articol extenso e comm

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

Taina Avramescu, Prof, MD, PhD

University of Craiova

AbstractThe present paper wishes to offer a general overview of Web-based learning inMedical Education in several European countries, based on the research, resultsand experience gained by an international partnership in 2 LDV projects.Documentary investigations and surveys were carried out to determine thenature, degree and scope of distribution in medical e-Learning across Europe.

Apart from outlining the major characteristics of web based learning it focuses onseveral particular issues of its implementation in contemporany medical

education, good points, bad points, further analysis of training expectations andlacks.

IntroductionSignificant changes occur lately in the healthcare sector. More, as the context ofmedical education is changing, new challenges occur. All areas of healthcare andeducation are moving towards more professionalised systems and expectationsfrom those involved. Swanwick (2008) suggests that postgraduate medicaleducation is moving into a new era driven by the three interlinked trends ofprofessionalisation, increasing accountability and the pursuit of excellence.Professionalisation also involves the idea of continuing development andrevalidation. 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 oron the job and which may be measured through formal assessment or moreinformally in practice. They should then aim to keep up to date in their areathrough continuing professional development activities (CPD)

Judy McKimm (2009) considers that the main challenge for medical educatorsand clinicians when engaging in professional development is to reach acombination of staying current in terms of clinical or scientific knowledge andskills whilst also staying up to date with contemporary teaching, learning andassessment methods, and in the mean time to deliver high quality teaching,learning, assessment and supervisory activities for medical students, trainerssand other health professionals. Managing development in both these aspects canbe very demanding, particularly for clinical educators who also have to deliverthe health service.A flexible training offer by developing an online learning community to providethe resources and digital materials to those interested in medicine and to supportthe development of e -learning strategies, e learning courses, encouraginglearning by doing, with opportunities for reinforcement and consolidation throughreflections shared and feedback from tutors and peers is a real necessity.However, as a young and relatively new area, it is expected that this basicpedagogic model will continue to evolve in line with advances being made inresearching 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. Withinthe framework ofLeonardo da Vinci WBT WORLD project , RO/02/B/F/PP 141053 a

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Report on the Best Practices in Web-Based Learning across Europe waseleborated. This report turned out that a great number of educational institutionsprovide a form of web-based learning starting from as early as comprehensiveschools and getting as far as university programmes for undergraduate andpostgraduate students. The number of participating countries is increasing, moreaspects of higher education are included and the number of activities andprojects is growing.Despite of this positive aspects, medical education has so far been neglected inthe process and awareness of the development at medical schools has beenlimited. Repositories or digital libraries have been established to manage accessto e-Learning materials, but they are few at this time, even if it is a well knownfact that the position of medical education towards the Bologna Process isessential. A survey conducted by the Time Centre of Grenoble Ecole deManagement on behalf of the European Commission, june 2007, showed thatthe e-Learning Initiative created a dynamic around e-Learning in Europe, but thegeographical origin of the partners stems from France, UK, Italy, Germany, Spainand Belgium, so the eLearning Initiative did not manage to equally reach all of EU

countries, recte Romania,Bulgaria and HungaryMore, very few LDV projects in RO, but also in other European countries adress tothe medical field. LDV Action 142835- LLP-1-2008-1-IT-Leonardo-LMP identifiedmany indicators showing the huge training needs felt as an acute problem in thehealth 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 conceptfor most professions, no matter what activity we're talking. This becomes evenmore important in medicine, where patients' lives depends on the doctor's abilityto 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 technologygained ground in recent years in medical education at international level and inthe process of obtaining credentials for practicing physician, also influencing themethods used now in the process of learning.Regardless of country that is, to continue to practice, doctors must obtainannually a certain number of CME credits (Continuing Medical Education). Thescore varies with each state being established by some institutions in the medicalfield. Until recently, medical conferences and seminars on various specializedcourses or subscription to periodicals, were the only ways available for furthertraining.Learning on the Internet by the "e learning" method, fundamentally changed the

way by which doctors can get information and be involved in educationalactivities designed to ensure their continuous medical education.As a proof of this lies the very fact that time spent for study online by medicalprofessionals has increased dramatically in recent years at international level.According to studies conducted in 2010 about this way of learning, citing dataprovided by the Accreditation Council of CME activities (ACCME) to the U.S. forexample, workload spent on the Internet for obtaining CME credits has tripled in

just six years,the number of doctors who participated in online training activitiesincreasing 10 times in the same period.Moreover, according to the latest statistics on the subject, further training andobtaining CME credits online will maintain its upward trend worldwide. By 2016 itis estimated that doctors will get via the internet about 50% of the required

credits.

