Medical e-Learning - development and perspective from the view of 2 LDV projects

Taina Avramescu, Prof, MD, PhD University of Craiova

Abstract The present paper wishes to offer a general overview of Web-based learning in Medical Education in several European countries, based on the research, results and experience gained by an international partnership in 2 LDV projects. Documentary investigations and surveys were carried out to determine the nature, degree and scope of distribution in medical e-Learning across Europe. Apart from outlining the major characteristics of web based learning it focuses on several particular issues of its implementation in contemporany medical education, good points, bad points, further analysis of training expectations and lacks. Introduction Significant changes occur lately in the healthcare sector. More, as the context of medical education is changing, new challenges occur. All areas of healthcare and education are moving towards more professionalised systems and expectations from those involved. Swanwick (2008) suggests that postgraduate medical education is moving into a new era driven by the three interlinked trends of professionalisation, increasing accountability and the pursuit of excellence. Professionalisation also involves the idea of continuing development and revalidation. In terms of medical or clinical education, teachers need to reach a level of knowledge, skills and behaviours, which may be learned on a course or on the job and which may be measured through formal assessment or more informally in practice. They should then aim to keep up to date in their area through continuing professional development activities (CPD) Judy McKimm (2009) considers that the main challenge for medical educators and clinicians when engaging in professional development is to reach a combination of staying current in terms of clinical or scientific knowledge and skills whilst also staying up to date with contemporary teaching, learning and assessment methods, and in the mean time to deliver high quality teaching, learning, assessment and supervisory activities for medical students, trainerss and other health professionals. Managing development in both these aspects can be very demanding, particularly for clinical educators who also have to deliver the health service. A flexible training offer by developing an online learning community to provide the resources and digital materials to those interested in medicine and to support the development of e -learning strategies, e learning courses, encouraging learning by doing, with opportunities for reinforcement and consolidation through reflections shared and feedback from tutors and peers is a real necessity. However, as a young and relatively new area, it is expected that this basic pedagogic model will continue to evolve in line with advances being made in researching new models of learning with virtual communities. The degree of webbased learning in medical education across Europe. Thanks to the growth of educational technologies and the Internet, the number of e-Learning resources available to educators has dramatically increased. Within the framework of Leonardo da Vinci WBT WORLD project , RO/02/B/F/PP 141053 a

Report on the Best Practices in Web-Based Learning across Europe was eleborated. This report turned out that a great number of educational institutions provide a form of web-based learning starting from as early as comprehensive schools and getting as far as university programmes for undergraduate and postgraduate students. The number of participating countries is increasing, more aspects of higher education are included and the number of activities and projects is growing. Despite of this positive aspects, medical education has so far been neglected in the process and awareness of the development at medical schools has been limited. Repositories or digital libraries have been established to manage access to e-Learning materials, but they are few at this time, even if it is a well known fact that the position of medical education towards the Bologna Process is essential. A survey conducted by the Time Centre of Grenoble Ecole de Management on behalf of the European Commission, june 2007, showed that the e-Learning Initiative created a dynamic around e-Learning in Europe, but the geographical origin of the partners stems from France, UK, Italy, Germany, Spain and Belgium, so the eLearning Initiative did not manage to equally reach all of EU countries, recte Romania,Bulgaria and Hungary More, very few LDV projects in RO, but also in other European countries adress to the medical field. LDV Action 142835- LLP-1-2008-1-IT-Leonardo-LMP identified many indicators showing the huge training needs felt as an acute problem in the health care system:skills shortage at all levels; lack of IT infrastructure, recriutment increase, reorganisation, duplication of efforts. From our point of view medical e-Learning can cover 2 main fields: 1. "Continuing professional development" that is a very important concept for most professions, no matter what activity we're talking. This becomes even more important in medicine, where patients' lives depends on the doctor's ability to learn and put into practice the new knowledge and treatments. For this reason of acute need to be permanent "in touch" with the important findings in medicine, the new learning methods facilitated by online technology gained ground in recent years in medical education at international level and in the process of obtaining credentials for practicing physician, also influencing the methods used now in the process of learning. Regardless of country that is, to continue to practice, doctors must obtain annually a certain number of CME credits (Continuing Medical Education). The score varies with each state being established by some institutions in the medical field. Until recently, medical conferences and seminars on various specialized courses or subscription to periodicals, were the only ways available for further training. Learning on the Internet by the "e learning" method, fundamentally changed the way by which doctors can get information and be involved in educational activities designed to ensure their continuous medical education. As a proof of this lies the very fact that time spent for study online by medical professionals has increased dramatically in recent years at international level. According to studies conducted in 2010 about this way of learning, citing data provided by the Accreditation Council of CME activities (ACCME) to the U.S. for example, workload spent on the Internet for obtaining CME credits has tripled in just six years,the number of doctors who participated in online training activities increasing 10 times in the same period. Moreover, according to the latest statistics on the subject, further training and obtaining CME credits online will maintain its upward trend worldwide. By 2016 it is estimated that doctors will get via the internet about 50% of the required credits.

