Clinical research outcomes depend on the correct definition of the research protocol, the data collection strategy, and the data management plan. Furthermore, researchers often need to work within challenging contexts, as is the case in tuberculosis services, where human and technological resources for research may be scarce. Electronic Data Capture Systems mitigate such risks and enable a reliable environment to conduct health research and promote result dissemination and data reusability. The proposed solution is based on needs pinpointed by researchers, considering the need for an accommodating solution to conduct research in low-resource environments. The REDbox framework was developed to facilitate data collection, management, sharing, and availability in tuberculosis research and improve the user experience through user-friendly, web-based tools. REDbox combines elements of the REDCap and KoBoToolbox electronic data capture systems and semantics to deliver new valuable tools that meet the needs of tuberculosis researchers in Brazil. The framework was implemented in five cross-institutional, nationwide projects to evaluate the users' perceptions of the system's usefulness and the information and user experience. Seventeen responses (representing 40% of active users) to an anonymous survey distributed to active users indicated that REDbox was perceived to be helpful for the particular audience of researchers and health professionals. The relevance of this article lies in the innovative approach to supporting tuberculosis research by combining existing technologies and tailoring supporting features. The lack of quality data is sometimes noted during or after the collection phase. In order to avoid this, it is essential to implement a reliable data capture system, in addition to employing a trained data collector2. These elements drive the quality and reliability of the collected data that will be used to analyze the outcomes of a given study.Additionally, the success of clinical research directly depends on the correct definition of the research protocol, the data collection strategy, and the data management plan3.Adopting new methods, tools, and data sources has changed how research is conducted. However, new challenges have arisen, demanding innovative approaches to collecting, managing, and publishing data. Well-managed data are easier to use and analyze to confirm a research hypothesis. Also, the reuse of data in further studies is enhanced. In other words, it stimulates research collaboration and maximizes funders' investment4 and should offer improved data integrity, cost savings, and a shorter time to study database closure5. They may help researchers comply with medical regulations and enhance data quality and researchers' management capability6. Preferably, EDC systems should also be interoperable so they can communicate with other systems and promote seamless data exchange and integration7.Electronic Data Capture (EDC) systems are valuable tools for clinical trials and research to capture data8 and KoBoToolbox9 are two well-known EDC systems. The first one presents a better approach to the whole research life cycle but has significant disadvantages, such as usability issues and the inability to working offline without additional software. The second one delivers a user-friendly interface and natively works offline through a mobile browser but has limited features for data management.Research Electronic Data Capture (REDCap)Moreover, in health research, researchers must work in different environments, ranging from facilities with high-tech devices to those with limited access to resources, such as poor or no internet connection or lack of reliable electrical power.10, the resources for research may be lacking, and the costs of using an EDC could be a limitation. The scenario is aggravated by the fact that Brazil is among the top 30 countries with the highest TB burden11. These aspects stand out as barriers to collecting data in TB research. Therefore, making data available for further data-driven studies is crucial to underpinning the development of new evidence-based decision-making tools.In the case of tuberculosis (TB), an infectious and neglected disease12. Thus, semantic interoperability is a critical consideration in information system design13. It is achieved when one system can understand the context and meaning of the information provided by another system14.Integrating information into more extensive systems is hampered by data formats and structural heterogeneity. Data must be correctly described in order for it to be beneficial15. It may enable semantic interoperability, allowing systems to interpret the data in accordance with its formal definition16. In this sense, data can be shared accurately and reliably to enhance communication among computerized systems. This capability is especially desirable in health information systems (HIS) due to the heterogeneity of the medical language and health-related concepts14.Meaning can be imparted to data by using ontologies or other semantic standards, i.e., well-defined vocabularies that allow a precise and machine-readable description of domain-specific knowledge17. An ontology comprises several properties, each describing a specific piece of data in the domain being represented18. Besides ontologies, simple standards such as the Humanitarian Exchange Language (HXL) help speed up data processing and create interoperability across data sources. HXL is a project by the United Nations Office for the Coordination of Humanitarian Affairs to coordinate disaster response using semantic web technologies. It uses simple marking through hashtags and aims to contribute to automating processes to improve information flow to decision-makers19.Ontologies are essential in semantic alignment for data integration, information exchange, and semantic interoperability20.In the case of health research, semantic annotation can help describe the data that is being collected. It can be helpful to extract and link different research datasets described using the same vocabulary. Usually, each study consists of several collection instruments, totaling hundreds of fields to fill during the research process. Manual annotation is a valid choice for semantic annotation, but automated approaches are preferable8 and KoBoToolbox9 systems. The authors of this manuscript developed REDbox to enhance research data collection and management in TB services, as well as in similar low-resource research environments in Brazil while providing a better user experience.This manuscript presents REDbox, a comprehensive framework based on the REDCapAdditionally, REDbox promotes the semantic interoperability of research data. Relying on ontologies and HXL to perform semantic annotations, the objective is to automate the design of an instrument based on a given ontology and the generation of ontologies derived from the instrument's schema, as well as to increase the availability of data for further data-driven TB research.In this research, the authors used no clinical data nor private or public databases to conceive and develop REDbox. All methods were carried out following relevant guidelines and regulations. Therefore, no ethical approval was necessary. This section details the scientific method and the essential technological tools upon which this work is based.21. Considering that the research has a practical component in addition to its theoretical development, action research appears to be a good approach.The basis for this work is action research. It is a suitable methodology because it simultaneously assists practical problem-solving, expands scientific knowledge, and enhances the respective actors' competencies23. The research started with identifying the research goal: a framework to support research in the challenging conditions of TB services in Brazil. The first step, ideation, provided a starting point. After conducting a literature review and identifying existing frameworks and tools, it was possible to identify challenges and unresolved issues. It was then possible to evaluate the research questions and refine them based on prior research. A thorough reflection on the problems and possible solutions through an iterative process involving researchers in the field pinpointed vital issues and ways to tackle them. Concretization of solutions involved cycles of analysis, reflection, and feedback.Action research is an interactive inquiry process that balances problem-solving actions implemented in a collaborative context with data-driven collaborative analysis or research to understand underlying causes, enabling predictions about future personal and organizational changeIn this sense, REDbox modules were developed by analyzing the primary needs reported by researchers and research teams with considerable experience in TB. The authors participated in several interactions with independent teams to build the framework based on the REDCap and KoBoToolbox tools, which were identified as valuable assets in scientific research. With that in mind, REDbox was developed to fill in the gaps left by these tools and allow researchers to work seamlessly with these platforms.Therefore, this research comprises steps to adequately identify the challenges and open issues regarding the computational tools available for data collection, management, and sharing in low-resource environments. Considering the theme's relevance, the research questions were defined to guide the solution proposal. Finally, the validation phase was performed through a field test covering user training and satisfaction analysis. Figure The primary needs were analyzed in the field through an iterative and interactive process, as shown in Table 24. Data sharing requires functional and semantic interoperability capabilities to properly communicate and understand the data26.Some obstacles make it difficult to make data available, such as using non-standardized vocabularies/terminologies, using legacy systems, and the enormous bureaucracy involved in accessing health data. Although complex, sharing health data can enhance research activities and increase a health service's clinical and operational effectivenessTherefore, the need for an accommodating option to conduct research and promote data sharing in TB services led to the conceptualization of the open-source solution proposed in this work. There was none found in the literature, and after rounds of discussions with researchers, developing a module-based and customized software to overcome existing technological barriers in TB services was defined as the main challenge to overcome.