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2. The development of e learning courses in basic medical education andpostuniversitary training. A growing number of reports draw attention to theneed of adjustment of the offer in medical education to labor market needs andthe knowledge-based society. Increasing relevance and compatibility of bacheloruniversity programs in relation to labor market needs and changes induced by

the knowledge society by developing new curricula and improving the internalquality assurance in higher education institutions of medicine at multiregionallevel are some of the mentioned priorities. Innovations in e-Learning technologiespoint toward a revolution in education, allowing learning to be individualized(adaptive learning), enhancing learners' interactions with others (collaborativelearning), and transforming the role of the teacher. The integration of e-Learninginto medical education can catalyze the shift toward applying adult learningtheory, where educators will no longer serve mainly as the distributors ofcontent, but will become more involved as facilitators of learning and assessorsof competency.E-Learning can be used by medical educators to improve the efficiency andeffectiveness of educational interventions in the face of the social, scientific, and

pedagogical challenges noted above.More, e-Learning presents numerous research opportunities for faculty, alongwith continuing challenges for documenting scholarship.Our previous experience in medical_e- learning included thecoordination of 2 LDV projects.1. LDV Pilot Project RO/04/B/F/PP 17 5006, entitled Training Centre forHealth Care, Prophylactic and Rehabilitation Services, coordinated by theUniversity 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 DiConsulenza Per Lunione Europea, Italy and Technical University Of Crete,GreeceStart date 1-03-2005; end date 1-03 2007

The necessity of this project was explained by the changes that took place inRomania in the last years with a strong impact on various organizationalstructures (as medical or educational ones), requirering new and dynamictrainings approaches, pedagogical abilities in the educational system in strictrelationship with the increased demands of society concerning prophylaxis andrehabilitation. We had to consider that kinetotherapist profession (the equivalentof physiotherapist/kinsithrapeut in Europe) is a new one on the labour marketin Romania and because of this, there are few places in Romania where theycould develop good routines by following specific standards and procedures. Forthis purpose we developed a Training Center for Health Care, Prophylactic and

Rehabilitation Services where students and recent graduated kinetotherapistscan improve their practical knowledge by working directly with patient underguiding and supervision of specialists. The other final products consisted inelaboration of new modules of formation, new training approaches (working withthe patient, interactive learning through open distance system), manuals and CDROMs, 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 graduatedkinetotherapists, can develop good routines in the rehabilitation process byfollowing specific standards and procedures by working directly with patientunder guiding and supervision of specialists. This will offer new forms of learningand developing basic skills in vocational and educational training, (improving the

quality of training process).

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to achieve and utilize new knowledge, equipments and technologies that willassure an optimal use of competencies to develop and adapt the most efficientprocedures with good results for the prevention and rehabilitation in variouspathologies, 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 curriculaadapted to European standards and creating a virtual center to create learning material (manuals, CDs) with specific information to helpcontinuing vocational training after the programme ends and also to help thedissemination of the project

The target group included students and young graduates in kinetotherapyThe main results were:1. The Training Centre for Health Care, Prophylactic and Rehabilitation Servicesincluding adapted infrastructure, specific equipement and technologies;computer network

