E-LEARNING MEDICAL EDUCATION IN PARTICIPANT COUNTRIES e-EDUMED COMPARATIVE REPORT

Project Title of the document Elaborated by Work package / Task Dissemination level Date of the document File name E-EDUMED Comparative Report for participant Countries UNIVERSITY OF CRAIOVA WP4 Research and Reporting Highlighted needs in Medical Education PU 1 August 2011 E-EDUMED Comarative Report

ABSTRACT
The Document introduces a brief picture of learning needs in Medicine and Nursing Profession, e-learning training offer for medical doctor in ultrasound and for Nursing Professionals. A further analysis of training expectations and lacks is available as well.
The views expressed in the report are those of the authors and do not necessarily reflect those of the European Commission or of the National Agency Leonardo da Vinci, nor does involve any responsibility on their part

Executive Summary

1. 2. 3. 4. 5. 6. 7. 8. 9.

Purpose of the report Research methodology Comparative evaluation results Current state of art of medical e-learning in participant Comparative analysis of health care systems training needs VET and eLearning prospects in medical education an EU e-Learning and Europe - the best practices concerning The EU Policy in e-learning Conclusions

countries; for partner countries approach current e-learning methodologies in medical education in EU

Bibliographical references Annexes

1. PURPOSE OF THE REPORT

The Bologna Process designates the ongoing activities whereby the Ministers responsible for Higher Education in Europe attempt to change and harmonize fundamental aspects of all higher education in the many countries involved. This grand scheme is gaining momentum. The number of participating countries is increasing, more aspects of higher education are included and the number of activities and projects is growing. Medical education has so far been neglected in the process and awareness of the development at medical schools has been limited. 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 eLearning 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 This report is the result of a research conducted in Romania, Italy, Bulgaria and Hungary, aiming to analyse the training needs in medicine and state of art of medical e-learning. The aim of this report has a special value as needs analysis is essential for the development of the e-EDUMED project; the project is designed to provide solutions to clearly identified needs of the target groups and this is the reason we have dedicated a comparative report for needs assesment. Even if the project includes an ex-ante analysis of the needs on EU context, this was based on EU literature, reports and reserchers for medical education in general, previous needs assesment in MEDITOP. Needs assesment of the target group will now foccus on specific issues (echograpy, nurses education) and were carried on in order to transfer previous results and integrate them in national and/or sectoral training systems . In this way the present research aims 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.

2. RESEARCH METHODOLOGY

The target groups. Representants of the target group for all participant countries included 214 subjects, with the following structure: Country RO BG IT HU Total Medical doctors 26 5 20 5 56 Nurses 15 5 2 5 27 Students Residents 30 16 5 30 81 Stakeholders Managers 11 3 3 10 27 Academic staff 10 3 10 23 Total 92 32 30 60 214

academic staff stakeholders/managers students&residents nurses medical doctors

20

40

60

80

100

Comments. In selecting and approaching this group we used conections with professional organisations and universities, alredy established at this time of the project, (see mailing lists on the project website www.e-edumed.ro). Motivation in selecting the structure of the target group was based on the fact that doctors and nursing Professionals represent the first beneficiary of the training courses developed by E-EDUMED partnership. A deep overview of their training needs, learning career expectations, restrictions related to digital divide, lack of time and job commitments, is essential in this first project phase in order to better tailor the training offer and cope with target group needs. Medical Students have been interviewed as future direct beneficiaries of the e-learning materials in terms of trainees, on order to detect their training expectations and an update overview of the basic Medical training offer. A deep picture of the actual first training medical offer will allow the partnership to cope with the future medical professionals training needs, avoid redundant existing modules and focus on precise future career prospective. Training courses will be developed according to field work and documentary research thus they will be effective and innovative for the next years. Medical Students will allow tailoring a valuable lasting training offer. Professionals in the medical educational system are the direct beneficiaries of the elearning materials in terms of trainers, so their opinion is crucial. More, an overview of their skills in ICT is of most importance in developing the materials. Stakeholders. This category leaded to several discussions, so the best approach is in defining the term. The most comprehensive definition for stakeholders is *a person, group, or organization that has direct or indirect stake in an organization because it can affect or be affected by the organization's actions, objectives, and policies. Key stakeholders in a business

organization include creditors, customers, directors, employees, government (and its agencies), owners (shareholders), suppliers, unions, and the community from which the business draws its resources.(www.businessdictionary.com/definition/stakeholder.html) Rachel Thompson statest that "Stakeholder management is critical to the success of the project. By engaging the right people in the right way in your project, you can make a big difference to its success... and to your career." (http://www.mindtools.com/pages/article/newPPM_07.htm) So, the partnership appreciated that the importance of stakeholder management to support the project in achieving its strategic objectives is crucial. In order to attain this we must first identify and assess the key people, groups of people, or institutions that may significantly influence the success of our project, interpreting and influencing both the external and internal environments and involve them from an early stage of the project,so their views can be considered in the development of outcomes. So, the benefits of using a stakeholder-based approach are that: we can use the opinions of the most powerful stakeholders to shape our project at an early stage. Not only does this make it more likely that they will support us, but their input can also improve the quality of our project By communicating with stakeholders early and frequently, we can ensure that they fully understand what we are doing and understand the benefits of our project this means they can support us actively when necessary and help for a future continuation of the project. For this reason we draw a list of all potential stakeholders, reviewed the list and identified the key stakeholders and the specific interests these have in our project, considering issues like: the project's benefit(s) to the stakeholder; the changes that the project might require the stakeholder to make; and the project activities that might cause damage or conflict for the stakeholder The table below shows potential stakeholders in our project : Educational program leadership Institutional officials at clinical sites Government key staff of department Medical Continous Education, Accreditors. Professional associations Interest groups Educational program leadership include individuals with local responsibility for educational programs at all levels of the continuumfor example, deans and their staff, department chairs, and residency program directors. These individuals have high credibility as well as detailed knowledge of their own organizations. Institutional officials at clinical sites. Clinical site administrators (hospital directors) and faculty/physician practice administrators are critical to ensure that proposed changes can be implemented in teaching institutions and that appropriate faculty are available to participate. They also may provide financial and other resources. Institutional leaders at the medical staff level also set requirements for credentialing and privileging. Managers responsible of Medical Training Services have also been interviewed in order to assess economic and political assumptions for the enhancement of the e-learning methodology, the rationale behind managers decisions, costs/benefits ratio, legal constraints and training requirements for medical professional profiles.

Accreditors. Organizations that accredit educational programs/providers at continuing level of medical education (Romanian College of Physicians)along with accreditors of health care organizations (European Union of Medical Specialists/European Accreditation Council for Continuing Medical Education (UEMS/EACCME), are important in that they set expectations at the level of the medical education system. Certifying and licensing bodies. Physicians-in-training and physicians demonstrate their knowledge and skills through the examinations and other assessments used for licensure and certification. These assessments define, at a national level, the requirements for entry into and continuation in practice. Therefore, it is critical to include the organizations responsible for setting these standards: Ministry of Education, Research, Youth and Sports, Ministry of Health, the Romanian College of Physicians, universities Medical education and related associations. National organizations serve as forums to bring individuals together and to serve as the voice of the profession and the medical education community to external groups. These include associations representing the medical profession and medical students at the national and state levels, professional medical societies and associations, institutions of medical higher education, medical research institutes medical departments/public health authorities and other CME providers accredited by the Romanian College of Physicians, professional associations (SRUMB- The Romanian Society of Ultrasound in Medicine and Biology). The methodology. The National Reports and the present 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. (A) 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. (B). A. 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)- annex 1. 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 elearning module began, in order to estimate the previous experience of using ICT and elearning as students and teachers, and to allow our tutors to prepare for our range of ICT skill levels. Based on the findings we will draw the technological architecture needed for new platform and make the adaptation and customization of the Virtual classroom environment to new modules (nurses training, echography). 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. In the present report a comparative analysis was carried on, for national evaluation results, curent state of art of medical e-learning and health care systems training needs for partner countries B. The second part of the national reports reffered to a General Educational Overview, a General Overview of Web-Based Learning in Medical Education, Standards and Professional Competences in Ultrasound and Patient approach, Standards and Professional Competences in Nursing Professionals Education, Educational contexts in Ultrasound and Educational Contexts in Nursing Profession. Institutional Public Health and private and public Higher Education Institutions websites have been investigated in order to collect all the main relevant data, as the need of Long-life Medical Education is broadly shared either among medical professionals or among Public Institutions, Hospitals, Clinics, etc The aim of this part of the reports is to establish the framework for recognition of competences and qualifications achieved by the target group, according to national regulations. The second part of the present report refers to the curent state of art of medical elearning in participant countries; offers a comparative analysis of health care systems training needs for partner countries, informations about VET and eLearning prospects 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 aim of this part is to offer a shows the results of the best practices in web-based learning based on documentary investigations carried out to determine its nature, degree and scope of distribution 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.