“Would the development of a tool for collecting and managing research data be useful for researchers in TB services and similar low-resource environments?”“What can be done to promote data interoperability and improve the availability of tuberculosis data for researchers?”Therefore, the following research questions were defined:Improve the collection and analysis of research data during the whole study period;Facilitate the management of research events and data;Increase the user experience by combining positive aspects of existing solutions;Increase the security of research data;Remove technological barriers by delivering an approach that works on any device and without an internet connection;Remove cultural barriers, such as the lack of confidence of researchers to drop paper-based methods;Promote semantic interoperability for data reuse and record linkage.The solution is relevant because it may:The solution has research teams, research centers, and study participants as stakeholders. Targeting their needs and identified challenges  was used .REDCap is a web-based, metadata-driven software built in 2004 by a team at Vanderbilt University to enable classical and translational clinical research, basic science research, and general surveys, providing researchers with a tool for the design and development of electronic data capture tools9. KoBoToolbox is powered by the Enketo open-source project29 and offers online and offline functionality and is accessible from any modern browser thanks to HTML5 features. The software relies on the XLSForm standard, which simplifies the authoring of forms in spreadsheets in a human-readable format30. A visual and intuitive form builder is available, or forms can be imported as XLS files.KoBoToolbox is a free, open-source suite of tools for data collection and elemental analysis developed by the Harvard Humanitarian Initiative. It was initially built for use in challenging environments in developing countriesThe scientific community widely uses the REDCap system to collect and manage research data, allowing researchers to conduct their studies independently. However, the software may present some usability issues during data collection, such as a polluted graphical interface, gradual performance degradation, and the lack of offline operation without depending on a mobile application.Although it presents basic functionalities, the KoBoToolbox delivers modern styles and allows users to work offline directly from the web browser. Therefore, the software may be an essential component in mitigating the usability issues of REDCap.27. This annotation can be a property of an ontology or an HXL hashtag, depending on the user's preference.To better represent collected data, fields in research forms can be annotated with semantic vocabularies. REDCap offers the possibility to include annotations for each field, which will not be displayed on the form or survey but will be available to the designer and in data exports to help understand the dataKoBoToolbox natively supports the use of HXL. When authoring an XLSForm, the user must insert one extra column in the spreadsheet and fill it with HXL hashtags identifying the type of information in each column. The form builder also provides an intuitive way to relate a hashtag to an instrument's field.31 and is composed of five modules, which are as follows: (i) a metadata database and an Admin System; (ii) a Form Converter; (iii) an extract-transform-load (ETL) processor; (iv) a Data Quality Module; (v) and the Ontology Services. Figure The framework was developed using the PHP v7.4 scripting language32 and JavaScript33 programming languages to efficiently manage the mandatory metadata through create-read-update-delete (CRUD) operations. Figure The web-based Admin System was developed in C#redcap_project, the main table that stores descriptive information and REDCap's Application Programming Interface (API) credentials. Then, each project's instrument must be registered in redcap_forms. The form_metadata stores semantic mapping for the instrument's fields. Additionally, the Data Quality Module relies on the following tables in the database: redcap_validation_types, redcap_validation_rules, redcap_validation_issues, redcap_visits, redcap_visits_config, redcap_alerts, and redcap_alerts_log.In general, an entry must be created in Since instruments are built using specific standards in each software, a converter is desirable, so the designer does not have to create the exact form twice. This module allows forms in REDCap to be automatically created through ontological derivation or by converting a form designed to the XLSForm standard, as described below.To initiate the process, the user must upload the spreadsheet (.xls) or the ontology (.owl) file, fill in the form name, and choose between generating a .zip file, manually uploading it into REDCap, or automatically importing the form through the API. In the second option, the API token and URL must be provided. Figure Deriving from ontologies. Each property of a given ontology can be converted to fields in forms. The name and type of a field are obtained from the name of the property and the associated type (text is the default type). Minimum and maximum values defined as restrictions on properties are also converted.Converting from XLSForms. The converter supports all common field types, such as text, date, date and time, time, integer, decimal, calculation, single selection, multiple selection, files, and notes. These fields, including the variable name and values assigned to options in single and multiple selections will be converted as-is so that instruments on both systems will have a matching structure. Skip logic defined on KoBoToolbox is translated to REDCap branching logic and validation rules.checkbox_". This convention is needed to ensure the correct identification of a multiple-selection question structure during data transfer from KoBoToolbox to REDCap.In the designing process, there is a particularity related to multiple-selection questions (checkboxes). This type of question must have the field's name starting with "Before starting the conversion process, the converter module will pre-check the naming convention. If any inconsistency is detected, the conversion will fail, and the user will be informed of the error.After converting the instrument and transmitting it to REDCap, KoBoToolbox native REST Services must be enabled in the form settings to instantly submit collected data to the ETL processor through a POST request. The processor URL and basic HTTP authentication credentials must be provided.redcap_projects) and to verify if it is the first form in the project (from redcap_forms). If it is, a request is sent to the REDCap API to generate a new record ID, which means it is a new participant in a research project. Otherwise, the record ID will be searched in the log of collected data based on the participant identifier. Then, a request is sent to the REDCap API to import the data.The Processor receives the data collected in KoBoToolbox as a JSON object, parsed to remove unnecessary elements unrelated to the data of interest. After verifying the authentication credentials, the metadata is queried to obtain the URL and the token of the REDCap API , verifying the duplicity of records, and the instant lock of the saved record (to avoid changes in the data) are possible extra actions. These are valuable features that facilitate the management of research data.Once the data is in the REDCap database, changes in records are monitored through the Data Entry Trigger module, which can detect any changes. When it occurs, the Processor exports the edited data from REDCap and logs it into the relational database.34.Data management is a continuous process and represents a critical phase in clinical research due to its importance in generating high-quality and reliable data for statistical analysis, which must meet the protocol-specified parameters and adhere to research protocol requirementsThe management activities must occur in parallel with the data collection. The data manager usually carries out a data validation process, which includes the verification of the consistency, completeness, and accuracy of collected data. This is expected to prevent data loss and increase quality.In health research, most data are acquired during participant visits. Therefore, keeping track of the schedule of visits and their status  is essential for achieving all milestones.However, all of these tasks are time-consuming because they demand the careful inspection of a significant amount of data. The REDCap software natively offers valuable tools to help data managers and researchers. As examples, the Resolution Workflow and Scheduling features allow the opening of queries to request the verification of the collected data and assist in scheduling expected visits for participants during the study , respectively.The Data Quality Module is composed of six submodules that complement the functionalities offered by REDCap, focusing on the reduction of the workload for data managers and researchers, namely: Data Validation Rules, Events/Visits Calendar, Alert System, Instruments Validation, Data Management Plan Creator, and User Support.First, an automatic rule-based validation procedure searches for inconsistencies through each field in all instruments. Rules must be pre-defined in the form of metadata and represent the format or range of values expected for a given field. The procedure runs several times a day, at the same time, to check for new issues and verify the resolution of previously identified ones. When an issue is detected, a query is opened in the Resolution Workflow (in REDCap), and the data collector is alerted by email. Figure The Events/Visits Calendar is a panel that visualizes all upcoming participants' visits. Each row in the panel is a participant, and each column is a visit. The color of the cells represents the status of a visit . Dates are calculated based on a reference date field  and the days offset for each event. This information is also stored as metadata. The panel is created in real-time with online data extracted from the REDCap database, saving time for researchers who usually create their panels using spreadsheets. Figure The Alert System was designed to periodically send