2. The development of e learning courses in basic medical education and

postuniversitary training. A growing number of reports draw attention to the need of adjustment of the offer in medical education to labor market needs and the knowledge-based society. Increasing relevance and compatibility of bachelor university programs in relation to labor market needs and changes induced by the knowledge society by developing new curricula and improving the internal quality assurance in higher education institutions of medicine at multiregional level are some of the mentioned priorities. Innovations in e-Learning technologies point toward a revolution in education, allowing learning to be individualized (adaptive learning), enhancing learners' interactions with others (collaborative learning), and transforming the role of the teacher. The integration of e-Learning into medical education can catalyze the shift toward applying adult learning theory, where educators will no longer serve mainly as the distributors of content, but will become more involved as facilitators of learning and assessors of competency. E-Learning can be used by medical educators to improve the efficiency and effectiveness of educational interventions in the face of the social, scientific, and pedagogical challenges noted above. More, e-Learning presents numerous research opportunities for faculty, along with continuing challenges for documenting scholarship. Our previous experience in medical_e- learning included the coordination of 2 LDV projects. 1. LDV Pilot Project RO/04/B/F/PP 17 5006, entitled Training Centre for Health Care, Prophylactic and Rehabilitation Services, coordinated by the University of Craiova, and having as partners: Prefecture of Dolj County, FUKO Universitary Foundation For Kinetoterapy Oradea, University Of Oradea., Hogeschool West-Vlaanderen , Belgium, Entente UK., SCUE / Studio Di Consulenza Per Lunione Europea, Italy and Technical University Of Crete, Greece Start date 1-03-2005; end date 1-03 2007 The necessity of this project was explained by the changes that took place in Romania in the last years with a strong impact on various organizational structures (as medical or educational ones), requirering new and dynamic trainings approaches, pedagogical abilities in the educational system in strict relationship with the increased demands of society concerning prophylaxis and rehabilitation. We had to consider that kinetotherapist profession (the equivalent of physiotherapist/kinsithrapeut in Europe) is a new one on the labour market in Romania and because of this, there are few places in Romania where they could develop good routines by following specific standards and procedures. For this purpose we developed a Training Center for Health Care, Prophylactic and Rehabilitation Services where students and recent graduated kinetotherapists can improve their practical knowledge by working directly with patient under guiding and supervision of specialists. The other final products consisted in elaboration of new modules of formation, new training approaches (working with the patient, interactive learning through open distance system), manuals and CD ROMs, available also on the WEB site of the project. The main objectivese of the project were: to offer a well equipped center where under and post graduated kinetotherapists, can develop good routines in the rehabilitation process by following specific standards and procedures by working directly with patient under guiding and supervision of specialists. This will offer new forms of learning and developing basic skills in vocational and educational training, (improving the quality of training process).

 to achieve and utilize new knowledge, equipments and technologies that will assure an optimal use of competencies to develop and adapt the most efficient procedures with good results for the prevention and rehabilitation in various pathologies, offering new pathways to achieve specific training. to offer to disabled people and to other people with special needs from our region a place where they can be treated and rehabilitated with no cost at all, offering social protection to implementate lifelong learning strategies by elaborating a new curricula adapted to European standards and creating a virtual center to create learning material (manuals, CDs) with specific information to help continuing vocational training after the programme ends and also to help the dissemination of the project The target group included students and young graduates in kinetotherapy The main results were: 1. The Training Centre for Health Care, Prophylactic and Rehabilitation Services including adapted infrastructure, specific equipement and technologies; computer network 2. Surveys. During the first half of the project implementation the partnership carried on an exhaustive survey about the teaching and training in the field of kinetotherapy in each partner country, starting from the analysis of local universities programmes and then extending the research to national and European level (questionnaires). Common European education, such as degrees, study programmes, curricula, methods, learning material), information on transparency (skills profiles, occupational profiles etc) were taken into consideration. Several materials were eleborated: Report regarding Kinetoterapy Education in Europe . (media written in English, 76 pg. and annexes). The information within the report is designed to meet the needs of those who are involved in either the acquisition, promotion or provision of post-basic and post-graduate education for physiotherapists . The goal was to provide information, for both physiotherapists and the appropriate authorities within the European Region, on the concepts and principles that underliyne lifelong learning within our profession and the availability of basic education for physiotherapists across Europe. Informations are based on reports of WCPT (World Confederation for Physical Therapy) and own research. National report (media written in Romanian, 140 pg. and annexes). It tries to offer a guidelines for Romanian institutes and stakeholders wanting to start physiotherapy education or (in most cases) to restructure and renew their current physiotherapy curriculum, describing a full methodology to do so. It is structured in 3 chapters and annexes: introduction, synthesis of educational aspects regarding kinetotherapy education in Europe, standards and competencies in kinetoterapy, including also the list of interventions adressesd to the Romanian Ministry of Education and Research. European standards and competencies in kinetoterapy . (media written in English, 31 pg.). A description of competences, standards for registered kinesiotherapists , credit allocation for each competence, based on a consultation at European level and relevant national levels of different stakeholders. European curricula in kinetoterapy ( media written, English, 74 pg.). The present document was drawn in order to attain compatibility assurance between Romanian higher education system and other European systems, offering examples of good practice in curricular development by countries with great experience. Taking into account the experience exchanges using this project the team members selected bibliographic and action references in order to develop the universitary curriculum, through implementation in analytical programme of