3.

COMPARATIVE EVALUATION RESULTS

As mentioned before, analysis has been conducted processing information gathered from documentary and fieldwork research. All respondents underlined the importance of IT implementation in medicine while mentioning various fields where IT could be beneficial: Electronic Health Records applications; Preventing medicine applications; Medical training applications (medicine, nursing), intelligent cards for health; Medical imaging solutions; Second medical opinion solutions Medical portals and virtual communities. Also, they all mentioned the importance of IT field for the continuous improvement and knowledge updating. Need of Long-life Medical Education is broadly shared either among medical professionals or among Public Institutions, Hospitals, Clinics. Continuous medical education is obligatory in all participant countries in the project and this kind of education is implemented in accordance with the European regulations and practice. Moreover, some important remarks have to be underlined. Distance learning in medical education it is not broadly diffused. Nevertheless, Professionals Individual Motivation, training needs and legal assumptions represent a flourishing ground to make pilot project on medical distance learning growing up. Although Medical Professionals use to attend workshops, use weekly/monthly the enlisted sources of information and continuously train in any relevant topic, they share the area from good knowledge of e-tools and distance learning methodologies to having no knowledge of the issues. Even if their experience in elearning, e-platforms and virtual classes is small, they all trust the methods and means for the topics enlisted. Even strongly empirical topics and subjects are of interest when linked to e-tools and an acceptance of free of charge or paid (partially contribution from employees) is obvious. As for the specific field, ultrasound for a medical doctor already specialised in a medical field, need to be deepen with many images (3D if possible), case studies, high quality of content, group discussions and practical information. Information Technology is a flexible and powerful tool able to make the difference. 3D images, videos and virtual classrooms will support medical and nursing professionals in training without having the presumption to be exhaustive, but propaedeutical to practice. The collaborative and committed behaviours of medical professionals will represent the core engines of successful learning venture. Based on these facts, the necessity for the project are quite high in Romania, Bulgaria and Hungary, while Italian experience in the field can, together with the high quality of classes, topics, subjects and teaching/learning materials and methods, prove to be successful among the medicine schools from the above mentioned countries.

4. CURENT STATE OF ART OF MEDICAL E-LEARNING IN PARTICIPANT COUNTRIES

a. ROMANIA
Medical studies. Study of medicine is admitted only after graduating from a medium school (high school) and takes place in the medical faculties of universities for a period averaging six years. At the end of the study is given a degree of professional qualification (doctor) and the right to free practice of medicine.

Participants of the Bologna Process Workshop 2009 in Cordoba, Spain have compiled flipcharts about different medical education systems

In Romania, medical school is a department of a medical university, which typically includes Dentistry and Pharmacy departments as well. The name facultate is used for departments in their universities too, but the Medicine departments distinguish themselves by the length of studies (6 years), which grants to graduates a status

equivalent to that of a Master in Science. The Medicine departments are also marked by reduced flexibility - in theory, a student in a regular university can take courses from different departments, like Chemistry and Geography (although it usually does not happen, majors being clearly defined), while the medical universities do not have any extra offers for their students, due to their specialization. Admission to medical faculty is usually awarded by passing a Human Biology, Organic Chemistry and/or Physics test. The program lasts 6 years, with first 2 years being preclinical and last 4 years being mostly clinical. After these six years, one has to take the national licence exam (which consists of mostly clinically-oriented questions, but some questions also deal with basic sciences) and has to write a thesis in any field he/she studied. Final award is Doctor-Medic (titlu onorific) (shortened Dr.), which is not an academic degree (similar to Germany). All graduates have to go through residency and specialization exams after that in order to practice, although older graduates had different requirements and training (e.g., clinical rotations similar to sub-internship) and might still be able to practice Family Medicine / General Medicine. Continous medical education. Postgraduate medical and pharmaceutical education provides specialization and professional development of staff with higher education in the medical field, in order to acquire improve the level of knowledge, skills and abilities necessary to increase the quality of care and level of performance in health. It is coordinated by the Ministry of Health. Strong links are realised with the Romanian Medical College of Physicians (CMR), Romanian Dental College, Romanian College of Pharmacists, Order of Biochemists, Biologists and Chemists in Romanian Health System. together with Ministry of Education, Youth and Sports According to the Decision no. 2 of 23 January 2009, issued by the Romanian Medical College, under art. 406, 414 and 431 of Law no. 95/2006 on healthcare reform, the National Council of the Romanian College of Physicians decided on establishing a credit system of continous medical education, upon which it is possible to evaluate the professional training of doctors, the criteria and rules for credit forms of continuing medical education, and the rules and criteria for accreditation of continuing medical education providers. In this way in Romania CME is compulsory; the CME competent authority is the Romanian College of Physicians (www.cmr.ro) CME credits are granted in relation to the hours actually spent in the CME activity. For an hour of effective CME activity is given up to one CME credit. For a day of actual work is granted a maximum of 6 credits CME. Equivalence to the previous credit system is: an CME credit equals one hour of CME. 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. The 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.

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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. Necessarily, at least one third of required CME credits must be represented by participation in courses. 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. CME in the format of e-learning is not accepted. No eLearning or Online Education accreditation accepted so far. Ultrasound education. Romania is one of the few European countries where ultrasound practice is allowed/performed by a wide range of clinical specialties and not exclusive as in most European countries - only the speciality of radiology and imagistics. There are at least 6000 (or more) of practitioners of ultrasound, directed on the speciality, probably 1/6 of the total number of medical practitioners - in public and private environment. In Romania echography (ultrasound) is a competence (complementary studies).The general ultrasound module is included in vocational training of residents for 7 specialities, vocational training in complementary studies and vocational continous education. Ultrasound represents a multilevel technique of diagnosis and treatment, practiced in several specialties). The"multilevel" concept for the practice of ultrasound is based on clinical experience, ultrasound experience, practical competencies, registration of activity and research, ability in teaching, andin the same time, introduces training requirements for each level. With a separate mention we speak about general ultrasound diagnostic - abdominal, thoracic and peripheral- in most medical and surgical specialties (internal medicine, cardiology, oncology, hematology, nephrology, rheumatology, surgery, urology) as well as in overspecialization - in Senology, vascular disease, musculoskeletal pathology, endocrine pathology, and ultrasound with limited practice. in neurosonology, si ophtalosonology Competence in general ultrasound is offered by a certificate issued by different Medical Universities (Department of Postuniversitary Training), and recognised by the Ministry of Education and Resarch, This cerfificate is valued with 75 EMC/CME (CONTINUING MEDICAL EDUCATION). These credits cam be accorded only if the trainee follows 2 modules: Module I (3 months) with specific theoretical ultrasound issues. This module can be followed by residents (in some specialisations being included in educational training) or medical doctors in CME Module II (3 months) regarding practical issues- the trainees must see and prove that have seen 300 echographic images on their own For the certificate in general Ultrasound specialists or primary physicians, and medical graduates with the right of free practice as physicians who have completed additional studies programs in general ultrasound level I (duration 3 months) and level II general ultrasound (duration 3 months) with a total of 6 months of training (according to MS order no. 418/2005). The 6 months of training can be divided into two modules of 12 weeks (3 months course + 3 months individual practice, during which the student will make at least 300 examinations under direct supervision of a physician designated for such activity by national leaders of the program. Doctors confirmed as residents in different specialties, in whose training curriculum is provided a general ultrasound module lasting 3 months (equivalent level I), can sustain the exam for obtaining the certificate in general ultrasound only after confirming the completion of specialist training and general ultrasound level II program (3 months), with total training time 6 months;