notifications to the research centers regarding not-answered queries and pending data collection based on the scheduled events of each study. Through these reminders, the system helps researchers keep participants' data up-to-date according to the formal protocol, avoiding critical protocol violations. The notifications may be sent by email or SMS to the recipients' lists stored as metadata.The Instrument Validation module allows the research team to comment on the data collection forms and exchange insights in a centralized platform. In this sense, the discussion focuses on specific aspects of each instrument pointed out by team members, allowing researchers to identify and address possible design errors quickly. After obtaining comments from invited users, the coordination staff can start discussing them  through an administrative web interface. Figure https://redbox.technology/pgd.php) is a web tool that allows users to quickly create a complete plan based on a document model established in collaboration with several researchers. This model contains all the essential content a data management plan must have, such as information about the study data and resources, security and privacy, ways of accessing and archiving data, and ethical and regulatory aspects. The user must fill out some metadata fields , and a Google document (the only requirement is to own a Google Account) is instantly generated with the user as the owner. The resulting document can be manually edited and adapted to a specific project. The data management plan is generated only in the Portuguese language.The Data Management Plan Creator  and the project's coordination staff Fig. . This toThe solution offers a service that provides practical tools to enhance the use of ontologies in the system and allow the continuous integration of different data sources, adapt to the evolution of ontologies, ensure availability, and avoid data loss.36. The D2R is a tool that converts relational content into semantic formats, allowing a quick conversion between these formats by automatically creating ontologies based on the schema of the content.As previously stated, the form converter can derive an instrument from an ontology. Similarly, this service enables the creation of an ontology based on an instrument. This feature relies on an external application, the D2R ServerRelying on this feature, REDbox can define an ontology from a data collection instrument. For this, a temporary table is created on a relational database, where each column represents a field in the instrument. Then, the D2R generates and publishes an ontology using the table structure, i.e., converting columns to properties, which can be later customized. Table The Ontology Service guarantees semantic interoperability between the applications and formularies that use different versions of the same ontology or even between different ontologies by maintaining the history of changes and mapping the concepts from one ontology version to another. This service accepts annotated files with an ontology version that can be converted to an older or newer version of the same ontology and annotated files to be converted to a correlated ontology .All REDbox framework modules work in an integrated way. In a research project's initial phase, two paths must be followed to execute the planned activities seamlessly. Figure The first path (red round label with “1”) refers to the pre-collection phase. The research team must proceed with developing and validating the collection instruments. These are crucial activities for defining the types of data and formats needed and the collection strategy. It must be carried out carefully with the participation, preferably, of representatives of all research centers involved in the project.Then, the instruments must be designed in the KoBoToolbox —the result is a form in the XLSForm standard—and converted to the format accepted by REDCap Comma Separated Value (CSV) through the Form Converter module. The resulting file must be uploaded into REDCap. Finally, the metadata of each form must be mapped, namely the fields that contain personal identifiers and the semantics  potentially associated with each field.The second path (red round label with “2”) refers to the collection and continuous research data management process. Data are collected during the interviewer's interaction with the research participant through the form available in the KoBoToolbox system. After that, the Processor extracts, transforms, and processes the data for later storage in the REDCap database. The Processor also monitors possible changes in the data through the Data Entry Trigger, offering flexibility for new processing while enhancing the security of the research data.Finally, using additional tools provided by the Data Quality module , the research project team can manage the data and follow the project during the research lifecycle. Data can be visualized and exported directly from the REDCap system.The validation of the proposed solution is performed by using it in several cross-institutional research projects related to TB in Brazil, namely: (I) Longitudinal Study of the Impact of Social Support on Tuberculosis Indicators: ELISIOS; (II) Validation of the Line Probe Assay's performance as a rapid diagnostic method for drug-resistant tuberculosis in reference centers in Brazil; (III) Validation of Recombinant PPD in the Diagnosis of Tuberculosis Infection; (IV) ProBCG: Use of the Bacillus Calmette–Guérin (BCG) vaccine as prevention of COVID-19 in health professionals; and (V) Multicenter prospective clinical trial to assess the diagnostic accuracy of the Truenat method for routine use. Table There are a significant number of instruments and fields on each project. The form converter module is crucial in this scenario, where each form must be designed only once in KoBoToolbox and then converted to the REDCap format. The expected number of records is also significant, which may demand easy-to-use and offline tools.So far, the main benefits reported by end users of research centers relate to the ability to collect data in interviews with patients in scenarios with an unstable internet connection, receive personalized alerts based on events, and the possibility to quickly visualize the expected visits of each participant during the study.Besides frequently evaluating the feedback received through interactions with key users to guide the development and improvement of the REDbox framework, registered and active users  to strongly disagree (7), to measure human attitude39, and assess perceived usability. The CSUQ produces four scores , one overall and three subscales40, as follows:Overall: average responses for questions 1–16 System Usefulness (SysUse): average responses for questions 1–6Information Quality : average responses for questions 7–12Interface Quality : average responses for questions 13–15.The IBM Computer System Usability Questionnaire (CSUQ) version 3Seventeen responses were collected, representing 40% of the active users. Of this total, seven (41.18%) respondents were men, nine (52.94%) were women, and one (5.88%) did not provide an answer to the question about their gender. The respondents' ages ranged from 21 to 49 years. The job position was also asked and distributed as follows: nurse (2), physician (5), system analyst (1), student (2), researcher (2), project fellow (3), laboratory technician (1), and not answered (1).41. Yet, small samples are typically seen in usability and satisfaction tests and are generally sufficient for usability evaluations43. Therefore, the number of responses obtained is satisfactory.CSUQ can be used with larger sample sizes (more than 100) and smaller ones (fewer than 15). Despite the difference in precision, according to Tullis and Stetson, a sample size of 12 generates the same results as a larger sample size 90% of the timeThe participation of users was wholly voluntary and anonymous. Knowing the respondents' identities would not be useful in this phase, so only the minimum data was collected. A public survey link was made available and is the same for everyone, not allowing authors to track respondents. However, due to the anonymity of the survey, it could not be restricted to single participation (one response per user). To mitigate this, we provided instructions in the invitation email that multiple responses should not be sent.It was a participatory activity to engage users in the system and providing feedback regarding information quality, interface quality, and system usefulness. Table The relevance of this article lies in the innovative approach to supporting TB research. The REDbox framework offers valuable tools and a better user experience by integrating the REDCap and KoBoToolbox EDC systems and using semantics. The proposed solution facilitates the collection and management of research data. Despite being based on the TB context, the framework can be applied in other contexts with the same demands.The primary motivation for this work was to allow health research to be carried out in TB services, where, in general, technological resources are scarce and precarious. Considering that the cost of an EDC system is high, the monthly or annual payment of licenses harms the research budget. Yet, as alternative solutions, REDCap and KoBoToolbox do not meet all the researchers' needs. Therefore, the gaps filled by the REDbox framework represent a significant advance in the free tools available for research.The CSUQ questionnaire allowed the authors to verify the overall satisfaction of active users and the System Usefulness, Information Quality, and Interface Quality subscales. Even though it got a small number of responses, it still represents a good portion of the active user database. As already mentioned, despite the difference in precision between larger and smaller samples, the results obtained through the application of the CSUQ are valid for small samples of usability and satisfaction tests.Overall, the average demonstrated that users are mostly satisfied with the system. Also, the three subscales performed above the middle range (3.5) of the 7-point Likert scale and showed that the system has room for improvement. The InfoQual and IntQual subscales may show that the information should be better organized. The system could be improved in terms of communication and interaction with the user, and the user interface could be more friendly and intuitive. However, SysUse demonstrated that