a didactical strategy set, for increasing the quality standards for the formation of physical therapy professionals. The result consisted in designing a competence based curricula including the allocation of ECTS-credits to educational modules The target levels of this project are first (bachelor) and second (master) level. Third level studies like PhD, post-doctoral studies and post graduate studies, and links between profession, education and research can be targeted in a subsequent project. A Web site and a virtual center ( http://www.cerps.tuc.gr/) . The aim was to offer a gateway for information on European educational and skills based programmes for bachelor and post-graduate learning in kinetoterapy/ physiotherapy. The WEB site of the programme was inserted from the beginning of the project and performs a number of different functions, in accordance with the aims and objectives of the project. The first function was to support the project team in its communications, which it does by providing a central repository for documents, and a forum for discussions. This allows the team to communicate and consult on project outputs with the immediate project team and with the kinetotherapy community at large. The website has a public interface, designed for students, physiotherapists, kinetoterapists, employers and employees, researchers, educators, and anybody else with an interest in kinetoterapy This provides useful information on kinetoterapy/ physiotherapy related topics such as: articles on kinetoterapy topics, & safe and healthy physical activity, published documents produced by the project; Kinetotherapy related events. In addition, a list of educational centers in kinetotherapy and in physiotherapy available in Europe, is being compiled and constantly updated. The aim is to offer a gateway for information on European educational and skills based programmes for bachelor and post-graduate learning in kinetoterapy/ physiotherapy. The virtual center has an educational platform that provides courses and practical activities for each important field in kinetotherapy and on line tests. It includes 10 packages of on-line courses just tailor made on the specific needs of the target group. Each training module is formed by, course curricula, practical works curricula, manual and CD. The courses are modular and include on-line evaluation questionnaires. For each course, the trainees have the possibility to download in electronic format a handout for future reference; The on-line questionnaire meant to help the student to evaluate their competencies, to discover their strengths and weaknesses, and to act consequently; several courses will be recommended in order to satisfy the specific needs. New methodologies of training were also developed (new methods in kinetoterapy, e-Learning, on line courses). The innovation, and also the added value of the project consists in the use of eLearning approaches for the first time in Romania in this specific field. Innovative approaches were also represented by the introduction in the project of a new concept of psychology applied to physical rehabilitation training and physiotherapy of pain, reahabilitation in endocrine pathology. Curricula in the field was updated and renewed not only from the point of view of contents (materials, programmes, subjects, etc), but also and above all in terms of methodology and attitude towards the profession. We consider also as an innovative aspect the fact that the CERPS project aimed in creating the premises for improving the quality of the kinetotherapy education by developing new approaches by developing web-based powerful tools and methodologies. In this way our project makes an original contribution to introducing changes into national vocational training systems and practices and adopting European strategies for vocational training. Europe's future economy and society are being formed in the classrooms of today. Students need to be

both well educated in their chosen field and digitally literate if they are to to take part effectively in tomorrow's knowledge society. 2. LDV TOI project e-Learning educational center in medicine/ eEDUMED e-EDUMED (e-Learning Educational Center in Medicine) is a two year European funded project 2010-1-RO1-LEO05-07378 /contract LLP/LdV/TOI/RO/2010/006) aiming to answer to the needs of medical staff in improvement/updating/accessibility/equal chances to knowledge and harmonization in training of medical specialists . The 2year e-EDUMED project straded in january 2011 and will finish in January 2013. The consortium is formed by higher education institutions and.having a long standing reputation for providing student-centred, innovative programmes of health education, The partners have long lasting professional cooperation at international level.- University of Craiova (project coordinator), Ecomedica (RO), INNOVAMED
Medical and Educational Development (HU), Profi-Mdia (HU), FOR.COM (IT), AGPPMP Sunnymed Ltd (BG).