2. Surveys. During the first half of the project implementation the partnershipcarried on an exhaustive survey about the teaching and training in the field ofkinetotherapy in each partner country, starting from the analysis of localuniversities programmes and then extending the research to national andEuropean 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 wereeleborated:Report regarding Kinetoterapy Education in Europe . (media written inEnglish, 76 pg. and annexes). The information within the report is designed tomeet the needs of those who are involved in either the acquisition, promotion or

provision of post-basic and post-graduate education for physiotherapists . Thegoal was to provide information, for both physiotherapists and the appropriateauthorities within the European Region, on the concepts and principles thatunderliyne lifelong learning within our profession and the availability of basiceducation for physiotherapists across Europe. Informations are based on reportsof WCPT (World Confederation for Physical Therapy) and own research.National report(media written in Romanian, 140 pg. and annexes). It tries tooffer a guidelines for Romanian institutes and stakeholders wanting to startphysiotherapy education or (in most cases) to restructure and renew their currentphysiotherapy curriculum, describing a full methodology to do so. It is structuredin 3 chapters and annexes: introduction, synthesis of educational aspects

regarding kinetotherapy education in Europe, standards and competencies inkinetoterapy, including also the list of interventions adressesd to the RomanianMinistry of Education and Research.European standards and competencies in kinetoterapy . (media written inEnglish, 31 pg.). A description of competences, standards for registeredkinesiotherapists , credit allocation for each competence, based on a consultationat European level and relevant national levels of different stakeholders.European curricula in kinetoterapy ( media written, English, 74 pg.). Thepresent document was drawn in order to attaincompatibility assurance betweenRomanian higher education system and other European systems, offeringexamples of good practice in curricular development by countries with greatexperience. Taking into account the experience exchanges using this project the

team members selected bibliographic and action references in order to developthe universitary curriculum, through implementation in analytical programme of

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a didactical strategy set, for increasing the quality standards for the formation ofphysical therapy professionals. The result consisted in designing a competencebased 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, andlinks between profession, education and research can be targeted in asubsequent project. A Web site and a virtual center( http://www.cerps.tuc.gr/) . The aimwas to offer a gateway for information on European educational and skills basedprogrammes for bachelor and post-graduate learning in kinetoterapy/physiotherapy. The WEB site of the programme was inserted from the beginningof the project and performs a number of different functions, in accordance withthe aims and objectives of the project. The first function was to support theproject team in its communications, which it does by providing a centralrepository for documents, and a forum for discussions. This allows the team tocommunicate and consult on project outputs with the immediate project teamand with the kinetotherapy community at large. The website has a public

interface, designed for students, physiotherapists, kinetoterapists, employersand employees, researchers, educators, and anybody else with an interest inkinetoterapy This provides useful information on kinetoterapy/ physiotherapyrelated topics such as: articles on kinetoterapy topics, & safe and healthyphysical activity, published documents produced by the project; Kinetotherapyrelated events. In addition, a list of educational centers in kinetotherapy and inphysiotherapy available in Europe, is being compiled and constantly updated.

The aim is to offer a gateway for information on European educational and skillsbased programmes for bachelor and post-graduate learning in kinetoterapy/physiotherapy.

The virtual center has an educational platform that provides courses andpractical 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 ofthe target group. Each training module is formed by, course curricula, practicalworks curricula, manual and CD. The courses are modular and include on-lineevaluation questionnaires. For each course, the trainees have the possibility todownload in electronic format a handout for future reference; The on-linequestionnaire meant to help the student to evaluate their competencies, todiscover their strengths and weaknesses, and to act consequently; severalcourses will be recommended in order to satisfy the specific needs.New methodologies of training were also developed (new methods inkinetoterapy, e-Learning, on line courses).

The innovation, and also the added value of the project consists in the use of e-

Learning approaches for the first time in Romania in this specific field.Innovative approaches were also represented by the introduction in the project ofa new concept of psychology applied to physical rehabilitation training andphysiotherapy of pain, reahabilitation in endocrine pathology. Curricula in thefield was updated and renewed not only from the point of view of contents(materials, programmes, subjects, etc), but also and above all in terms ofmethodology and attitude towards the profession.We consider also as an innovative aspect the fact that the CERPS project aimedin creating the premises for improving the quality of the kinetotherapy educationby developing new approaches by developing web-based powerful tools andmethodologies. In this way our project makes an original contribution tointroducing changes into national vocational training systems and practices and

adopting European strategies for vocational training. Europe's future economyand society are being formed in the classrooms of today. Students need to be

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both well educated in their chosen field and digitally literate if they are to to takepart effectively in tomorrow's knowledge society.2. LDV TOI project e-Learning educational center in medicine/ e-EDUMEDe-EDUMED (e-Learning Educational Center in Medicine) is a two year Europeanfunded project 2010-1-RO1-LEO05-07378 /contract LLP/LdV/TOI/RO/2010/006)aiming to answer to the needs of medical staff inimprovement/updating/accessibility/equal chances to knowledge andharmonization in training of medical specialists . The 2year e-EDUMED projectstraded in january 2011 and will finish in January 2013.