the system fulfills the function for which it was designed, and that is, in fact, efficient and effective for end users.Although the CSUQ questionnaire does not point out precisely what REDbox's shortcomings are, it is noted that users still have the perception that some points can be improved, even with the good performance indicated by the information and interface quality metrics.However, it is possible to speculate on aspects that can be improved in future software versions, including providing more accurate information, handling errors and on-screen messages, improving the usability and responsiveness of graphical interfaces on mobile devices, the provision of user manuals, and creating new features. Once the system's deficiencies are overcome, a higher score is expected in future usability and satisfaction tests.44 is available to enable offline data collection, more may be needed due to the dependency on smartphones and/or tablets available in research centers, the poor usability, and the non-compatibility of some advanced features45. Also, mobile devices in digital data collection projects are frequently not owned by the people entering the data, which can be considered a risk to be managed46. On the other hand, due to the use of HTML5 features, KoBoToolbox provides a better user experience through modern form styles and a way to work offline, if needed, without using any additional applications, such as mobile apps.Although a REDCap mobile applicationBenefits are added for both EDC systems, and the user/researcher can take advantage of the best of each system. In this sense, the negative aspects of one can be mitigated by the positive characteristics of the other. REDCap is effective and efficient for managing data and conducting research after the initial collection phase, allowing researchers to have a more comprehensive view of the project database, including creating custom reports and accessing descriptive data analysis. KoBoToolbox allows for a more delightful collection through a clean, friendly, practical, and accessible interface for any device. Then, the REDbox framework fills the remaining gaps by offering extra functionality to enhance the researcher experience and underpin the research data lifecycle. The Table Semantics. Semantic annotation can underpin the exchange, use, and integration of data from different sources thanks to the aggregation of meaning in raw data. In other words, data becomes machine understandable and can be interpreted by distinct systems.In research project IV, as shown in Table Although the solution does not perform or implement semantic interoperability mechanisms, it focuses on adding meaning to data to support semantic data integration and interoperability based on standards, vocabularies, and ontologies. Standard EDC systems usually do not present this type of feature.Users can prepare their research datasets to be shareable, reusable, and understandable. The ability to map variables when creating data collection instruments is a breakthrough because the dataset will be fully annotated (with semantics) when the collection phase is over. Therefore, regardless of how the data is exported and shared, the researcher will always have the option of including the semantics associated with the data.The other possibility is also valid and helpful, as it can reduce the workload of the research teams associated with creating data collection instruments. The derivation of a set of variables and forms from an ontology facilitates the visualization of what should or must be collected in a given knowledge domain, reducing the occurrence of human errors and also automatically aggregating meaning to data.Application Programming Interfaces—APIs. APIs enable interoperability and data integration between software components and the development of extensions to existing systems.Regarding REDCap, the API is well documented, and several endpoints are available, allowing for programmatically managing a whole project. In this work, some endpoints were used, specifically to: i) import and export data; ii) import files; iii) generate unique identifiers (record IDs); iv) import metadata ; and v) export metadata.In KoBoToolbox, the API must be adequately documented. However, there is a feature to instantly send collected data to an external server (data is sent in JSON standard). This feature is handy when using the system only for data collection, which is the intention of this work, and because it eliminates the need to develop a client to extract data.Data safety. Data is generally stored in three distinct logical units: the KoBoToolbox, REDCap, and relational databases. Only the data stored in REDCap is intended for analysis, but data can be quickly restored in the event of a failure. Finally, the whole process is transparent to the final user, who can focus only on data collection, management, and analysis.Limitations. In the form converter, the designer must pay attention to the following aspects:(i)need to use a variable naming convention for multiple selection fields (checkboxes). Using a naming convention for variables in multiple selection fields is crucial. Otherwise, data transfers may fail.(ii)calculated fields. When using calculated fields, KoBoToolbox does not allow setting up a label for this kind of field, unlike REDCap. The designer can use the "Guidance Hint" option as a workaround, which will be transformed into a label when converted to REDCap format. However, this is optional since REDCap accepts blank labels in calculated fields.A drawback of using the REDbox framework is the need to define several configuration parameters in the metadata database for the proper functioning of the system and the effective integration of REDCap and KoBoToolbox. It may represent a workload in the initial phase of the research project (the setup must be carried out before starting the data collection), which varies according to the modules used. The Admin System and user's manual seek to make this task more accessible, but some technical knowledge may be necessary for a correct configuration.This work has presented REDbox, a comprehensive framework for integrated data collection and management in tuberculosis research. The use of REDCap and KoBoToolbox together has allowed the transparent combination of the advantages of each, helping researchers manage and maintain data while increasing the satisfaction of the final users responsible for collecting data in the field.The Form Converter avoids rework in defining variables/fields and designing data collection instruments. The ETL Processor enables data transformation and transmission. The Data Quality module speeds up and enhances data management by reducing the workload of time-consuming and delicate tasks. Supporting semantic data integration is also another significant contribution of this work. The Ontology Service allows users to add meaning to raw data and monitor the evolution of ontologies through versioning, which is essential to promote the quality and availability of research data over time.The REDbox framework is constantly evolving to meet the target audience's needs, taking into account the dynamism and multidisciplinarity of the health research area. As future work progresses and as the software matures, specific comments from key users will be collected to guide the evolution of each module. Although the TB scenario motivated the solution, it applies to other health fields as well.


This article was migrated. The article was marked as recommended.The COVID-19 pandemic has profoundly impacted the medical meetings planned for 2020. This health crisis has caused the cancellation, postponement or a pivot in educational design to virtual formats. In the latter case, the format for virtual meetings has remained very similar to the cancelled face-to-face meeting, by using primarily web conferencing systems.This article intends to start a dialogue with the medical education and events community about possible delivery formats. Among them, the concept of an “Extended Congress” is introduced.The extended congress uses the extension of time, space and languages to a scientific meeting. It aims to: 1) unleash the reach of traditional meetings through the use of technology to access larger audiences in different languages, across a country and internationally, with local leaders to help interpret the knowledge and localize it, and 2) to improve knowledge translation into practice through a sequential and active learning process.An ongoing example is described as a proof of concept: the Latin American Peritoneal Dialysis Extended Congress attracted 774 remote participants from over 20 countries, 93% of whom were paid registrants. Initially designed as a hybrid (live plus remote) event scheduled for March 2020, it had to be reframed as a remote only meeting due to the COVID-19 pandemic, thus protecting the health of members while providing continued value to the organization and attendees of the event.With this experience in mind, the authors are currently designing programs in the United States, through collaboration with the University of Virginia Office of Continuing Medical Education.In summary, the design of meetings can better utilize and integrate technology and reach larger audiences with a blend of formats. Those organizations that adapt more quickly to offer these events will concentrate more of the share, as seen with the adoption of technology by other industries. The COVID-19 pandemic, among its many effects in almost every facet of our lives, has profoundly impacted the medical meetings planned for 2020. For the meetings and conferences scheduled in the first half of the year, organizations were faced with decisions such as cancellation, postponement or a pivot to virtual formats , with liIn many occasions, these scientific meetings that were modified to virtual formats were provided at no cost, as shown in this example , which aFurthermore, this traditional format - with live activities via web conference - is not well suited for the remote participant, because it is not feasible to keep the participants’ undivided attention through internet-based activities over many hours and days, and often in different time zones. In a live meeting, almost all of the participants’ time is devoted to the meeting, but in a virtual event their dedication is highly impacted by their daily work obligations and family life, therefore requiring a more realistic and staged approach that