The present project whishes to enhance the acces, development and quality of higher education for health care professionals, developing an European dimension by e-Learning, based on the results of 2 previous EU projects, recte PEDITOP and MeditopE (www.meditopEU.com). PEDITOP won the HELSINKI AWARD, as one of the best Leonardo projects in Europe. The project aimes to answer to the needs of medical staff in improvement/updating/accesibility/equal chances to knowledge, as well as and harmonisation in higher education by implementing e-Learning solutions in medical education. It addresses to nurses, medical students, young doctors in specialisation (residents) and specialists in medical practice as well as to training and vocational training institutions, hospitals, involving new languages as Romanian and Bulgarian added to previous used language: Czech, English, Italian, German, Hungarian, and Spanish Together we aim to develop a complex Web site in English and partners languages and a virtual health educational center, interprofessional in outlook; interdisciplinary in approach; intercultural in background; interactive in design and international in scope. In this way the developed e-Learning platform together with its users may be seen as an Educational Network. The E-Learning health education center will provide on-line education and training materials, by an interactive lifelong learning platform. 2 interactive training modules in ultrasound and nurses education and a module addressed to patients aiming to improve health culture (general presentation of each disease from other training modules) will be developed. A glossary for medical terms will help in understanding specific issues. The selected approach will be based on modular three-level architecture (presentation level, intermediate level, data level). The student can choose the level and/or type of training (resident, competence in echograpy, LL training). For each module there will be out-line courses (PPT presentations); on-line courses: packages including a section for patient history, clinical signs, paraclinical evaluations, echographic imagines, an evaluation and self assessment software. The system will provide a feedback by showing students the correct diagnosis. Products available at this moment: are reports and comparative studies between the participants countries regarding the state of art and needs in medical educational field and the project Web site (http://www.e-edumed.ro) The impact envisaged consist in offering an EU dimension and helping the harmonisation in higher medical education. Harmonisation will be attained for training curricula, learning methods, communication systems and specific language, mechanisms for exchanging experiences, evaluation and certifications. For sectors (education, health) it will offer an development and updating of

competencies on EU level, both at work and on personal level. Morever the project could serve as a model for transfer to the health sector as a whole. Regarding the topic of the present conference, we wish to present the results of our e-EDUMED comparative report regarding E-LEARNING in medical education for participant countries . This report is the result of a research conducted in Romania, Italy, Bulgaria and Hungary, aiming to: 1. analyse the training needs in medicine and state of art of medical learning in participant countries; 2. define the needs of the target group 3. identify e-Learning level in medical education in participants countries; 4. offer a general image of the Educational contexts in Ultrasound and Educational Contexts in Nursing Profession Education 5. define the professional competences in ultrasound and nurse education 6. describe the reference levels, certification principles and VET methods and programmes in the field of echography and nurses education in participants countries 7. offer a realistic and uptodate image of health care systems training needs for partner countries, informations about VET and eLearning prospects in medical education in an European approach 8. present the best practices concerning current e-Learning methodologies in medical education in EU as well as the EU Policy in e-Learning. The methodology. The National Reports and the comparative report have been conducted gathering results come from a documentary research and a field work survey. Field work research summarizes information come from Paper/electronic by completing of special designed questionnaires. Questionaires were developed, taking into consideration the structure of the target group. In this way we have developed 3 types of questionnaires administered to representatives of target group (Doctors and Nursing Professionals, Medical Students, Managers, Academic Medical Staff)- (available on the project Web site). The aim of those questionnaires was to evaluate the perceived level of IT ability and accessibility, the experiences and attitudes towards e-Learning and clinical skills training, the interest in courses developed by our platform, to identify what information and in which form would make the professional development easier, to quantify the training need for each ISCO medical category. This had to be done before the designing of our e-Learning module began, in order to estimate the previous experience of using ICT and e-Learning as students and teachers, and to allow our tutors to prepare for our range of ICT skill levels. Questionaires were provided in English and have been translated into each national language in order to increase the impact of communication and the quality results of field word research. They have been posted on the project web site, administered by hand, by email and as a basis for phone interviews. Emails to invite to contribute to the survey and fill the questionnaire have been sent to the main contacts representatives of target group. The Italian version of questionnaires has been uploaded into Survey Monkey, an online survey software & questionnaire, in order to easily collect more responses and support data processing https://www.surveymonkey.com/s/e_edumed; https://www.surveymonkey.com/s/eedumed_manager Reponses have been collected, processed and summarized, offering a national image for each participant country. Documentary research summarizes information gathered from Universities institutional websites, Ministry of Education, private and public training agencies, professional networks and associations, different professional publications,