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Doctors confirmed as specialists in radiology and medical imaging specialties, nuclear medicine and gastroenterology, who performed a training in general ultrasound, according to curricula in residency are entitled to perform general ultrasound procedures without supporting the certification exam, according to the order MS no. 418/2005. The exam will consist of three tests: - practical test with the patient (eliminatory, the minimum required score 6.00) - theoretical written test in the form of multiple choice test with 50 multiple-choice questions, simply complement type - practical test of ultrasound pathology on videotape. Romania is one of the few European countries where ultrasound practice is allowed/performed by a wide range of clinical specialties and not exclusive as in most European countries - only the speciality of radiology and imagistics. There are at least 6000 (or more) of practitioners of ultrasound, directed on the speciality, probably 1/6 of the total number of medical practitioners - in public and private environment. In Romania echography (ultrasound) is a competence (complementary studies).The general ultrasound module is included in vocational training of residents for 7 specialities, vocational training in complementary studies and vocational continous education. Ultrasound represents a multilevel technique of diagnosis and treatment, practiced in several specialties). The"multilevel" concept for the practice of ultrasound is based on clinical experience, ultrasound experience, practical competencies, registration of activity and research, ability in teaching, andin the same time, introduces training requirements for each level. With a separate mention we speak about general ultrasound diagnostic - abdominal, thoracic and peripheral- in most medical and surgical specialties (internal medicine, cardiology, oncology, hematology, nephrology, rheumatology, surgery, urology) as well as in overspecialization - in Senology, vascular disease, musculoskeletal pathology, endocrine pathology, and ultrasound with limited practice. in neurosonology, si ophtalosonology Competence in general ultrasound is offered by a certificate issued by different Medical Universities (Department of Postuniversitary Training), and recognised by the Ministry of Education and Resarch, This cerfificate is valued with 75 EMC/CME (CONTINUING MEDICAL EDUCATION).European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) proposed minimum requirements for training in medical ultrasound practice in Europe and standards of practice in most specialisations (www.efsumb.org). These standards identify three levels of training and practice in ultrasound - Level I - up to 5 years practice, Level II - Second Opinion - the practice must be over five years, studies, publications in the field, third level - expert in practicing one or more ultrasound techniques and participation in ultrasound education. The boundaries between the three levels should be regarded as a guide to the different stages of competence and experience. The detailed programs trying to specify the type of experience needed for each level of training. Romanian Society of Ultrasound in Medicine and Biology SRUMB is a professional corporation, non profit, legally constituted, affiliated and full member in the European Federation of Societies of Ultrasound in Medicine and Biology EFSUMB. After the competence examination continous medical education will be carried out on regular and relevant basis, ensuring appropriate professional development. It is the responsibility of the doctor to ensure that his practical skills arte maintained by performing ultrasound examinations continuously, by EMC hours, and by examining a wide range of pathologies. In order to remain current with the development of the field, persons who have passed their certification examinations for ultrasound must demonstrate completion of at least

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1/3 from the 200 of qualified CME credits every 5 years in ultrasonography and the same number of EMC credits in each specialty in which they are certified. Participation in research, scientific publication, and completion of advanced degrees in rder to stay current with the profession is strongly encouraged and supported by the field. However, clinically relevant continuing education is still mandatory. Nursing Professionals Education.The preparation of general medical assistants, nurses and medical assistants of other specialties in Romania is done through the following forms of education: a) short and long term upper medical education b) post-high school healthcare education, for a period of 3 years The learning plans and educational curricula for the two forms of education are differentiated. The medical assistant with long term upper studies may be a medical assistant for general healthcare or a medical assistant specialised in various fields: obstetricsgynaecology, pediatrics, hygiene, hygiene and public health, clinical laboratory, radiology, pharmacy, medico-social, nutrition and dietetics, physiotherapy, kinetotherapy and recovering, medico-surgical emergencies, dental prophylaxis, dentistry, dental assistance or hygiene assistant for dentists offices. There are in the healthcare system medical assistants with post-high school studies, but also medical assistants with middle studies, with graduation diploma from a healthcare high school for a period of 5 years. Continuous training of medical assistants and nurses Medical assistants and nurses have to take training courses and other accredited forms of continuous education. OMANR (The Order of Medical Assistants and Nurses in Romania) gives credit only to the members taking training courses or other forms of education approved by the organisation. OMANR may suspend the right of practice of the medical assistants and nurses who, over a period of 3 years, do not earn the minimal number of credit points established by the organisation. Credit points may be earned by participating to continuous medical education courses, scientific manifestations, contributions to field publications. The National Programme for Continuous Medical Education regulates the scientific manifestations for which credit points are given, as well as the rules for giving them. e-learning. Romanian education system is under continuous changes and improvements in various domains and levels, according to economic, social, political and cultural changes identified within the society. In recent years, Romania has included the principles of lifelong learning in policy documents as priorities in the area of education, continuous training and employment. Examples of such documents are the strategy Education and Research for the Knowledge Society and the National Education Law. Because Romania did not have a coherent and comprehensive lifelong learning strategy, the Ministry of Education, Research, Youth and Sports initiated in 2009 the development of a Lifelong Learning Strategy with the participation of specialists and all stakeholders. As a result of recent activity, progress has been made in identifying strategic priorities and directions for action in the area of lifelong learning such as recognition and validation of non-formal and informal learning, educational and vocational guidance and counselling throughout life and in-service learning systems. 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, at least in Romania, this happens sporadically.

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By studying the educational offer for the academic year 2010- 2011 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), Elearning.Romania is offering recommendations regarding the existing offers for online education on the Romanian market, educational software, applications support for the education, virtual environments for formal and non-formal education, elearning university online courses and virtual universities, policies and strategies in e-learning (http://www.elearning.ro/).National Society of Family Medicine (SNMF) launched the portal www.formaremedicala.ro. This is the first online learning tool launched by SNMF and dedicated to the professional development of the approximately 11 800 family doctors in the country Starting March 1, 2010 the College of Physicians in Mures County in partnership with the University of Medicine and Pharmacy Tg. Mures has started a program of distance continuing medical education (CMED). Through this program, any doctor in the country can register for on-line courses posted on the County College of Physicians Mures platform (www.cjmm.org), can choose the course they want to accomplish and after its assimilation and final evaluation, will receive a number of credits proportional to the size and complexity of the course map. Each of the proposed courses are credited by the Romanian College of Physicians and course materials are elaborated by academic staff of the University of Medicine and Pharmacy Tg. Mures. Other medical education programs on line www.medicalUPDATE.ro Includes a program of Continous Distance Medical Education - UPDATE plus, credited by CMR with CME hours www.CMEb.ro Online CME Program Pilot of Romanian Medical College in Bucharest www.hivability.ro Prevention and management of HIV / AIDS free CME courses The RomanianCollege of Physicians, Iasi Branch and the Center for Continuing Medical Education Iasi initiated a series of online courses available at http://teste.bioetica.ro. Romanian Society of Cardiology has provided an online e learning platform dedicated to continuing medical education, enabling online access from any location for permanent medical staff, reducing time and costs. (www.cardioportal.ro.) The Center for Health Policies and Services by the platform E-SanatatePublica provides medical specialists in the area, the resident doctors, the medical students with online courses. EPathology.ro educational platform. comes to help students and young doctors to deepen knowledge of pathology. In 2009, MedicalStudent.ro, consisting of online scientific journal, Atlas of Histopathology (now support the practical work) and Atlas of Pharmacognosy, was honored at the gala's Health Congress 2009 by the British Medical Journal and Tarus Media. At E Health Congress 2010 "Over Revolution Health's Medical Practice and Economy" ePathology.ro platform received the "Award of Excellence in eHealth in 2009." B. ITALY