allows for flexibility in participation.For the meetings scheduled for the second half of 2020, a decision to convert to a virtual format allows more time for planning and implementation to provide a better educational and networking design . As orgaPlease note that the term “medical meetings” is used in this article to refer to scientific conferences for healthcare practitioners and those in related fields. Moreover, many of these concepts could be applied to other industries where scientific meetings take place.This article intends to start a dialogue with the medical education and events community about possible delivery formats, that may be helpful to the medical organizations and meeting organizers in charge of coming events, along with other colleagues who are reflecting on these topics and having an open dialogue with the medical education community through this Journal . Among pExtended Congress” . This increased accessibility could include domestic and foreign live and remote participants from different states, countries or continents, allowing participants to be able to both attend and present their research live or remotely. Expandtime by extending the activity over 4 to 8 weeks, to allow those live attendees and those who attend remotely, to network with each other and to acquire the valuable new knowledge and validate it with colleagues through an engaging conversation .The concept of “ngress”  leverageFurthermore, distributed live activities in English and/or local languages during the congress could coexist, at different locations of the countries or the world, either face-to-face or remotely through the Internet, led by local congress ambassadors, taking into account the possible decreased international mobility of participants after the pandemic, and willingness or not of participants and speakers to attend crowded spaces. Finally, a possible spin-off of the live meeting could be the Conference highlights, delivered later in time, summarizing and discussing in English and/or local languages the key results of the meeting over a period of 6-8 weeks, similar to a massive open online course (MOOC), thus evolving from its traditional format .virtual extended meetings could become a new type of event with its own merits for these organizations, together with the hybrid and traditional live meetings.Although this concept was originally designed to be incorporated into hybrid events with a central live meeting as an integral part of the educational plan, the conversion to a fully virtual Extended Congress approach could serve as a substitute for the live or hybrid event, because of the travel and gathering restrictions that are currently in place for this year. In any case, theProfessional communities of specialists benefit from meetings as a dedicated space for sharing the latest research, and interacting with peers and experts. Many reputed conferences already host a large international audience, and the associations that organize them have year-long relationships with national and regional societies of the same specialty  and theinstitution organizing the meeting, as well as the commercial supporters, the professional conference organizers, and other vendors and contractors involved in the conference services industry.However, none of these examples mentioned above comprehensively address the needs of the different stakeholders involved in a medical meeting, particularly the potentialMeetings serve as a primary source of value, revenue and networking for its members and attendees. The customs and patterns of engagement associated with traditional live meetings help organizations to share their organizational identity and have been a consistent source of revenue. Major changes that impact the organization’s value proposition can be viewed with suspicion and anxiety. The consideration of a new approach is now a reality due to the pandemic and requires a re-assessment of existing practices as these decisions may ultimately affect overall sustainability for the organization, and learning experiences, after the assessment of ongoing implementations, will be available.Two of the authors’ team (AM/AL) envisioned the concept of technology-based education through Extended Congresses for years, but the risk benefit equation was not reasonable for many associations and organizations. However, in October 2019, the Colombian Association of Nephrology, organizers of the 7th Latin American conference of Peritoneal Dialysis, accepted the challenge and the project was launched Extended.The design of the Peritoneal Dialysis Extended Congress is shown inThe design of the extended congress included:- The first week, when the live conference takes place , were focused on the main topics of the conference, addressed with short lectures, reading materials, clinical simulations and case discussions in clinical forums. Collective reflection with peers and experts is maximized by interaction and participation with experts and tutors and the use of social networking tools in the platform , included closing discussions and a farewell forum.In addition, a nursing track was specifically designed for the extended congress, thus allowing an important segment of the target audience related to peritoneal dialysis to have a unique set of content and activities, tutored by nephrology nurses.By March 11, 2020, less than three weeks before the scheduled date for the live congress, the face-to-face event was cancelled because of the COVID-19 pandemic. In light of this change, all participants were encouraged to participate in the virtual component of the congress where most of the characteristics of the live event were included, particularly the presentations of research already accepted and coverage of the main topics of the congress. Naturally, the conversations and discussions include the use of peritoneal dialysis and COVID-19. The extended congress is now progressing, including discussions about the higher value of peritoneal dialysis in an era of confinement, or the use of peritoneal dialysis in COVID-19 related acute kidney injury.As of April 10, the distribution of participants to the extended congress is similar to anticipated expectations. The extended congress has a wide attendance from over 20 Spanish-speaking countries of the region and Brazil, Spain, USA and Portugal .Seven hundred and twenty (93%) of the attendees are paid participants; the other 54 (7%) are full scholarship participants from Venezuela and others who requested them. Additionally, another 1986 professionals were granted free access to the initial week, as pre registrants to the activity, which is done automatically with all the educational activities: 393 (20%) of them accessed the platform. A full report of the congress statistics will be available following the conclusion of the congress.In software jargon, a “vanilla” version is when the software is not customized, when it is the plain or standard version. When this activity was implemented as a proof of concept, we decided to run it with a minimum viable set of functionalities , taken from the online courses that we already were implementing . TherefoThe decision of focusing on Spanish-speaking participants mostly (and not Portuguese-speaking ones) was selected, to minimize risk. However, faculty presenters were diverse, speaking English, Portuguese and Spanish, with lectures being subtitled and slides translated into Spanish when necessary. More functionalities and a more comprehensive model could be implemented in following programs, after a formal assessment of this pilot project .The concept of extended congress in normal times is received with anxiety by the conference organizers, because of the perceived risk of potential damage to the onsite attendance. In this example, the authors saw an opportunity to implement it, because the local attendees were already subsidized by the national association to participate onsite, and not too many international attendees were expected; at the same time, the conference organizers were keen to implement innovative formats, based on recent experiences together.A second challenge, particularly when the event is fully virtual, is to implement a reasonable alternative for the live exhibit hall, because the budget for traditional events usually is substantially supported by exhibitors. In our example, there was no commercial funding for the virtual component (income was based on registration fees), but this is not generally the case.A third potential challenge is to enroll remote participants in these activities: in this example there was a good reach, but it is something to consider.Finally, ensuring online networking is paramount, as in any congress.The University of Virginia (UVA) Office of Continuing Medical Education - CME -  has been involved in web-based and innovative continuing education for physicians, nurses and healthcare professionals for over twenty years. The expansion of hybrid continuing professional activities to integrate live and pre-produced content  creates new opportunities for incremental learning and professional development. Educational programming, through the extended congress or other innovative designs, can create a nimble and responsive environment that is accessible to healthcare professionals and teams as needed. The University of Virginia is actively working to utilize platforms such as the extended congress approach, to enhance networking, active learning that is relevant, timely and evidence-based. The COVID crisis has significantly changed the accessibility of continuing professional development and creates an urgent need for asynchronous learning opportunities that can be utilized without leaving the work environment. We are designing courses and activities that can benefit multiple target audiences, consistent with the changing care environments, team member roles and responsibilities and need for comprehensive quality care. The extended congress is particularly helpful as we can modify the balance of live and hybrid content as needed to meet the needs of our target audiences and stakeholders.The University of Virginia Office of CME and SONCE (School of Nursing continuing education) are working collaboratively to create programming that leverages the expertise of our faculty, our professional joint providership relationships and to drive substantive discussions based on current research and clinical evidence. The University of Virginia collaborated with EviMed, Hospital