mentioned in the bibliographic references. In this way the report refers to the curent state of art of medical e-Learning in participant countries; offers a comparative analysis of health care systems training needs for partner countries, informations about VET and e Learning prospectives in medical education in an European approach and presents the best practices concerning current e-Learning methodologies in medical education in EU as well as the EU Policy in e-Learning The development and perspective of e-Learning in medical education in participat countries, as shown by our analyse, can be synthetise as follows. Continuing Medical Education In all countries, Continuing Medical Education or CME courses are required for continued licensing. CME requirements vary by country. In Bulgaria this kind of education is implemented in accordance with the European regulations and practice. It states that each medical doctor (or nursing professional) has to obtain 150 credits during 3 years. In Italy the programme ECM (Continuous Training in Medicine) has been regulated by the Decision of the National Commission ECM on 13/01/2010. Ministries of Education, Health and Agenas Agency assess and certify ECM (Continuous Medical Education) training providers (Universities, Hospitals itself, Training Agencies, etc). Quality of Education, didactic team, services, credits system applied, structures are evaluated and assessed. A list of certified Providers is published on Official Public Websites. Compared with the previous years, there are some changes which aim to develop an ongoing monitoring of individual areas of competencies. It is confirmed, same as in the past, that a health Professionals must achieve 150 learning credits in 3 years 2011 2013 (50 credits per year - minimum 25 and maximum 75). It is not possible to use the credits earned during the past years. In Romania the management of CME activities is conducted by the Romanian College of Physicians by the national continuing medical education program in accordance with the procedures provided for in this Decision, directives and recommendations of the European Community (EC) or with agreements and mutual recognition of credits as established with European Union of Medical Specialists/European Accreditation Council for Continuing Medical Education (UEMS/EACCME), and with other medical authorities or professional bodies on European and national level, involved by the nature of their work, in education or continuing professional development of physicians. Credits earned by doctors from participating in CME activities contribute to the composition score of medical professional. Assessment score for a professional doctor is done regularly, at a 5-year period. he minimum number of CME credits that a doctor needs to accumulate for regular professional evaluation is 200 for 5 years, set by the date of evaluation, or 40 annually for retirees seeking the annually aprouval for extended activity. Participation in CME activities should be mainly in the field of specialisation. It is admited than maximum one third of the minimum score to be represented by the educational activities of other specialty medical fields than basic. If medical doctors do not realize the minimum number of CME credits, free right to practice is suspended, according to the law, pending to the realization of the requested number of credits. The training activities recognised to earn credits are similar in studied countries and include: - In presence training/traditional training courses - Distance Learning courses - Individual Training

- Studies Groups, Commissions, Research Activities/projects, workshops,scientific events - Publishing activities - Clinic and /or assistance audits - Teaching and tutoring Limits of acceptance could be defined for some aforementioned activities. For example, in Italy pofessionals dont have to overlap 60% (or 90 credits) of total training activity through Distance courses. Furthermore, the number of credits awarded through the participation to sponsored events can be more than 50%. In Romania at least one third of required CME credits must be represented by participation in courses. Online Medical Education (Medical e-Learning) This type of education has attained different degrees of development in participants countries, even if efforts were carried on according to Eu policies. Regarding the higher education system, the level of implementation of the new learning technologies as well as of up-to-date ICT infrastructure is quite high, mainly due to the involvement higher education institutions within European and international projects in the field of technology-enhanced learning or aiming at institutional development for all participant countries. Unfortunately, medical education is considered by many as one of the most conservative education providers in terms of methods used. Although other specialties, especially technical education, computer assisted education has long been integrated into educational curriculum, in medical education, this happens sporadically, mainly in the SE European countries. By studying the educational offer for the academic year 2010- 2011 in Romania it is easy to observe that none from all Universities of Medicine and Pharmacy in Romania have yet offers for online courses in the lists of postgraduate courses provided, although several reports show that over half the universities in Romania (58%) offer eLearning solutions in teaching and nondidactic activities. Most trainers that do not actually use these solutions (68%) say they would like to develop in the near future, it is said in a study commissioned by SIVECO Romania. Today's medical e-Learning learning is promoted in and by different projects or from the initiative of professional societies and the Romanian Medical College of Physicians (CMR). Even it is recognised that Distance courses for medical education is more suitable, in Bulgaria such kind of education it is also in its very beginning. There are problems in e-Learning, such as lack of sufficient e-Learning content; insufficient preparation and readiness of university lecturers and school teachers to use e-Learning technologies; insufficient didactical readiness of teachers to use e-Learning technologies; lack of a regulatory system in schools and in some universities to stimulate school and university teachers to develop and use eLearning content. At tertiary education levels, e-Learning elements are slowly being integrated intothe curricula at several universities, but these are rather isolated cases. In the best way we can tell that such e-Learning is yet to take off. Methodologies and tools for on line teaching and learning are not yet widely implemented at Bulgarian universities, but sone efforts and modest developments are already visible in this direction (Plodviv University, Medical University Sofia). Compared with the other countries, e-Learning in medical education in Italy is well developed. E-Learning platforms on ECM (Educazione Continua in Medicina Continuous Training in Medicine) are thus certified by Agenas http://ape.agenas.it/homeEsterno.aspx the Agency responsible for medical training on behalf of Ministry of Health http://www.salute.gov.it/ecm/ecm.jsp. A database of qualified providers is listed in the website of Agenas, other websites