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Medical studies In Italy, the contents of the medical school admission test is decided each year by the Ministry of Education, Universities and Research (MIUR) and consists of eighty questions divided in five categories: logics and "general education ("cultura generale"), mathematics, physics, chemistry, and biology. The test is usually taken in early September, following the conclusion of a 5-year high school cycle in July. Each medical school administers the test separately, and the result of the test is only valid for entry in the medical school where the test was taken. As a general rule, all state-run medical schools in the country administer it on the same day, whereas all privately run medical school administer it on another day, so that a candidate may take the test once at a state-run school and once at a private school of his/her choice, but no more. Medicine is one of the university faculties implementing numerus clausus ("numero chiuso"): the overall number of medical students admitted every year is constant, as each medical school is assigned a maximum number of new admission per year by MIUR. Medical school lasts 6 years (12 semesters). Traditionally, the first three years are devoted to "biological" subjects (physics, chemistry, biology, biochemistry, genetics, anatomy, physiology, immunology, pathophysiology, microbiology, and usually English language courses), whereas the later three years are devoted to "clinical" subjects. However, most schools are increasingly devoting the second semester of the third year to clinical subjects and earlier patient contact. In most schools, there are about 36 exams over the 6-year cycle, as well as a number of compulsory rotations and elective activities. At the end of the cycle, students have to discuss a final thesis before a board of professors; the subject of this thesis may be a review of academic literature or an experimental work, and usually takes more than a year to complete, with most students beginning an internato (internship) in the subject of their choice in their fifth or sixth year. The title awarded at the end of the discussion ceremony is that of "Dottore in Medicina e Chirurgia" ("Doctor of Medicine and Surgery"), which in accordance with the Bologna process is comparable with a master's degree qualification. After graduating, new doctors must complete a three-month, unpaid, supervised tirocinio post-lauream ("post-degree placement") consisting of two months in their university hospital (one month in a medical service and one in a surgical service) as well as one month shadowing a general practitioner. After getting a statement of successful completion of each month from their supervisors, new doctors take the esame di stato ("state exame") to obtain full license to practise medicine. They will then have to register with one of the branches of the Ordine dei Medici ("Order of Physicians"), which are based in each of the Provinces of Italy. Registration makes new doctors legally able practice medicine without supervision. They will then have to choose between various career paths, each usually requiring a specific admission exam: Most either choose to train as general practitioner (a 3-year course run by each Region, including both general practice and rotation at non-university hospitals), or choose to enter a Scuola di Specializzazione ("specialty school") at a university hospital 5-year or 6-year course. Continuous medical education Educazione Continua in Medicina (ECM) - Continuous Medical Education regulated by the Ministry of Health has been established through the decree of 30th December 1992, n. 502, integrated with decree of 19th June 1999, n. 229. The Italian Health Ministry started a mandatory system for all healthcare professionals in 2002.. A special national Committee controls the CME providers and has defined the accreditation criteria. CME is compulsory; the name of the CME competent authority: Committee under the National Health Ministry (In addition: 21 Regional CME Committees) website: www.ministeriosalute.it

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Training activity is mandatory for each professional who has to earn a number of vocational credits (CFU) per year. Until 2010 Providers have been accredited for each single CME program. From 2010 they are accredited on a 2-4 year basis. National CME providers have to apply directly on the Health Ministry website and pay a fee. Their program can be used nationwide. Regional Providers have to apply to the Regional Committees. Their program can be used at regional level. CME credits (both National and Regional) are valid nationwide. At the moment, the Italian CME Accreditation authority (Health Ministry) does not participate in the EACCME system because EACCME and the Italian Accreditation authority use different accreditation criteria. Therefore there is no automatic mutual recognition but the Authority accepts that up to 50% of the CME credits can be obtained through the participation of Italian health professionals in accredited CME activities in other EU countries, the USA, Canada or Australia. The main objective of Continuous Medical Education is to update medical professional competences. Individual experience needs to be continuously refreshed by training, studies, and practice stages in order to ensure a high quality patient assistance. Continuous medical education it is compulsory as stated by the AGENAS Agency (National Agency for the Health Regional Services on behalf of Ministry of Health). Credits are compulsory and are included in Certificates of Service. National Commission of ECM on behalf of Ministry of Education and Health certifies the training Institutions/Agencies that are able to provide qualified training courses and credits according to continuous medical education legal framework. It has stated that each doctor (or nurse) had to obtain 150 credits during 3 years 20082010. As concerns 2011, the Ministry of Health has recently published a legal reference; it confirms the same decision, 50 credits per year (150 within 2011-2013). Credits are compulsory and are included in Certificates of Service. The programme ECM (Continuous Training in Medicine) has been regulated by the Decision of the National Commission ECM on 13/01/2010. 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. The following training activities are recognised to earn credits: - In presence training - Distance Learning - Individual Training - Studies Groups, Commissions, Research Activities - Clinic and /or assistance audits - Teaching and tutoring Limits of acceptance could be defined for some aforementioned activities. For example, Nursing Professionals 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%. 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. From 2010 Italian CME Accreditation authority recognize e-learning or distance learning. Ultrasound education Technician Qualification Bachelor Degree in Techniques of Medical Radiology through Images and Radiotherapy

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Students attend a three years university course. The deepen knowledge about techniques, instruments, radiotherapy, and ultrasound functions. At the end of the course they can continue University Studies enrolling a Master Degree in Medicine and Surgery or can be employed in Hospital as technician of diagnostics through images (Radiotherapy and Ultrasound). Aware of the aforementioned premise concerning Italian Education System, A Student could choose to become a Technician of Diagnostic Through Images (ultrasound and radio). He has to award a Bachelor Degree in Techniques of Medical Radiology through Images and Radiotherapy obtaining the qualification of technician. Differently, a student could choose to become a Medical Doctor (specialised in Internal Medicine, Obstetrics, or Cardiology, etc...). He has to award the Master degree and the Specialisation obtaining the qualification of Medical Doctor specialised in Internal Medicine for example. Medical Doctor Qualification 1st step of training to become Medical Doctor - Master Degree in Medicine and Surgery (6 years, 360 credits) Training in Ultrasound starts since the beginning of the training path. In fact, Medical Students during the Master Degree in Medicine and Surgery, which lasts 6 years, usually have specific modules/exams concerning Diagnostic through images including ultrasound and radiotherapy. They study diagnostics through images either focusing on general techniques or ultrasound in specific medical fields (oncology, diseases of blood, etc...). (University of Rome http://www.unicampus.it/offerta-formativa/corso-di-laureamagistrale-a-ciclo-unico-in-medicina-e-chirurgia) 2nd Step of training to become Medical Doctor - Course of Specialization (5 years) - Specialist in Diagnostic through images: as soon as the six years are finished, Graduate Medical Doctors can decide to become expert in Diagnostic through images, Radiotherapy and Ultrasound. They enrol a Specialisation course which usually lasts five years in Diagnostic through images or radiotherapy. - Medical Doctor Specialised in other medical fields (genecology and obstetrics, paediatrics, internal medical doctors, cardiologists, etc...): ultrasound is essential for several kinds of medical professionals. During the specialisation course which lasts usually five years, medical doctors deepen knowledge about instruments and techniques of ultrasound, have practice on these in hospital through job shadowing. 3rd Step of training after Specialisation Courses Vocational Training, High Training, Master Medical Doctors, which have started working, need to benefit from continuous training and refreshment courses in order to enhance skills and competences, being acquainted about last practices, instruments, and techniques. The duration and the delivery is quite different, it can be a workshop, a conference, a traditional course, a distance course, a clinic audit, etc The broadly recognised high level of training centres allow to outline a list of the most qualified Centres. Usually they are spin off of University research centres, professional associations, and private agencies. According to the Italian legal framework, medical professionals (medical doctor, Nursing Professionals, etc...) have to earn 50 credits per year for training attended in extra working hours (150 credits for 3 years). The Survey La Formazione Continua nelle Regioni e nelle Aziende Sanitarie (Continuous training Offer in Italian Regions and Health Care Public Agencies) has been promoted by the Department of Public Function in the framework of the project Governance dei Sistemi Sanitari Regionali, 2006 (Governance of Regional Health Systems). It shows the state of the art of the Continuing Medical Education in Italy during the first five years.

