management commitment in the implementation and development of the SSM are not mentioned in the legislation. Multiple institutions, operators and researchers have studied and developed safety and security in educational institutions over the past decade. Typically the approach has been fragmented and without bringing up the importance of the comprehensive SSM. The development needs of the safety and security operations in universities have been studied. However, in universities of applied sciences (UASs) and in elementary schools (ESs), the performance level, strengths and weaknesses of the comprehensive SSM have not been studied. The objective of this study was to develop the comprehensive, risk based SSM of educational institutions by developing the new Asteri consultative auditing process and study its effects on auditees. Furthermore, the performance level in the comprehensive SSM in UASs and ESs were studied using Asteri and the TUTOR model developed by the Keski-Uusimaa Department for Rescue Services. In addition, strengths, development needs and differences were identified. In total, 76 educational institutions were audited between the years 2011 and 2014. The study is based on logical empiricism, and an observational applied research design was used. Auditing, observation and an electronic survey were used for data collection. Statistical analysis was used to analyze the collected information. In addition, thematic analysis was used to analyze the development areas of the organizations mentioned by the respondents in the survey. As one of the main contributions, this research presents the new Asteri consultative auditing process. Organizations with low performance levels on the audited subject benefit the most from the Asteri consultative auditing process. Asteri may be usable in many different types of audits, not only in SSM audits. As a new result, this study provides new knowledge on attitudes related to auditing. According to the research findings, auditing may generate negative attitudes and the auditor should take them into account when planning and preparing for audits. Negative attitudes can be compensated by producing added value, objectivity and positivity for the audit and, thus, improve the positive effects of auditing on knowledge and skills. Moreover, as the results of this study shows, auditing safety and security issues do not increase feelings of insecurity, but rather increase feelings of safety and security when using the new Asteri consultative auditing process with the TUTOR model. The results showed that the SSM in the audited UASs was statistically significantly more advanced than that in the audited ESs. However, there is still room for improvement in the ESs and the UASs as the approach to the SSM was fragmented. It can be assumed that the majority of Finnish UASs and ESs do not likely meet the basic level of the comprehensive, risk based the SSM.

Introducing e-learning in a large multisite academic health sciences centre: a case study of e-curriculum planning and educator support /

This qualitative study investigated how a team of 7 hospital educators collaborated to develop e-curriculum units to pilot for a newly acquired learning -r management system at a large, multisite academic health sciences centre. A case study approach was used to examine how the e-Curriculum Team was structured, how the educators worked together to develop strategies to better utilize e-leaming in their ovwi practice, what e-curriculum they chose to develop, and how they determined their priorities for e-curriculum development. It also inquired into how they planned to involve other educators in using e-leaming. One set of semistructured interviews with the 6 hospital educators involved in the project, as well as minutes of team meetings and the researcher's journal, were analyzed (the researcher was also a hospital educator on the team). Project management structure, educator support, and organizational pressures on the implementation project feature prominently in the case study. This study suggests that implementation of e-leaming will be more successful if (a) educators involved in the development of e-leaming curriculum are supported in their role as change agents, (b) the pain of vmleaming current educational practice is considered, (c) the limitations of the software being implemented are recognized, (d) time is spent leaming about best practice, and (e) the project is protected as much as possible from organizational pressures and distractions.