The consortium is formed by higher education institutions and.having along standing reputation for providing student-centred, innovative programmesof health education, The partners have long lasting professional cooperation atinternational level.- University of Craiova (project coordinator), Ecomedica (RO), INNOVAMEDMedical and Educational Development (HU), Profi-Mdia (HU), FOR.COM (IT), AGPPMP SunnymedLtd (BG).

The present project whishes to enhance the acces, development and quality of

higher education for health care professionals, developing an Europeandimension by e-Learning, based on the results of 2 previous EU projects, rectePEDITOP and MeditopE (www.meditopEU.com). PEDITOP won the HELSINKIAWARD, as one of the best Leonardo projects in Europe. The project aimes toanswer to the needs of medical staff in improvement/updating/accesibility/equalchances to knowledge, as well as and harmonisation in higher education byimplementing e-Learning solutions in medical education. It addresses to nurses,medical students, young doctors in specialisation (residents) and specialists inmedical practice as well as to training and vocational training institutions,hospitals, involving new languages as Romanian and Bulgarian added toprevious 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 designand international in scope. In this way the developed e-Learning platformtogether with its users may be seen as an Educational Network.

The E-Learning health education center will provide on-line education andtraining materials, by an interactive lifelong learning platform. 2 interactivetraining modules in ultrasound and nurses education and a module addressed topatients aiming to improve health culture (general presentation of each diseasefrom other training modules) will be developed. A glossary for medical terms willhelp 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 thelevel and/or type of training (resident, competence in echograpy, LL training). Foreach module there will be out-line courses (PPT presentations); on-line courses:packages including a section for patient history, clinical signs, paraclinicalevaluations, 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 betweenthe participants countries regarding the state of art and needs in medicaleducational field and the project Web site (http://www.e-edumed.ro)

The impact envisaged consist in offering an EU dimension and helping theharmonisation in higher medical education. Harmonisation will be attained fortraining 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

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competencies on EU level, both at work and on personal level. Morever theproject 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 ofour e-EDUMED comparative report regarding E-LEARNING in medicaleducation for participant countries . This report is the result of a researchconducted in Romania, Italy, Bulgaria and Hungary, aiming to:1. analyse the training needs in medicine and state of art of medical learningin participant countries;2. define the needs of the target group3. identify e-Learning level in medical education in participants countries;4. offer a general image of the Educational contexts in Ultrasound andEducational Contexts in Nursing Profession Education5. define the professional competences in ultrasound and nurse education6. describe the reference levels, certification principles and VET methods andprogrammes in the field of echography and nurses education in participantscountries7. offer a realistic and uptodate image of health care systems training needs

for partner countries, informations about VET and eLearning prospects in medicaleducation in an European approach8. present the best practices concerning current e-Learning methodologies inmedical education in EU as well as the EU Policy in e-Learning.The methodology. The National Reports and the comparative report have beenconducted gathering results come from a documentary research and a field worksurvey.Field work research summarizes information come from Paper/electronic bycompleting of special designed questionnaires. Questionaires were developed,taking into consideration the structure of the target group. In this way we havedeveloped 3 types of questionnaires administered to representatives of targetgroup (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 abilityand accessibility, the experiences and attitudes towards e-Learning and clinicalskills training, the interest in courses developed by our platform, to identify whatinformation and in which form would make the professional development easier,to quantify the training need for each ISCO medical category. This had to be donebefore the designing of our e-Learning module began, in order to estimate theprevious experience of using ICT and e-Learning as students and teachers, andto allow our tutors to prepare for our range of ICT skill levels.Questionaires were provided in English and have been translated into eachnational language in order to increase the impact of communication and the

quality results of field word research. They have been posted on the project website, administered by hand, by email and as a basis for phone interviews. Emailsto invite to contribute to the survey and fill the questionnaire have been sent tothe main contacts representatives of target group.