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In each Local health department it has been constituted a Unit area for continuous training (Operative Training Units - Unit Operative Formazione). Local, National or International Institutions, recognised at National and International level, provide training courses/credits and certify individual competencies in specific fields. SIUMB is a multidisciplinary Society which includes several professionals (internal medical doctors, radiographers, surgeons, general medical doctors, and gastroenterologists). It has a training School to support and provide studies and training activities towards use of ultrasound in Medicine and Biology. They can be workshop, traditional courses, congresses, etc... The methodology is mainly in presence. http://www.siumb.it/presentazione.html SIUMB Training School certifies the qualifications of Medical Doctors in Ultrasound through 2 kinds of Diploma (National Diploma in Clinic Ultrasound, National Diploma in Specialist ultrasound) which certify practice and theoretical competencies. Nursing Professionals Education The Reform of the University System started in the 1992. Bachelor Degrees (Short Degrees) were introduced. At the end of 1992, Decree n.502 (later on 517) defined the competencies of the University, of the Regions, and of the local Agencies for Health care in the field of Nursing Education. There were almost 1000 students enrolled to the first University Courses for Nursing activated in 18 Italian Universities. After a transition phase, in 1996/1997 all the basic training for nursing profession belonged to the University. On the Degree, beside the signature of the Responsible of the course, was the signature of the Rector of the University. Nursing Profession Education actually consists of first in the 3 years Bachelor Degree in Nursing Profession (180 credits). Students are required to have a High School Diploma (5 years) and 18 years old. A further important reform was defined by law 251/2000 (Reform of the Health Nursing Professions). This law established that a Nursing Professional could continue his University studies enrolling the Master Degree in Nursing Profession increasing the level of qualification. 1st Step of training - Bachelor Degree in Health Nursing Profession (3 years) (About 19 exams + qualification exam to start working, 180 credits) Graduated in Nursing are defined as Health operators according to the competencies set by the Ministry of Health (14/09/1994 and next modifications/addenda). They are responsible for the general nursing assistance. It has to be preventive, healing, palliative and rehabilitating. The nature of the assistance has to be technical, relational and educative. The main functions are: prevention of diseases, assistance to patients/disables of all ages and health education. As concerns the subjects, they will be an example, Human Anatomy, Physiology, General Pathology and Bio clinics, general Nursing, Clinic Nursing, Public Health, European Nursing, Health Management, Clinic Nursing Methodology, Health Law, General deontology and applied bioethics. As soon as the Nursing students awarded bachelor degree, they can continue university studies enrolling Master Degree in Nursing Profession or enrolling the Master described below. 2nd Step of training Master Degree in Health Nursing Profession and Obstetrics More advanced training of scientific and management issues. 3rd Step of training Vocational Training, Master/Short training courses for Health Nursing Profession As Medical Doctors, Nursing Profession has to be continuously updated and informed about last practices, technologies, approaches, guidelines and protocols. Continuous training is essential for the quality of the work. Each year, they have to earn 50 credits in

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training activities (150 in 3 years). They can be workshop, distance courses, congresses, Master, clinic audit, etc Training courses could have different contents; it depends on the interest and work specific activities of the worker. There could be a course focused on Nursing Profession competencies or specific issues such as ultrasound for Nursing Profession, or security, crisis management, etc Nursing Professionals acquire knowledge about uses of ultrasounds in Internal Medicine and similar fields, the methodology of carrying out the ultrasound test. Practice is taught through directly or indirectly, or through tutoring of experts. http://www.ecografiabologna.org/ As concerns ultrasound for Nursing Professionals they usually receive just general information about instruments and procedures in ultrasound in the 3 years university training path. 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. 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 provides a database of qualified providers. Other websites with additional information and available courses/events are: www.e-ecm.it; www.corsiecm.it; Med3 is a consortium of Public Institutions which provides Distance learning http://www.med3.it/ ; Distance Courses for medical professionals http://www.ecm-fad.it/; Research engine for Continuous Education in Medicine http://www.virtualecm.it/ C. BULGARIA Medical studies Higher Education is organized into two stages: Bachelor and Master. According regulation 34 of the Law for Higher Education in Republic Bulgaria the medicians are able to obtain speciality in medicine; via the Law for Academic Degrees and Titles the procedures for obtaining Ph.D as well as academic positions such as assistant, head assistant, associated professor and professor are regulated. 1. Bachelor degree is awarded after a four-year course of study and aims at transferring the core subjects as well as more specialized, professional topics. During the fourth year, students usually acquire work experience by doing an internship. The degree is awarded after 240 credits ECTS earned credits and students can either enter the job market or continue studies attending a Masters degree. 2. Master degree is awarded after two years of graduate studies for a total of 120 credits ECTS and after awarded Bachelors degree. It aims to provide rigorous, advanced training in more highly specialized areas. Note: Some specific studies, such as Medicine, are made up of a single long cycle which lasts six years. Students have to earn 360 credits (CFU) in six years; 60 credits/per year (1500 hours). In Bulgaria, a medical school is a type of college or a faculty of a university. The medium of instruction is officially in Bulgarian. A six- to one-year course in Bulgarian language is required prior to admittance to the medical program. For European candidates, an exam

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in Biology and Chemistry in Bulgarian is also required. While a number of Bulgarian medical schools have now started offering medical programmes in English, Bulgarian is still required during the clinical years. Students join medical school after completing high-school. Admission offers are made by individual medical schools. Bulgarian applicants have to pass entrance examinations in the subjects of Biology and Chemistry. The competitive result of every candidate is the based on their marks these exams plus their secondary-school certificate marks in the same subjects. Those applicants with the highest results achieved are classified for admission. The course of study is offered as a six year program. The first 2 years are pre-clinical, the next 3 years are clinical training and the sixth year is the internship year, during which students work under supervision at the hospitals. During the sixth year, students have to appear for 'state exams' in the 5 major subjects of Internal Medicine, Surgery, Gynaecology and Obstetrics, Social Medicine, and Pediatrics. Upon successful completion of the six years of study and the state exams the degree of 'Physician' is conferred. For specialization, graduates have to appear for written tests and interviews to obtain a place in a specialization program. For specialization in general medicine, general practice lasts three years, cardiology lasts four years, internal medicine lasts five years, and general surgery lasts five years.

Participants of the Bologna Process Workshop 2009 in Cordoba, Spain have compiled flipcharts about different medical education systems 3. Specializing Master - Graduate Students (doctors) can continue their education under the part-time form according curriculums for specializations Health Management and Health Care. They could be assigned to specialization under regulation 34 or a regular/free PhD course of study.