with additional information and available courses/events are: www.e-ecm.it; www.corsiecm.it.. Some Hospital and Medical University are providers of Distance Medical learning itself. Some training providers are specialised in Distance Learning for Medical Education, other are specialised in blended medical learning. Key Issues revealed by the questionaires Analysis has been conducted processing information gathered from documentary and field work researches. The collected answers for the category managers and academic medical staff witness that continuous medical education is essential for job performance and efficiency since patients satisfaction strictly depends on medical professionals qualification and training. Being updated and informed about recent technologies, practices, medications absolutely influences the success of medical mission and the impact on patient health. As long as training activities have to be attended after working hours, managers think that 50 credits per year are too much, while 30 credits should be a more suitable request. Also is stipulated that it is very hard to earn requested credits. Sometimes hospitals, in order to cope with this problem, have defined periodical ward meetings (as well as clinic audit) as training sessions and assigned the requested number of credits. Most of Managers are quite interested either in e-Learning or mobile learning even if this last methodology/device it is not familiar. Digital divide is still an actual issue, in particular for 40/50/60 years old medical professionals. As concerns the domains on the web for e-Learning 100% of Managers are motivated to promote e-Learning in its Institution, but most only for courses based on theoretical concepts (i.e. about legal issues, safety, guideline and protocols, procedures, medicine for travel, approaches to specific patients, transversal topics, etc.. ). Many are sceptical about ultrasound or other topics which foreseen practical experience. For example, ultrasound techniques and diagnostic through images strictly require a period of work-shadowing or coaching in order to learn techniques and try them suddenly on site. They think that E-Learning is not suitable for topics that foresee practical experience. By the way, most of managers appreciate e-Learning and mobile learning methodologies added values, they want to use e-Learning platform for continuous education for employees either on free basis or on payment basis. If it is not free of charge, the use depends on the costs, the quality of the offer, and only for courses based on theoretical concepts. 100% of managers prefer the national language for the course information. But for some of them, English it is accepted as well since most of the medical publications are in English. 100% of managers are interested in all topics proposed (ultrasound, e-courses for Nursing Professionals, e ECHO-Atlas, Manual). Guideline and protocols have to be stressed as key topics for training courses in a private/public Hospital since medical categories have to be updated and informed. After a brief explanation of what are, the methodology and the benefits, 100% of managers are interested either in virtual classrooms (even if they dont have had any experience) or Forum on medical topics, ultrasound or nursing issues. As concerns Medical Doctors, Nursing Professionals, Medical Students, Residents, most of responses refer daily to the use of online sources; other information sources are all used, but with a various frequency, different from professional profiles. Moreover, most of them are daily interested in Medical Legislation, Medication, Medical events, Science & Research and Clinical issues. All medical doctors interviewed profiles stressed how continuous training is important.