The Italian version of questionnaires has been uploaded into Survey Monkey, anonline survey software & questionnaire, in order to easily collect more responsesand support data processinghttps://www.surveymonkey.com/s/e_edumed;https://www.surveymonkey.com/s/eedumed_managerReponses have been collected, processed and summarized, offering a nationalimage 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,

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mentioned in the bibliographic references. In this way the report refers to thecurent state of art of medical e-Learning in participant countries; offers acomparative analysis of health care systems training needs for partnercountries, informations about VET and e Learning prospectives in medicaleducation in an European approach and presents the best practices concerningcurrent e-Learning methodologies in medical education in EU as well as the EUPolicy in e-Learning

The development and perspective of e-Learning in medical education in participatcountries, as shown by our analyse, can be synthetise as follows.Continuing Medical EducationIn all countries, Continuing Medical Education or CME courses are required forcontinued licensing. CME requirements vary by country.In Bulgaria this kind of education is implemented in accordance with theEuropean regulations and practice. It states that each medical doctor (or nursingprofessional) has to obtain 150 credits during 3 years.In Italy the programme ECM (Continuous Training in Medicine) has beenregulated 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, creditssystem applied, structures are evaluated and assessed. A list of certifiedProviders is published on Official Public Websites.Compared with the previous years, there are some changes which aim to developan ongoing monitoring of individual areas of competencies. It is confirmed, sameas in the past, that a health Professionals must achieve 150 learning credits in 3years 2011 2013 (50 credits per year - minimum 25 and maximum 75). It is notpossible to use the credits earned during the past years.In Romania the management of CME activities is conducted by the RomanianCollege of Physicians by the national continuing medical education program in

accordance with the procedures provided for in this Decision, directives andrecommendations of the European Community (EC) or with agreements andmutual recognition of credits as established with European Union of MedicalSpecialists/European Accreditation Council for Continuing Medical Education(UEMS/EACCME), and with other medical authorities or professional bodies onEuropean and national level, involved by the nature of their work, in educationor continuing professional development of physicians. Credits earned by doctorsfrom participating in CME activities contribute to the composition score ofmedical professional. Assessment score for a professional doctor is doneregularly, at a 5-year period. he minimum number of CME credits that a doctorneeds 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 aprouvalfor extended activity.Participation in CME activities should be mainly in the field of specialisation. It isadmited than maximum one third of the minimum score to be represented by theeducational activities of other specialty medical fields than basic.If medical doctors do not realize the minimum number of CME credits, free rightto practice is suspended, according to the law, pending to the realization of therequested number of credits.

The training activities recognised to earn credits are similar in studied countriesand include:- In presence training/traditional training courses- Distance Learning courses

- Individual Training

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- Studies Groups, Commissions, Research Activities/projects, workshops,scientificevents- Publishing activities- Clinic and /or assistance audits- Teaching and tutoringLimits of acceptance could be defined for some aforementioned activities. Forexample, in Italy pofessionals dont have to overlap 60% (or 90 credits) of totaltraining activity through Distance courses. Furthermore, the number of creditsawarded 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 inparticipants countries, even if efforts were carried on according to Eu policies.Regarding the higher education system, the level of implementation of the newlearning 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 atinstitutional development for all participant countries.Unfortunately, medical education is considered by many as one of the mostconservative education providers in terms of methods used. Although otherspecialties, especially technical education, computer assisted education has longbeen integrated into educational curriculum, in medical education, this happenssporadically, mainly in the SE European countries.By studying the educational offer for the academic year 2010- 2011 in Romania itis easy to observe that none from all Universities of Medicine and Pharmacy inRomania have yet offers for online courses in the lists of postgraduate coursesprovided, although several reports show that over half the universities inRomania (58%) offer eLearning solutions in teaching and nondidactic activities.