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4. Doctoral Program - PhD is awarded after finishing of regular (3 years) or free PhD course of study and successful defence of scientific dissertation. Continous medical education This kind of education is implemented in accordance with the European regulations and practice. CME is compulsory and the competent authorityis : Bulgarian Medical Association Website: www.blsbg.com CME was made mandatory by the Health Act. There is a special Directive for CME according to which every practicing physician must obtain 150 CME points per year. The points accredited to Bulgarian doctors through their participation in accredited EACCME accredited events are not automatically recognized by the Bulgarian Medical Association. Professionals Individual Motivation, training needs and legal assumptions represent a flourishing ground to make pilot project on medical distance learning growing up. 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. E-learning activities are not accepted as valid CME activities to collect CME credits in Bulgaria. Ultrasound education Based on the characteristics of the educational system in Bulgaria, students can choose to become a technician through diagnostic imaging (ultrasound and radio). Students must acquire a bachelor's degree in techniques of medical radiology and radiotherapy through image and receives training techniques. Students may choose to become a doctor (specialist in internal medicine, obstetrics, cardiology, etc.). They must acquire a master degree in medicine (6 years), then be assigned a specialization under Regulation 34. Technicians and doctors can enhance their competence in ultrasound through seminars, training courses etc. Ultrasound for a medical doctor already specialised in a medical field, need to be deepen with many images (3D if possible), case studies, high quality of content, group discussions and practical information. Nursing Profession Education Nursing Profession Education actually consists of first in the 4 years Bachelor Degree in Nursing Profession (180 credits). Students are required to have a High School Diploma (5 years) and 18 years old. Nursing professionals can continue their studies at university, writing a master's degree in Nursing. e-learning In the final years of the process of pre-accession of Bulgaria to the European Union, the conditions for involving and efficient use of e-Learning in different educational institutions were significantly improved. The basic factors that positively influenced the improvement of the e-education index in Bulgaria could be summarised as follows: the participation of educational and research institutions in a lot of international projects; government policy; initiatives by universities, educational and research institutions; wellqualified experts in information and communication technologies, didactics, psychology and other subject areas that, with enthusiasm, add value to the development and dissemination of e-learning content. Unfortunately, there are problems, such as lack of sufficient e-Learning content, especially in the humanity areas; 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

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schools and in some universities to stimulate school and university teachers to develop and use e-Learning content. At tertiary education levels, the data concerning availability and quality of the ICT structure is rather fragmented, and does not allow for an accurate and comprehensive assesment. E-learning elements are slowly being integrated intothe curricula at several universitie, but these are rather isolated cases. It is recognised that Distance course for medical education is more suitable but in Republic Bulgaria such kind of education is in its very beginning In the best way we can tell that such e-learning is yet to take off, in spite of the existence of computerised infrastructure and the accompanying library facilities, two necessary requirements. All acredited higher education institutions offer some level of computers and internet acces to faculty and students. In most cases, this level is only sufficient to cover the minumum requirements set by the National Agency for Assesment and Accreditation, but compared to the growing needs of the academic community, it is largely insifficient in terms of quality (number of computers, capacity and speed of internet connections) and reach (practical accesibility for all staff and students). A second important constraint to a wider implementation of ICTs in tertiary education is the lack of adequate human resources. Administering and maintaining complex computer network, and providing good quality internet and intranet servicesrequire highly qualified professionals who are rather expensible and often unaffordable to the universities. Most often, the reason is shortage of funds, but sometimes also a lack of flexible management, and not very good understanding of the importance of using modern technologies for learning purposes. Such attitudes can result in unrealiable network operations, and poor ICT support to the research and education process. Merhodologies 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 (Sofisa University, Plodviv University, Technical University Sofia, Technical University Russe, Medical University Sofia). A number of Bulgarian universities have already recognised the need for integrated elearning platforms, and have taken steps for their implementation. The decision to develop their own platform is usualy justified by 2 main reasons: (a) products available on the market are too expensive, adn (b) building their own tools allows greater flexibility, and closer adaptation to the specific institutional needs and practices. Sustainability, however, is a very important issue there. Putting such system in practice requires high levels of robustness and reliability, as well as continuing support. Another crucial issue is the need to train users and implement changes in the academic culture. The latter seem to be even more difficult to achieve than technological innovation. We mention the project titled MedStudy.net, which is currently being implemented in the Medical University Plovdiv with the financial support of the Center for Competitive Teaching and Management System (http://www.ctms.bg) at the Ministry of Education and Science. Also this university was developing its qwn elearning system, PeU (http://peu.pu.acd.bg), as a platform for developing and maintaining a Web-based environement for modelling the process of teaching and learning. The Medical University of Varna has had, on a trial basis, successful telemedicine and teleconference video links with the Medical Faculty of the Aristotelian University of Thessaloniki, Greece. Subsequently, the Information Centre of the Medical University of Varna is currently involved in a series of activities such as video teleconferencing, preparation of interactive lectures and seminars, multimedia projections, and medical videotape projections for small groups of medical post-graduate students. Most importantly, the future of medical education

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in Bulgaria is predicated on a mix of sound economic background and the level of enthusiasm and commitment displayed by all stakeholders in this project. Laying the foundations of virtual Web-based Medical University is the most important task for improvement of the quality education. To fulfil this, a new university on-line operating information system, referred to as MUS-portal, has been developed with the main features of an advanced virtual learning environment. There are two modules of MUS portal: 1) for e-Learning in different disciplines and 2) for planning, organizing and controlling of regular education. The system is planned to be used by all university units (faculties with their preclinical and clinical departments, Deans and Rectors offices, colleges, hospitals, library, etc., but at the beginning the creation of the database, the analysis and the assessment of the advantages or disadvantages of the portal from different users point of view in this pilot project concerns mainly the pre-clinical departments. The Medical University Sofia, supported by the Open Society Foundation, has taken the first steps in introducing a flexible problem-solving oriented web based e-learning platform in Biochemistry.

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 e-learning environments with Bulgarian 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. D. HUNGARY Medical studies. Hungary has four medical schools, in Budapest, Debrecen, Pcs and Szeged. Medical school takes six years to complete, of which the last year is a practical year. Students receive the degree dr. med. univ. or dr. for short, equivalent to the MD degree upon graduation. The Faculty of Medicine obtained its basis for education by running a high-level clinical and research work. The task of the Faculty is represented by three different fields: education, research-work, prevention-treatment. The Education at the Faculty of Medicine lasts for 6 years and at the Faculty of Dentistry it lasts for 5 years. The aim of the reforms is to change the curriculum so that it meets the requirements of a high-level education of the 21st century by reducing the number of classes and increasing the number of practices, and optimizing the credit-system. Continous medical education in Hungary is compulsory, Name of the CME competent authority: The Association of Hungarian Medical Society MOTESZ; website: www.motesz.hu The Association of Hungarian Medical Society - the MOTESZ was established in 1966. It is responsible for the protection and improvement of the standards of continuous medical education. A Regulation making CME mandatory was released in 1999 and updated in 2003. The MOTESZ is in charge of the accreditation of CME activities, working closely with the scientific societies. Doctors are required to collect 250 CME credits over 5 years. The MOTESZ does participate in the UEMS EACCME system. It accepts credits gained through the participation of Hungarian doctors in CME e-learning activities.