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As concerns familiarity with e-tools, answers were strongly different between professional profiles. Students, more confident with digital tools know Chat, Audio conferencing, Video conferencing, Forum, e-mail groups, Internet Mobile/Mobile learning very well. They dont use WIKI, but they have heard about it. The majority of students reported good access to computers and the internet, both on and off campus and appear confident using IT. Overall students felt that eLearning had a positive impact on their learning of clinical skills and was comparable to other traditional forms of clinical skills teaching Also students rate e-Learning just as highly as other traditional methods of clinical skills teaching and acknowledge its integration in a blended approach, however they vary in their utilization of such learning environments. Developers of clinical skills curricula need to ensure e-Learning environments utilize media that encourage deeper approaches to learning. Medical Doctors and Nursing Professionals with a high work experience suffer from a low confidence with digital tools. All of them get use to Audio/Video conferencing, Forum, Internet and email, but they are not familiar with Chat, WIKI, e-mail groups, Internet Mobile/Mobile learning, they have never heard about them. 100% of responses daily use Internet and prefer receiving information by email. 100% of responses prefer or use to attend traditional courses or workshops to update medical skills and knowledge. Added values of E-Learning are not diffused. 100% dont have attended online courses either during University or post University courses. Notwithstanding, 100% of responses are curious about eLearning potential Medical Doctors/Nursing Professionals dont know mobile learning, but they would like to hear more about potential. Medical students are interested in mobile learning, even if they dont have ever benefited from them. None look for e-Learning courses in Internet until that time either . As concerns medical fields, many responses consider e-Learning methodology useful in particular to transfer concepts such as Guideline, Procedures and Protocol. It is more suitable for theoretical contents since images and practical interaction has to be learnt in presence. Most of responses assign an average of 30 hours per year of refreshment 100% of responses prefer an online platform free of charge for continuous education, rather than on payment basis. 100% of responses prefer national language for course information and content, but English would be fine as well since most of the Medical Publications/Manuals are in English . All mentioned topics for learning are interesting; but it mostly depends on the quality of the content . 100% of representatives of target group are interested in Virtual classrooms, after a brief explanation of what they consist in . 100% of responses are interested in Forum and sharing content with images for a second opinion. As concerns the last question, what information you need for your professional growth, many answers has been given, different from professional profiles: Medical Doctors/Nursing Professionals focused on Guideline, Protocols, Procedure, clinical issues; Students focused on new jobs and career opportunities, European new techniques, technologies, publications and Science and Research last innovations. They have a cross border overview. Conclusions In general terms we can affirm that the quick and continuous development of Health and Medical fields, as well as the pressing of progress in terms of

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technologies and management/organization, contribute to make more difficult the alignment of each competence profile to the requested changed standards. Three characteristics of Medical Professionals in terms of skills and abilities have been outlined: To know: have updated theoretical knowledge; To do: have technical or manual skills; To be: have communication and relations skills. Maintaining refreshed those three aspects of medical professional profiles means to be trained and informed. Moreover, some important remarks have to be underlined. Distance learning in medical education it is not broadly diffused. Medical Professionals (medical Doctors, Nursing professionals) use to attend workshops, job shadowing or traditional training courses to enhance their skills and in particular practice. Unfortunately, despite the efforts in the last years for the development of informatics networks, continous medical education by e-Learning platforms is still not fully developed. Training by e-Learning platforms, though appreciated for the offered advantages (low cost and flexibility) is rather a secondary option for representatives of training providers and employers. Arguments offered relates to the lack of direct contact between student and trainer and/or trainees, a number of technical barriers and the belief that the e- learning system is not suitable for a range of courses that emphasize communication and interactivity. The conclusions of our research underline severel identified needs in the field of medical e-Learning. 1. The need of using e-Learning in medical education is obvious as there was a great interest in e-Learning from all categories in the target group.. 2. The need and importance of continous medical training was recognised by all participants to our survey. As long as training activities have to be attended after working hours, managers think that 50 credits per year are too much, while 30 credits should be a more suitable request. E-Learning is accepted by all participants to our survey as the best method in gaining CME credits. 3. The need to increase the perceived level of IT ability and accessibility for medical and academic staff Regarding familiarity with e-tools, answers were strongly different between professional profiles. The majority of students reported good access to computers and the internet, both on and off campus and appear confident using IT. Medical Doctors and Nursing Professionals with a high work experience suffer from a low confidence with digital tools. 4. The need to increase the experiences and attitudes towards eLearning and clinical skills training. Despite the great interest for e-Learning, most of the interviwed managers and academic medical staff prefer or use to attend traditional courses or workshops to update medical skills and knowledge. They have expressed their motivation to promote e-Learning in its Institution, but most only for courses based on theoretical concepts. Despite the affirmation most of subjects are interested in all topics proposed (ultrasound, e-courses for Nursing Professionals, e ECHOAtlas, Manual) that include a lot of practical issues. This is a proof that added values of E-Learning are not diffused. More, all subjects didnt have attended online courses either during University or post University courses. None look for e-Learning courses in Internet until that time either, that looks rather worring. 5. The need of development of high quality learning material in national language Most of the interviewed motivated they want to use e-Learning platform for continuous education for employees either on free basis or on payment basis. If it