Most trainers that do not actually use these solutions (68%) say they would liketo develop in the near future, it is said in a study commissioned by SIVECORomania. Today's medical e-Learning learning is promoted in and by differentprojects or from the initiative of professional societies and the Romanian MedicalCollege of Physicians (CMR).Even it is recognised that Distance courses for medical education is moresuitable, in Bulgaria such kind of education it is also in its very beginning. Thereare problems in e-Learning, such as lack of sufficient e-Learning content;insufficient preparation and readiness of university lecturers and school teachersto use e-Learning technologies; insufficient didactical readiness of teachers touse e-Learning technologies; lack of a regulatory system in schools and in some

universities to stimulate school and university teachers to develop and use e-Learning content. At tertiary education levels, e-Learning elements are slowlybeing integrated intothe curricula at several universities, but these are ratherisolated cases.In the best way we can tell that such e-Learning is yet to take off. Methodologiesand tools for on line teaching and learning are not yet widely implemented atBulgarian universities, but sone efforts and modest developments are alreadyvisible in this direction (Plodviv University, Medical University Sofia).Compared with the other countries, e-Learning in medical education in Italy iswell developed.E-Learning platforms on ECM (Educazione Continua in Medicina Continuous Training in Medicine) are thus certified by Agenashttp://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. Adatabase of qualified providers is listed in the website of Agenas, other websites

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with additional information and available courses/events are: www.e-ecm.it;www.corsiecm.it.. Some Hospital and Medical University are providers of DistanceMedical learning itself. Some training providers are specialised in DistanceLearning for Medical Education, other are specialised in blended medical learning.

Key Issues revealed by the questionaires

Analysis has been conducted processing information gathered from documentaryand field work researches.The collected answers for the category managers and academic medical staffwitness that continuous medical education is essential for job performance andefficiency since patients satisfaction strictly depends on medical professionalsqualification and training. Being updated and informed about recenttechnologies, practices, medications absolutely influences the success of medicalmission and the impact on patient health.As long as training activities have to be attended after working hours, managersthink that 50 credits per year are too much, while 30 credits should be a moresuitable 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 therequested number of credits.Most of Managers are quite interested either in e-Learning or mobile learningeven if this last methodology/device it is not familiar. Digital divide is still anactual issue, in particular for 40/50/60 years old medical professionals.As concerns the domains on the web for e-Learning100% of Managers are motivated to promote e-Learning in its Institution, butmost only for courses based on theoretical concepts (i.e. about legal issues,safety, guideline and protocols, procedures, medicine for travel, approaches tospecific patients, transversal topics, etc.. ).Many are sceptical about ultrasound or other topics which foreseen practicalexperience. For example, ultrasound techniques and diagnostic through imagesstrictly require a period of work-shadowing or coaching in order to learntechniques and try them suddenly on site. They think that E-Learning is notsuitable for topics that foresee practical experience.By the way, most of managers appreciate e-Learning and mobile learningmethodologies added values, they want to use e-Learning platform forcontinuous education for employees either on free basis or on payment basis. If itis not free of charge, the use depends on the costs, the quality of the offer, andonly for courses based on theoretical concepts.100% of managers prefer the national language for the course information. Butfor some of them, English it is accepted as well since most of the medicalpublications are in English.