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Participants of the Bologna Process Workshop 2009 in Cordoba, Spain have compiled flipcharts about different medical education systems

Ultrasound education Diagnostic, vascular and interventional ultrasound represents one of the most important activity of the Hungarian radiologists, since the vast majority of this type of work is performed in radiology departments in Hungary. The Ultrasound Section has close cooperation with other ultrasound related non-radiological organizations (gynecologist, gastroenterologists, ophthalmologists, orthopedists etc.). Nursing Professionals Education During past decades, the changes in education have replaced the more practically focused, but often ritualistic, training structure of conventional preparation. Nurse

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education integrates today a broader awareness of other disciplines allied to medicine, often involving inter-professional education, and the utilization of research when making clinical and managerial decisions. Nursing education in Hungary has over 100-year traditions, specialising courses and continuing education has also been organised for some five decades in different forms, with contents changing and developing all the time. Specialising courses and continuing education are usually parts of adult education. Reform process in health care was started more than ten years ago (with significant international support) and it has been accelerating in the last five years. A national vocational education system was created, which also affected nursing education. Up-todate knowledge and professional experience become more and more important, and parallel with that, the need for flexible educational systems is growing, which altogether redefine the meaning and philosophy of life long learning" principle. Nursing assistant education can be started at and over the age of 16, after leaving elementary school. Secondary school qualification is needed for nursing, child-care nursing, midwifery and ambulance nursing studies, and also for college level nursing education, which is supplemented with university level nursing education. After completing basic professional education individuals can take part in post-basic specialising courses, which mean higher level of education and extended area of professional competence, in the following fields: intensive care nurse, intensive child-care nurse, nephrology nurse, oncology nurse, psychiatric and mental health nurse, community nurse, diabetology nurse, geriatric nurse, hospice care nurse and coordinator, epidemiology nurse, operating theatre nurse and anaesthetic nurse. B.A. nurses may also attend the post-basic specialising courses, and they will have the possibility to join specialising continuing education. Professional basic education is organised in three (primary-secondary-advanced) levels, specialisation is carried out in post-basic level of education. Continuing education -aiming at refreshing, updating professional knowledge and skillsis provided for professionals with basic education and also for those completing specialising course(s), which is in close connection with practise Nursing education is regulated by acts and ministerial decrees. The relevant acts are the Act of Vocational Education (1993) and the Act of Health (1997). Ministerial decrees of certain professions have been issued in connection with the Act of Vocational Education in order to describe the area of activity and determine the required theoretical and practical knowledge (supplemented with the method of examination). The Act of Health prescribes vocational qualification, continuing registration and continuing education so as to ensure and develop the quality of health care. One of the most important reforms in health care was introducing the obligatory professional education, and forming other conditions for practice (continuing registration requiring continuing education). Several forms of continuing education are recognised: training courses with examination, participation or presentation in conferences, seminars, study tours, publications. The system accepts" all types of activities serving the professional development of the individual, but values them differently. 100 points are to be collected within the five year registration period: working in health care means 15 points per year, training courses are between 20 and 40, participation in conferences are 5-10, presentations 10-20, publications 15-50, individual study 10-20 points. At the same time registration relies on the individual's responsibility. Credit system has only been introduced in colleges and universities, and not in vocational education. Continuing training cannot be converted into specialising courses, in the near future the Act of Adult Education will be issued, which will help to eliminate the weaknesses of the present system. Basic nursing education is mainly organised in full time training courses in school-system. Specialising courses are part-time ones outside school-system therefore they belong to

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the category of adult education. In several professions distant learning courses have been introduced in order to provide a new, flexible form of education, raise the quality of training and reduce the costs and time spent away from work for education. The motivation for specialising courses is compiled of two elements, which are usually parallel: the need of professionals to refresh and extend their knowledge, and that of health care institutions for highly qualified health professionals. For continuing education individuals' motivation is clear, as the career possibilities of unregistered health workers are rather limited and registration requires participation in continuing education. In the five-year registration period professionals have to spend at least three years working in health care service and undertake some form of continuing education (training course, conference, publication, etc.). Besides individuals' thrives, health care institutions are also motivated to support their employees' education as they have to fulfil the conditions described in the Act of Health and other relevant regulations. This type of obligation is in tune with the institutions' interests and commitment to provide high quality service and continually improve it. Since the Act of Health was introduced three years ago this parallel system of motivation has brought outstanding results, which was founded by the system of state financing. The whole new system of nursing education ensures high standards of health care provision. Specialising courses have to meet certain requirements of content and form: the educational framework is prescribed by ministerial decree and local programmes are approved by expert groups. Independent Examination Committees are set up to evaluate students' knowledge and performance, where professional organisations also send their delegates. Written exam sheets are issued centrally, which serves as a good control of fairness and standard. Continuing education courses are also evaluated for content and form: in the possession of an expert opinion, a ministerial committee recognises and values them for continuing registration points. In this field it is important for training organisers to consider the priorities preset by this body. The committee also has a crucial role in directly controlling the quality of continuing education courses. The content of specialising courses is determined on the basis of real professional requirements, and is elaborated with modern methods (f. e. DACUM). In the process of preparing the programmes all the relevant parties are involved: health care professionals, training organisers, professional organisations, health managers. The programme plans are next examined by professional groups, which did not participate in the first preparation phase. Their opinion and proposals are also considered when finalising the contents of the educational programme. The contents of continuing education courses are pre-determined by the priorities set up by the expert committee mentioned above, and also by the needs of health care institutions. With this method a national concept can be followed and local requirements can also be met at the same time. The principle of multidisciplinarity can be interpreted in two ways: it means the transferability" of knowledge between professions, and also the involvement of different professional areas in the educational contents. In the continuing education courses, social studies are involved, where it is reasonable, and in teacher training courses cooperation with the educational sector is also possible. In general, continuous development requires applying and building the latest scientific results in all types of education. Concerning their content, both specialising courses and continuing training courses are regularly evaluated in the way described above, just as the professional examinations, which are assessed by experts on the basis of a preset list of aspects. A national statistical database of education is maintained, the data are regularly assessed and published.

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5. COMPARATIVE ANALYSIS OF HEALTH CARE SYSTEMS TRAINING NEEDS FOR PARTNER COUNTRIES

a. ROMANIA
Analysing the field survey results and the documentary research, the general conclusions could be gathered in the following categories: - The knowledge of new means for training/assessment mut be continuously updated; - The knowledge of theory and its empirical use and terminology; - Use of training/assessment methods and tools which fit the medical areas; - The impact of assessment on the teaching/learning process and on teacher/instructor; - The continuous improvement of various abilities development while using new means and techniques of training/assessment; - Practicing the training/assessment abilities and the feedback continuously reported; - The posibility of application and use of knowledge and competences gained based on the new means and tecqniques for training/assessment. Accordingly, the results were checked taking into account 2 criteria: - professional level; - age. Therefore, the following groups were covered: 1. Medical doctors (including academic staff, doctors) and managers 2. Nurses 3. Medical students and residents 1. Medical doctors and managers All respondents underlined the importance of IT implementation in medicine while mentioning various fields where IT could be beneficial: Electronic Health Records applications; Preventing medicine applications; Medical training applications (medicine, pharmacy, nursing), intelligent cards for health; Medical imaging solutions; Second medical opinion solutions Bioinformatic system for immunity monitoring; Medical portals and virtual communities. Also, they all mentioned the importance of IT field for the continuous improvement and knowledge updating. Both categories use weekly/monthly the enlisted sources of information and continuously train in any relevant topic. They share the area from good knowledge of e-tools and distance learning methodologies to having no knowledge of the issues. All use email and internet. They would like to spend from 60 to 365 hours per year for training, but the schedule and work planning do not allow them the fulfilment. Even if their experience in e-learning, e-platforms and virtual classes is small, they all trust the methods and means for the topics enlisted. Even strongly empirical topics and subjects are of interest when linked to e-tools and an acceptance of free of charge or paid (partially contribution from employees) is obvious. 2. Nurses Identically, nurses spend weekly/monthly hours checking e-sources of information and relevant topics for their profession. They can use e-mail and Internet but they do not have knowledge of e-tools and distance learning means. They would like to spend 30 to 50 hours (sometimes more than 50 hours) per year for training, but the schedule and work planning do not allow them the fulfilment.