Italiano de Buenos Aires (a main academic center in Argentina) and the Global Alliance for Medical Education - GAME- on a regional meeting in Latin America focused on advances in continuing medical education in 2015. This initial collaboration fostered new ideas and approaches that are now being integrated into much of UVA’s continuing education (CE) and Performance Improvement opportunities.UVA is now exploring how to pivot much of the programming into hybrid formats. The need for virtual learning is now a critical component in quality CE as we are aware that healthcare institutional resources are going to be limited. In spite of these financial challenges, there has never been a greater need for highly relevant and timely CE programming. Everyone in the healthcare team can benefit from quality CE that is workplace based and relevant to the provision of quality patient care. The changes in the delivery of healthcare that utilizes telehealth technologies also increases the familiarity and ease of technology-based solutions. UVA, like many academic institutions, includes regularly scheduled series (RSS), departmental conferences as well as asynchronous web-based continuing education. Our joint provider organizations need our guidance and leadership to create ongoing CE opportunities for their constituent audiences.The transition of our CE programming, particularly in light of the changing healthcare environment, is moving at a rapid pace. We are actively creating alternative approaches for our course directors and planning committees that reflect this new reality. We plan to leverage our long-standing experience in web-based education into a broad-based armamentarium of educational design options that can be tailored to the needs of our learners. The process we use is shown in “Supplementary File 1”.When going virtual, an appealing solution could be to use Virtual Reality (VR), as several organizations have . AccordiIn practice, two ways for the use of VR in medical meetings can be envisioned:•Without special VR lens: VR is an added presentation layer, similar to the way Street View is an added layer to Google Maps. It looks like a computer game. The question is how much this additional layer adds to the main layer , where the main value to the participants lies. Additionally, how much of a barrier will it become, in terms of complexity and development cost, hardware and bandwidth, participant’s technological ability, among other concerns. There might be niche uses in specific parts of the virtual meetings, for example by integrating into gamification.•With special VR lens: It is a very immersive experience, like a live conference. The problem is that with current technology VR with lens is not tolerable for long periods of time, in contrast to a live conference where participants often spend all day over several days engaged. Additionally, its use adds hardware requirements (the VR lens) that are not yet of general usage. There might be niche uses in specific parts of the virtual meetings, for example in skills-based simulation workshops.In both cases, the effort to develop these solutions is significant. There certainly will be early adopters of it , but theTechnology evolves over time, and features may change in a way that will make it easier to adopt in the future. Right now, the added value of Street View to Google Maps is an analogy to keep in mind.What has been your biggest challenge professionally and at your organization during the pandemic? The responses fell into these main buckets: dealing with the loss of income or revenue; uncertainty preventing their ability to plan “intelligently”; communication issues; difficulty convincing leadership of the need to pivot to digital; canceling events and managing contracts, damages, and payments; getting a handle on producing a virtual event; managing their teams, particularly during this time of stress and uncertainty; and navigating the possibility of having to change their own roles in the wake of event cancellations.”The impact of the COVID-19 pandemic on scientific meetings has been daunting. It is summarized in : “What This pandemia precipitated the need to integrate technology. The Extended Congress and other virtual conferences have demonstrated in practice that a significant proportion of the human learning and interaction can be implemented online with reasonable results, thus speeding the adoption of digital technologies in various aspects of our lives. Scientific meetings are not the exception, and they could meet their key objectives (knowledge transfer and networking) by introducing new approaches to educational delivery that could increase their reach, knowledge translation into practice, and encourage global discussions and intercommunication between peers and course faculty.This paper addresses how technology can help address the impact of the pandemic on 2020 medical meetings. In turn, these ongoing experiences will provide evidence to decision-makers that can influence the long-term impact of the introduction of technology to all stakeholders involved. For example, while conference organizers worry that remote activities risk onsite attendance, in our experience this consequence does not happen . As stated by a participant in  and virtual only events, based on the explosion of experiences during this year, where organizations take more risks than usual , and improving the educational impact on practice. Regarding the insurance aspect of designing a virtual component, it is expressed by a participant in the PCMA survey , “I’d inFinally, a concentration effect with the introduction of digital technologies can be expected for the major conferences of each specialty, as shown with the entertainment and news industries . QuotingCongresses will probably continue to be mostly onsite, with a more intensive integration of technology to reach members of the professional community who cannot attend the live events. As stated by a participant in a survey , “face-tThe main stakeholders will continue to have an important role in the new state of affairs. However, those organizations that adapt more quickly will concentrate more of the share, as seen with the entertainment and the news industries . Many of•Meetings of the future will probably utilize technology more extensively to reach members of the professional community who cannot attend the live events.•The Extended Congress concept is one of the possible formats to be used, extending a traditional meeting in the dimensions of time, space and languages.•The current stakeholders will continue to have an important role in the new state of affairs.•Those organizations which adapt more quickly to implement these new models will concentrate more of the share, as seen with the adoption of technology by the entertainment and news industries.Alvaro Margolis is an internist with a Master’s degree in Medical Informatics from the University of Utah (USA). He has held academic positions at the Schools of Medicine and Engineering, Universidad de la República, Uruguay, is Founding Member of the International Academy of Health Sciences Informatics, and Associate Editor of Applied Clinical Informatics. He is the President of the Global Alliance for Medical Education (GAME), and Director of EviMed, a CME company working across the Americas. ORCID:https://orcid.org/0000-0002-2631-2323Jann Torrance Balmer PhD RN serves as the Director for Continuing Medical Education (CME) of the University of Virginia School of Medicine and as the Co-Lead Nurse Planner for the School of Nursing. Dr. Balmer serves on the NPD Commission on Accreditation for the American Nurses Credentialing Center. She served on the American Board of Medical Specialties Vision Commission, and as the President, Past President and Board Member of the Alliance for Continuing Education in the Health Professions (formerly Alliance for CME) from 2005 - 2012.Andrea Zimmerman, EdD is learning engineer at the Office of CME of the University of Virginia, and has worked in higher and continuing education since 2007 to provide innovative and engaging learning opportunities to clinicians and biomedical scientists, bridging the gap between bench and bedside. Dr. Zimmerman serves on the Excellence in Educational Design Award Committee for the Alliance for Continuing Education in the Health Professions. ORCID:https://orcid.org/0000-0002-3688-0842Antonio López-Arredondo is a computer engineer, Adjunct Professor at the Health Informatics Laboratory, Universidad de la República, Uruguay. He is also Chief Technology Officer at EviMed. This review has been migrated. The reviewer awarded 5 stars out of 5 The Margolis et al. (2020)1 publication should provide encouragement to organizations developing and implementing plans to continue their CPD work during and after this pandemic. There is no doubt that the CPD organizational survivors will be those who have determined ways to move into virtual and/or hybrid formats. The authors provide excellent and timely examples from their own work—the Latin American Peritoneal Dialysis Extended Congress and from the University of Virginia School of Medicine and Nursing. They offer practical advice on transitioning but also practical tips on how to make it happen and make it effective. They recognize the challenges of ensuring technological support, sufficient funding, marketing and online networking so that participants can engage with others as they would do at a face/face event.Hand-in-hand with the virtual conference is the need to support conference attendees to ensure they maximize their learning. A recent article by Tobin (2020)2 provides some guidance for learners. He presents several key strategies—going to a smaller program the first time, getting ready by blocking off the calendar so that the day is focused on learning, getting familiar with the software tools that will be available, taking notes and chatting with others during and after the session to consolidate ideas, be in the moment and realize you are unlikely to view on-line presentations later. For both the CPD organization and the learner, planning ahead and anticipating how to maximize the experience is key. It is a learning journey for everyone but worth the plunge. There is no doubt that learner expectations for safe high quality programming will be different post-COVID. 