100% of managers are interested in all topics proposed (ultrasound, e-courses forNursing Professionals, e ECHO-Atlas, Manual). Guideline and protocols have to bestressed as key topics for training courses in a private/public Hospital sincemedical categories have to be updated and informed.After a brief explanation of what are, the methodology and the benefits, 100% ofmanagers are interested either in virtual classrooms (even if they dont have hadany 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 informationsources are all used, but with a various frequency, different from professionalprofiles. 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 betweenprofessional profiles. Students, more confident with digital tools know Chat, Audioconferencing, Video conferencing, Forum, e-mail groups, Internet Mobile/Mobilelearning very well. They dont use WIKI, but they have heard about it. Themajority of students reported good access to computers and the internet, both onand off campus and appear confident using IT. Overall students felt that e-Learning had a positive impact on their learning of clinical skills and wascomparable to other traditional forms of clinical skills teachingAlso students rate e-Learning just as highly as other traditional methods ofclinical skills teaching and acknowledge its integration in a blended approach,however they vary in their utilization of such learning environments. Developersof clinical skills curricula need to ensure e-Learning environments utilize mediathat encourage deeper approaches to learning.Medical Doctors and Nursing Professionals with a high work experience sufferfrom a low confidence with digital tools. All of them get use to Audio/Videoconferencing, 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 receivinginformation by email.100% of responses prefer or use to attend traditional courses or workshops toupdate medical skills and knowledge. Added values of E-Learning are notdiffused.100% dont have attended online courses either during University or postUniversity courses. Notwithstanding, 100% of responses are curious about e-Learning potential Medical Doctors/Nursing Professionals dont know mobilelearning, but they would like to hear more about potential. Medical students areinterested 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 andProtocol. It is more suitable for theoretical contents since images and practicalinteraction has to be learnt in presence. Most of responses assign an average of30 hours per year of refreshment 100% of responses prefer an online platformfree of charge for continuous education, rather than on payment basis. 100% ofresponses prefer national language for course information and content, butEnglish would be fine as well since most of the Medical Publications/Manuals arein English . All mentioned topics for learning are interesting; but it mostlydepends 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 asecond opinion.As concerns the last question, what information you need for your professionalgrowth, 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 careeropportunities, European new techniques, technologies, publications and Scienceand Research last innovations. They have a cross border overview.

ConclusionsIn 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 difficultthe alignment of each competence profile to the requested changed standards.

Three characteristics of Medical Professionals in terms of skills and abilities havebeen 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 meansto be trained and informed.Moreover, some important remarks have to be underlined. Distance learning inmedical education it is not broadly diffused. Medical Professionals (medicalDoctors, Nursing professionals) use to attend workshops, job shadowing ortraditional training courses to enhance their skills and in particular practice.Unfortunately, despite the efforts in the last years for the development ofinformatics networks, continous medical education by e-Learning platforms is stillnot fully developed.Training by e-Learning platforms, though appreciated for theoffered advantages (low cost and flexibility) is rather a secondary option for

representatives of training providers and employers. Arguments offered relatesto the lack of direct contact between student and trainer and/or trainees, anumber of technical barriers and the belief that the e- learning system is notsuitable for a range of courses that emphasize communication and interactivity.

The conclusions of our research underline severel identified needs in the field ofmedical e-Learning.1. The need of using e-Learning in medical education is obvious as therewas a great interest in e-Learning from all categories in the target group..2. The need and importance of continous medical training was recognisedby all participants to our survey. As long as training activities have to beattended after working hours, managers think that 50 credits per year are toomuch, 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 staffRegarding familiarity with e-tools, answers were strongly different betweenprofessional profiles. The majority of students reported good access to computersand the internet, both on and off campus and appear confident using IT. MedicalDoctors and Nursing Professionals with a high work experience suffer from a lowconfidence with digital tools.4. The need to increase the experiences and attitudes towards e-Learning 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 workshopsto update medical skills and knowledge. They have expressed their motivation topromote e-Learning in its Institution, but most only for courses based ontheoretical concepts. Despite the affirmation most of subjects are interested inall topics proposed (ultrasound, e-courses for Nursing Professionals, e ECHO-Atlas, Manual) that include a lot of practical issues.

This is a proof that added values of E-Learning are not diffused. More, all subjectsdidnt have attended online courses either during University or post Universitycourses. None look for e-Learning courses in Internet until that time either, thatlooks rather worring.5. The need of development of high quality learning material innational language

Most of the interviewed motivated they want to use e-Learning platform forcontinuous 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. Alsomost of the subjects prefer the national language for the course information. Butfor some of them, English it is accepted as well since most of the medicalpublications are in English.6. The need of certification/accreditation of e-Learning courses

The accreditation of online learning is a validation process by which educationproviders are evaluated against established standards to ensure a high level ofeducational quality. To provide accredited courses, and to be an accreditededucation provider of online continuing medical education (CME), the providermust meet a set of stringent standards and criteria, as mentioned in standardsand 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 visiblequality system, with standard defnitions and control to realise globalharmonisation. Since CME systems evolve independently in each European state,doctors attending events outside of their home country would experienceproblems 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 ofwork to be done.