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is not free of charge, the use depends on the costs, the quality of the offer. Also most of the subjects prefer the national language for the course information. But for some of them, English it is accepted as well since most of the medical publications are in English. 6. The need of certification/accreditation of e-Learning courses The accreditation of online learning is a validation process by which education providers are evaluated against established standards to ensure a high level of educational quality. To provide accredited courses, and to be an accredited education provider of online continuing medical education (CME), the provider must meet a set of stringent standards and criteria, as mentioned in standards and accreditation for e-Learning (www.elearners.com/resources/ accreditation.asp). In an ever-increasing global market it is clear that there is a need for a visible quality system, with standard defnitions and control to realise global harmonisation. Since CME systems evolve independently in each European state, doctors attending events outside of their home country would experience problems in collecting `valid' CME credits. National policies and alignament to the European Accreditation Council for CME (EACCME) is highly required. Our final conclusion is that integration of e-Learning into Medical Education is a process at its very beginning and requires a lot of work to be done. As discussed above, the range of opportunities for medical and clinical educators is very wide and it can seem a daunting menu from which to choose. What we have to underline regarding this issue is that even if there is an evident need for e-Learning solutions, the wide implementation of e-Learning requires more then just development of technological platforms. Changes in the institutional vision, management, and organisation, as well in the attitudes and practices of administrative and teaching staff, are also required. In our view, to overcome the above problems, a regulatory system has to be approved to stimulate, develop and use e-Learning content at all educational levels; good practices need to be disseminated; open-source software and eLearning environments with English and national language interfaces should be popularised; joint research concerning the technological and didactical issues of e-Learning have to be conducted on a larger scale; and more universities should offer Masters programmes in e-Learning education. The integration of e-Learning into existing medical curricula should be the result of a well-devised plan that begins with a needs assessment and concludes with the decision to use e-Learning.Although some institutions have tried to use eLearning as a stand-alone solution to updating or expanding their curricula, we believe it is best to begin with an integrated strategy that considers the benefits and burdens of blended learning before revising the curriculum. Until now it is recognised that Distance course for medical education is more suitable for theoretical concepts (guideline, procedures, protocols, legal frameworks, or cross issues such as security, patient approach, preclinical disciplines). IOnline education can have a real value for theoretical module (Teaching and assessment) by providing recent and systematized, specific information, in a didactic approach, a real opportunity for online evaluation of theoretical knowledge and possibility of simulation of examination. The eplatform also can be valuable in preparing for practical test examinations and video examination, but also to support video on line examinations. Other advantages consist in the possibility of accessing material at any time and from any location, the sharing of information between students on the forum, opportunity of brainstorming, access to trainer s opinion and Second Opinion,

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noting the added value by the quality and systematisation, prompt accessof materials from anywhere. E-Learning doesnt have to substitute the practice but should aim at strongly enhancing the skills and knowledge of medical professionals to be better prepared to practice. More, it can be used for case studies, high quality of content, group discussions and practical information. As information technology is a flexible and powerful tool able to make the difference, 3D images, videos and virtual classrooms can support medical and nursing professionals in training without having the presumption to be exhaustive, but propaedeutical to practice. In continuous professional training and obtaining CME credits, on line training is a reliable and superior alternative to classic courses that require accommodation, time, etc.. and can be used fully in the development of courses EMC credited, offering a perfect option for continuing professional development and formal education in the possibilities offered for review and updating knowledge, sharing information and brainstorming. Other issues that we fiind important sor the development of medical e-Learning include raising the awarness and interest of medical professionals in e-Learning by: - Providing informations about e-Learning and its benefits, encouraging and initiating the Training of the Trainers (medical and academic staff); encouraging the training of the learners; increased dissemination on all levels (hospitals, universities, professional organisations, decision makers); - Transfer of the report to the Ministries of Health, Ministries of Education, Universities of Medicine in the participant countries and posting it on the project web site - informing other bodies interested in e-Learning and identified as references on the mailing list about the present report and the opportunity of becoming for users in our platform by newsletter - Maintaining the used questionnaires on project website http://www.e edumed.ro by appealing to visitors to help us in expanding research to other geographical areas. -A study to research the effectiveness of developing and using a generic introductory session to introduce the concept and use of online learning would be usefull. This could be related to providing a bridging step between traditional and online delivery for staff development. It could equally be related to the introduction of online elements within courses, which are going to become more evident over the next few years, and be used to ensure learners have the skills they need. - Networking with other medical educators carried out through professional associations, medical Colleges, or education meetings or through online communities. Staff or faculty development activities and distance and e-Learning programmes in medical or clinical education can also help identify or provide ideas for further training or development or future career options. Bibliography

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