1. Margolis A, Balmer J, Zimmerman A, López-Arredondo A, 2020, 'The Extended Congress: Reimagining scientific meetings after the COVID-19 pandemic', MedEdPublish, 9, [1], 128, https://doi.org/10.15694/mep.2020.000128.12. Tobin TJ, How to make the most of a virtual conference, Chronical of Higher Education, July 14, 2020. https://www.chronicle.com/article/How-to-Make-the-Most-of-a/249171Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 I would like to thank the authors for presenting a topic that is so relevant and useful for the current situation. As we are all shifting to digital formats for education and online communication, it is definitely important to introduce and test new concepts that can support and improve the electronic modes of learning.The extended congress model has a great opportunity to be widely used in the world of virtual learning. However, and as the concept is still in its early days, it is essential to use a comprehensive evaluation model to evaluate the learning process and to analyze data and feedback from different stakeholders over a reasonable period of time. It will also be interesting to test the applicability of the extended congress model to a variety of settings e.g. different countries, cultures, and healthcare professions. If this model proves its effectivity, I believe it will provide lots of opportunities for inter-professional education. It will also be helpful to delineate the difference between “extended in space” and the traditional virtual conference. The expanded time is an interesting concept that can reinforce the learning but I believe this requires effective techniques that ensure the engagement of participants, which might be a challenge, especially over a long period of time.For the readers’ convenience, it would be nice to have a summary of the article. Thank you again for the opportunity to review this paper and I will definitely be interested to use the concept as an educational modality and I am really keen to read a follow up on this article and to learn more about the extended congress model as it ripens and matures.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 Interesting paper on a timely problem: medical meetings during the pandemic.The authors present the example of one meeting that rapidly changed its format to the extended format. After an interesting introduction to the topic, they conclude that this is an option for the future.Would be interesting to have more information on aspects such as the continuity and engagement of the participants during the five weeks: does it decay?, is there any information concerning their active personal interaction? They mention “reasonable results” that need to be specified.Besides, if networking is one of the basic objectives of these meetings it is not clear how it can be sustained and promoted with this new format. A comment on that would be interesting.Are there any special characteristics of institutions that would benefit more (or less) of this format?In short it is a valid option for scientific meetings, and adding to the economic and financial aspects, the academic value of the extended meeting needs to be considered in detail.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 5 stars out of 5 The authors describe an educational design that has the potential to foster group discussions leading to collective reflection and sequential activities over time, features that foster knowledge translation into practice. The article succeeds as intended, to start a dialogue with the medical education and events community about delivery formats with the potential to achieve this ambitious goal. While many readers including CPD providers will focus on the obvious challenges of adopting extended congresses, such as the costs and ethics and acceptance of new technologies, I use this review to highlight an equally important issue which needs to be included in this dialogue. The extended congress has the potential to provide a home (1) for health professionals to regularly network with peers and engage in self-managed learning activities that inform practice. This goal is best achieved by changing how we think about learning and planning new programs. For instance, we should think of learning as emerging from continuing conversations among networked participants who, owning the education process, create content relevant to current practice and ‘pull’ evidence-based best practices into the conversation. (2) Relationships among trusted peers provide practitioners with the motivation to talk about their practice, critically reconstructing practice incidents as they do informally at work, for instance at coffee and lunch breaks. (3) Such engagement should be a prime objective in extended congresses. As Anand states describing HBX, the Harvard Business School’s learning platform, “If we could crack the code of engagement, we felt, reach would follow”. (4)For extended congresses to achieve these goals there is a need for planning and support teams to include information and network specialists, as mentioned by the authors, but also professionals with expertise in social learning (5) and community facilitation (6).1. Graham T. McMahon (2016) What Do I Need to Learn Today? — The Evolution of CME, N ENGL J MED 374;15.2. Jordan ME, Lanham HJ, Crabtree BF, et al. The role of conversation in health care interventions: enabling sensemaking and learning. Implement Sci. 2009;4:15.3. Lanham HJ, McDaniel RR Jr, Crabtree BF, et al. How improving practice relationships among clinicians and non-clinicians can improve quality in primary care. J Comm J Qual Patient Saf. 2009;35:457–466.4. Anand B. (2016). Chapter 29. The Content Trap: A Strategist's Guide To Digital Change, Random House.5. FutureLearn’s Social Lead, David Thair, shares his top six tips for getting the most out of social learning features https://about.futurelearn.com/blog/6-social-learning-tips6. Jakubec S, Parboosingh J, Colvin B. Introducing a multimedia course to enhance health professionals’ skills to facilitate communities of practice: experiences of the first cohort of course participants. J Health Organ Manage. 2014;28(4):477–494.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 5 stars out of 5 Thank you for the opportunity to review the manuscript, which I read with great pleasure.It reads well and despite long, the reader is urged to read along with continuing interest.If already relevant, the pandemic made central, the topic approached by Margolis and Associates. The way Authors introduce their writing purpose: a “starting dialogue” with the reader and the whole CPD community and the innovative learning methodology they introduce and propose: the “Extended Congress” raise immediate and unwavering curiosity till the conclusion of the article.The Authors, two at least are renowned experienced educators, start by comprehensive and systematically framing their work in evidence. They picture the difference between the model they propose with previous or ongoing others and underline the benefit of theirs and why they developed it. A table could be built upon this.The “Extended Congress” model allows for a triad learning expansion , which Authors very elegantly sustain. After wisely balancing the support of their model on evidence and prior experience, they provide a clear description of its implementation. A note of remark for caring to develop a blended model offering learning experiences encompassing dialogue and conversation beyond discussion, self and collective reflection on new learning and, including an online networking space to develop relationships and further new learning. The methodology is clearly explained to the point of replication and embraces social learning principles, active learning, multifaceted formats and incorporates the longitudinal component. All of those have been associated to effective CPD programs. Thank you for itemizing the challenges encountered and overcome.The Authors explained the importance of establishing bonds and partnerships to create and implement these kinds of CPD programs. The article provides a holistic perspective on longitudinal hybrid CPD programs and that includes all stakeholders usually involved in CPD live programs, challenges they can face and benefits these learning formats can bring. Probably new actors will emerge, some probably evolving from reshaping preexisting roles. New and exciting challenges are posed to CPD educators. Interesting thought on progressing the model eventually considering virtual reality. Would probably include this section as a possible line of continued investigation. There is a good discussion section and the expression“refocus energy to something you’ve already built rather than scramble to reinvent the wheel." translates well the authors´ vast experience and previous work on this medical education area. The take home messages were surgically extracted and summarize well the whole article.The supplementary file is an excellent standalone document showing a comprehensive and useful checklist to eventually underpin a future rubric to guide organizing teams to plan and evaluate learning experiences. Looking forward to reading the next article expanding on the impact of the “Extended Congress” model on several evaluation levels and to learn about further developments.References: RM Cervero, JK. Gaines, The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews Journal of Continuing Education in the Health Professions, 35(2):131–138, 2015IJ Parboosingh, VA. Reed, JC Palmer, HH Berstein. Enhancing Practice Improvement by Facilitating Practitioner Interactivity: New Roles for Providers of Continuing Medical Education Journal of Continuing Education in the Health Professions, 31(2):122–127, 2011Reviewer Expertise:NANo decision status is available