As discussed above, the range of opportunities for medical and clinical educatorsis very wide and it can seem a daunting menu from which to choose. What wehave to underline regarding this issue is that even if there is an evident need fore-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 ofadministrative 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 educationallevels; good practices need to be disseminated; open-source software and e-Learning environments with English and national language interfaces should bepopularised; joint research concerning the technological and didactical issues ofe-Learning have to be conducted on a larger scale; and more universities shouldoffer Masters programmes in e-Learning education.

The integration of e-Learning into existing medical curricula should be the resultof a well-devised plan that begins with a needs assessment and concludes withthe decision to use e-Learning.Although some institutions have tried to use e-Learning as a stand-alone solution to updating or expanding their curricula, webelieve 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 moresuitable for theoretical concepts (guideline, procedures, protocols, legalframeworks, or cross issues such as security, patient approach, preclinicaldisciplines). IOnline education can have a real value for theoretical module(Teaching and assessment) by providing recent and systematized, specificinformation, in a didactic approach, a real opportunity for online evaluation oftheoretical knowledge and possibility of simulation of examination. The e-platform also can be valuable in preparing for practical test examinations andvideo examination, but also to support video on line examinations. Otheradvantages consist in the possibility of accessing material at any time and fromany 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 accessofmaterials from anywhere.E-Learning doesnt have to substitute the practice but should aim at stronglyenhancing the skills and knowledge of medical professionals to be betterprepared to practice. More, it can be used for case studies, high quality ofcontent, group discussions and practical information. As information technologyis a flexible and powerful tool able to make the difference, 3D images, videos andvirtual classrooms can support medical and nursing professionals in trainingwithout having the presumption to be exhaustive, but propaedeutical to practice.In continuous professional training and obtaining CME credits, on line training is areliable 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 formaleducation in the possibilities offered for review and updating knowledge, sharinginformation 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-Learningby:- Providing informations about e-Learning and its benefits, encouraging andinitiating the Training of the Trainers (medical and academic staff); encouragingthe 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 projectweb site- informing other bodies interested in e-Learning and identified as references onthe mailing list about the present report and the opportunity of becoming forusers in our platform by newsletter

- Maintaining the used questionnaires on project website http://www.eedumed.ro by appealing to visitors to help us in expanding research to othergeographical areas.-A study to research the effectiveness of developing and using a genericintroductory session to introduce the concept and use of online learning would beusefull. This could be related to providing a bridging step between traditional andonline delivery for staff development. It could equally be related to theintroduction of online elements within courses, which are going to become moreevident over the next few years, and be used to ensure learners have the skillsthey need.- Networking with other medical educators carried out through professional

associations, medical Colleges, or education meetings or through onlinecommunities. Staff or faculty development activities and distance and e-Learningprogrammes in medical or clinical education can also help identify or provideideas for further training or development or future career options.

Bibliography

1. Casebeer Li, Brown J, Roepke N, Grimes C, Henson B, Palmore R, Granstaff U,Salinas G.D, Evidence-based choices of physicians: a comparative analysis ofphysicians participating in Internet CME and non-participants, BMC MedicalEducation (www.biomedcentral.com), 2010.

2. Chumley-Jones HS, Dobbie A, Alford CL. Web-based learning: sound

educational method or hype? A review of the evaluation literature. Acad Med.2002;77 (10 suppl):S86-S93.

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Jalobeanu M, 2001, Lifelong learning and internet training. History, evolution,estimationshttp://jalobean.itim-cj.ro/Wbdl.htmlClinici T, 2005, ICT instruments in traditional and distance medical highereducation, PhD thesis, UMF Clujhttp://www.umfcluj.ro/Document_Files/Doctorat-Rezumate-Teze-de-Doctorat/00000199/cpmqk_calinici.pdf8. Leonardo da Vinci II WBT WORLDRO/02/B/F/PP 141053 2005 Report

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