The mean age of the physicians was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. A thematic content analysis was performed to examine the responses of the participants and to prioritize the recommendations for and barriers to the implementation of ASPs from the perspective of healthcare providers. According to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness of the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. In conclusion, the abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.The perspectives of healthcare professionals on antibiotic stewardship programs (ASPs) should be explored. Any antibiotic stewardship strategy must be individualized based on patient needs, prescription habits, and local resources. The current study aimed to explore the perspectives of healthcare providers on antibiotics stewardship and their awareness of these perspectives. Furthermore, potential barriers to the application of ASPs should be identified and addressed. This exploratory cross-sectional study utilized a qualitative method to evaluate critical care physicians, pediatricians, and clinical pharmacists ( Antibiotics resistance (AR) is one of the most important issues affecting critical care. The misuse of antibiotics in society and even in hospitals and the increased utilization of broad-spectrum antibiotics have been contributing to the increased incidence of antibiotic resistance . These fStewardship refers to the cautious and conscientious management of something entrusted to one’s care . AntibioASP has become an unreplaceable initiative particularly in the critical care units. The first goal of the program is to collaborate with health care providers in treating patients with the most effective antibiotics at the right dose and appropriate timing. This was based on the four Ds of optimum antibiotics treatment by Joseph and Rodvold, which are as follows: right drug, right dose, de-escalation to pathogen-directed therapy, and right duration of therapy .Rationalizing the use of antibiotics is important in managing infections in an efficient manner, preventing complications caused by unnecessary antibiotic treatment, and combating antibiotic resistance. Further, by enhancing antibiotic prescription, ASPs can help clinicians in enhancing clinical outcomes while minimizing risks .According to a large and expanding body of research, hospital-based ASPs can decrease antibiotic resistance, improve treatment outcomes, and facilitate cost efficiency. The practicality of ASPs and the improvement of patient outcomes from such attempts are supported by evidence from different inpatient institutions, which include multiple types of hospitals and long-term care facilities with a broad range of staffing or financial resources. Previous studies have shown the importance of professional training, dissemination of information about the prescription rates between physicians, and resources for selecting the best clinical options in the outpatient context .Thus, the perspectives of healthcare professionals on ASP should be identified. ASPs must be individualized based on patient needs, prescription habits, obstacles, and local resources . A recenThis was an exploratory cross-sectional study that utilized a qualitative method. Critical care physicians, pediatricians, and clinical pharmacists who were working in critical care units in two university hospitals  were included in the analysis. Then, their opinions and perspectives on the implementation of ASP programs were evaluated. The current study was performed in accordance with the CORE-Q unified criteria for reporting qualitative research .Participants were enrolled using the purposive sampling technique. The eligibility criteria were as follows: female and male physicians or pharmacists who worked in the critical care units and who provided consent.When no novel themes, subthemes, or explanations arose from the interviews, data saturation was reached . In totaIn-depth interviews were performed by team members with experience in qualitative interviews and knowledge on stewardship. All interviews were conducted by one investigator. Two investigators ensured that the content and interview approach were consistent. The interviews were audio recorded. In relation to this, an interview guide was created based on domains identified via a literature review ,16,17,18The researchers used a collaborative codebook generation and coding approach with several steps . To faciTo identify the key themes arising from the data, the interview transcripts were coded, improved, and categorized. Initially, the transcripts were broadly coded to create a preliminary coding system. Thereafter, additional codes were created if new themes evolved. Emerging topics and subthemes were regularly polished, tested, and altered using the constant comparison technique. Data were analyzed until all themes were covered. Existing themes were refined and validated via discussions with co-researchers until a consensus decision was achieved. The researchers used Excel 2010 to store demographic data. The quantitative variables were expressed as the mean and standard deviation and qualitative variables as numbers and percentages.The research protocol was approved by the Ethics Review Committee of the Faculty of Medicine Cairo University . The study was performed according to the Declaration of Helsinki. The participants were informed about the aims of the study, and each of them provided a written informed consent. The identity of the informants remained confidential throughout the study. “I” (interviewee) accompanied by a number was used for each participant based on the chronological order of the interviews .n = 43) was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. The ASP-related experience of participants varied significantly, ranging from zero to three years. Meanwhile, their average weekly ASP activity time ranged from 0 to 30 h. Only three physicians and two pharmacists received ASP training.As the datasets had reached saturation, 43 interviews were performed, without new discoveries arising from the interviews. The HCPs interviewed 19 pediatric physicians, 10 critical care physicians, 10 pharmacists, and 4 clinical pathology physicians. The average age of the physicians .When asked about specific team members and time restrictions, the respondents believed that they or other pharmacists and physicians who are core members of the team do not have adequate time for antibiotic stewardship. Part-time allocation was common among the responders, particularly physicians, as they had difficulties in allocating time for stewardship.One responder believed that time limitations and personnel concerns were significant obstacles to the implementation of an effective program and that the impact of the program was constrained by the incapability of performing certain duties, which involve the proper supervision of health care providers. When interviewed about AMPs, the professionals stated that they could not engage in this program even though it is beneficial. This finding is consistent with that of a study by Mathew et al. . That isThe application of ASP was limited by the lack of awareness. Most participants at two of three sites were not aware of the ASP at their hospitals or the availability of resources that can be used to find this information. However, six respondents from one facility were aware of the ASP. Lack of awareness on ASPs among health care personnel inhibited the application of functional and efficient stewardship. Similarly, some misunderstandings on the importance of selective reporting about AST findings and inconsistent information on its usefulness, efficacy, or application limited its implementation (as stated by the majority of participants).There is a lack of local antimicrobial regulations and procedures in orientation programs for new health care workers, which has contributed to the frequently incorrect use of antibiotics. One physician stated.According to a study by Shallcross et al. , behavioRegarding the impact of programs, most participants responded that continuous monitoring with feedback ASP statistics, preferably via direct communication, subsequently led to the continuous support from local leadership and expanded involvement via the organization. The result of the current study was in contrast to that of a recent study conducted by Monmaturapoj et al. .lack of teamwork and guidance is one of the challenges that limit the application of AMPs. This finding is in accordance with that of a study conducted by Mathew et al. [Most participants at one of the three sites stated that there are no available AS stewardship guidelines. Moreover, the other participants stated that the w et al.  who showw et al. .The participants reported that education and training are important factors in the implementation and adoption of ASPs. Workshops for improving awareness on AR, education and training on antibiotics policies and guidelines, and appropriate ASP should be included. The participants, particularly senior physicians, emphasized the importance of increased awareness on AMR and education on the proper use of antibiotics.One pharmacist said, “This is really an issue because even the frontline personnel don’t know exactly what we need to do”.All participants agreed that training is required before ASPs can be implemented. One physician stated that “Yes. Training in the form of workshops is essential to obtain a deeper understanding, and I feel that healthcare providers should have certifications from an accepted course before they can be a part of the ASP”. This finding was consistent with that of the study conducted by Charani et al. , who empAudit is a really good intervention. However, it is resource-intensive and may be challenging to implement in all wards”. One participant said that “Audits must be performed in certain wards”.Only a minority of interviewees were aware of ASPs, and the majority agreed that executing a program with clearly defined goals and objectives and precise definitions of the role of key stakeholders is necessary. Moreover, the use of antibiotics should be audited, monitored, and managed similar to financial resources. All physicians, except five, agreed that combined supervision and antibiotic limitations could be significantly beneficial. “Human and non-human resources are important to effectively facilitate ASPs. The introduction of ASP has run into several difficulties, including lack of fund and information technology to delivering viable and effective ASP. Stated by the majority, this finding was in accordance with that of a recent study. Moreover, it is consistent with the findings of Hayat et al. , which sAccording to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness on the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. The abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.The current study had several limitations. That is, it only included personnel from two hospitals affiliated with one university hospital. As a qualitative method for adopting antibiotic stewardship programs at critical care units that is not designed to generalize the phenomenon, such limitations did not affect the results. However, multicenter studies utilizing different research techniques should be conducted in the future.