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They do not have any experience in either e-learning, e-platforms or virtual classes, but they are interested in the methods, topics and use. 3. Medical students and residents Even if never participated in virtual classes or distance learning, students and residents have competencies, training needs and expectations various from those of the above categories. They use and are familiar with e-tools and they heard about distance and mobile learning. They weekly/monthly sometimes, on a daily basis, check sources of information such as new jobs and career opportunities, European new techniques, technologies, publications and Science and Research last innovations. They use email, internet, e-tools and social network but they never checked or looked for distance courses. Based on these facts, the necessity for the project are quite high in Romania and, together with a high quality of classes, topics, subjects and teaching/learning materials and methods will prove to be successful among Romanian medicine schools.

b. ITALY
The analysis of the questionnaires, administered to Mangers responsible of medical training, Medical Doctors, Nursing Professionals as well as Medical Students, has highlighted main important behaviours. In order to summarize a clear picture of the most important training needs in medicine, the emerged state of art of medical e-learning, the specific needs and expectations of target group, we will focus on three core themes. 1. Knowledge and use of digital devices/tools in everyday life, in medical profession and lifelong training. 2. Thrust/experience in distance learning about medical topics and knowledge of specific distance learning methodologies/tools. 3. Italian Legal requirements and binds of medical profession since they represent important assumptions to the online courses attendance. According to these three main topics, the different ages of target groups, has to be considered since it is a discriminating factor for different behaviours, needs, priorities and expectations. 1. As concerns the first issue, knowledge and practice of digital devices/tools in everyday life, Medical profession and lifelong training, there is quite homogeneous picture among Medical Doctors. They spend a lot of time in training, refreshment courses, job shadowing and discussions with peers. They daily exploit all main sources of information and deepen any topic relevant for their profession. They dont have deep knowledge in etool and distance methodologies/devices. They use email and internet. They would like to spend 30/50 hours per year for training, but they have serious difficulties in matching training with workday. In the same way, Nursing Professionals spend many hours in training and refreshment courses. They almost daily consult main sources of information and relevant topics for their profession. They dont have knowledge of e-tool and distance methodologies/devices either. They sometimes use email and internet. They would like to spend at least 30 hours per year for training but they have serious difficulties in matching training with workday. Beside that, Medical Students, considering their young age and the fact that they are not employed yet in a work place (hospital, health institute, or clinics), they have different competencies, training needs and expectations. The use or are quite familiar with e-tools and they heard about distance and mobile learning. They weekly/monthly consult all sources of information (in particular Science and Research useful for their studies and internship).

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Often Professors suggest them Publications, medical events, etc They use email, internet, e-tools and social network. They spend all day studying and attending internship, thus they havent looked for distance courses before. 2. As concerns thrust/previous experience in distance learning for medical topics and knowledge of specific distance learning methodologies/tools, Medical Doctors and Managers of Medical Training dont thrust in distance learning for subjects such as ultrasound. Medical Doctors which have 6 years of Master Degree, plus five years of Specialisation course, dont need so many theories but require practice and job shadowing to enhance the quality of ultrasound diagnosis through images. Distance learning it is quite suitable for guidelines, protocols, cross topics such as security and crisis management, privacy, etc They dont have experience in Virtual Classrooms, but they would like to know more about it. Nursing professionals dont have any experience either in distance learning or virtual classrooms, but they are curious about methodology, virtual classrooms and e-learning platform. Even in this case Nursing Professionals underline the training needs of practice and request training about guidelines, protocols, cross topics such as security and crisis management, privacy, etc Students dont have practice as well either in Distance learning or in Virtual classrooms. This picture could seem seriously negative for a successful e-learning medical pilot project. It is important to face with real needs, lacks and restrictions of Italian contest. Detected data are needed to tailor the best elearning offer in ultrasound, nursing and patient approach. It has to be able to cope with actual medical learning needs. Aware of such feedbacks, elearning courses need to be high quality of content, there should be several meaningful images of case studies (if possible in 3D), videos, practical information and a group to share information, doubts and experience. As good example, despite of this, Fetal Medicine foundation provides distance learning in ultrasound with 3D images and many case studies. E-learning doesnt mean to substitute the practice but should aim at strongly enhancing the skills and knowledge of medical professionals in order to be better prepared to practice. Information Technology is a flexible and powerful tool able to make the difference. E-learning Methodology will offer high level content, technology potential, students interaction, share and teamwork in virtual classrooms. For example 3D images and virtual classrooms will support medical and nursing professionals in training without having the presumption to be exhaustive, but propaedeutical to practice. The collaborative and committed behaviours of medical professionals will represent the core engines of successful learning venture. 3. Italian regulations concerning ECM Continuous Medical Education require refreshments courses and a precise number of credits (150 for 3 years) for all medical professions. The request is very hard and it very difficult to fulfil the training extra working day. E-learning course, tailored to target group needs, will support learning flexibility and teamwork (National and international). c. BULGARIA The analysis of the questionnaires, administered to Academic medical stuff, Mangers responsible of medical training, Medical Doctors, Nursing Professionals, Medical Students as well as Residents has highlighted main important trends and needs in the domain. In order to summarize a clear picture of the most important training needs in medicine, the emerged state of art of medical e-learning, the specific needs and expectations of target group, we will focus on three core themes. Awareness and use of advanced ICT technologies/tools in everyday life, in medical profession and lifelong training. Thrust/experience in distance learning about medical topics.

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Bulgarian Legal requirements and binds of medical profession since they represent important assumptions to the online courses attendance. According to these three main topics, the different ages of target groups, has to be considered since it is a discriminating factor for different behaviours, needs, priorities and expectations. As concerns the first issue, knowledge and practice of digital devices/tools in everyday life, Medical profession and lifelong training, there is quite homogeneous picture among Medical Doctors. They spend a lot of time in training, refreshment courses, job shadowing and discussions with peers. They daily exploit all main sources of information and deepen any topic relevant for their profession. They dont have deep knowledge in etool and distance methodologies/devices. They use email and internet. They would like to spend 30/50 hours per year for training, but they have serious difficulties in matching training with workday. d. HUNGARY In Hungary 62% of the respondents use on-line resources at daily rate and 48 % of respondents (including nurses, MCH nurses,) require UH information at a daily rate. Regarding the use of internet tools the situation is synthetised in the following table: Never heard 0 0 0 2 0 0 20 Heard but never used 4 4 20 42 28 4 68 Manage with help 38 31 65 38 12 1 10

Chat Wiki Audio conferencing Video conf. Forum e-mail Mobil learning

Use 42 25 20 60 95 2

71 % of respondents access Internet daily, 20% 2-3Xweekly and 8% weekly and 40 % prefers receiving information on the web. 65% of respondent use the Internet daily. 51% of the target group prefer to improve their career by Classical courses, Workshops and 49% by e-learning. 68 % of respondents never benefited from e-learning during university training. As about the estimated hours per year to refresh knowledge and improve skills the different categories of the target group expressed as follows: Hours students residents managers stakeholders Academical staff members of organisations 120 180 40 80 36 32

48% of respondents were interested in Mobil learning and 52 % of respondents have looked e-learning on Internet, 73 % of respondents interested in Virtual Classroom (real time courses) and 57 % of respondents are interested in sharing content with images from their own experiences for second opinion E-learning could make easier the respondents professional development

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6. VET and e-Learning prospects in medical education an EU approach

Present state of art in medical education. Significant changes occur lately in the healthcare sector. More, the context of medical education is changing, new challenges occur. 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. Judy McKimm (2009) considers some of the challenges for medical educators and clinicians when engaging in professional development activities and explores opportunities for medical educators and those responsible for medical students and trainees education and training to develop their educational expertise. However, a lot of authors showed that all those involved in clinical teaching and medical education are increasingly required to deliver high quality teaching, learning, assessment and supervisory activities with medical students, trainees and other health professionals. Medical education is becoming more professionalised, driven by quality assurance activities and requirements from professional and statutory bodies in both undergraduate and postgraduate contexts. All areas of healthcare and education are moving towards more professionalised systems and expectations from those involved. Professionalisation involves developing sets of standards against which people or organisations can be measured and towards which they can strive. Professionalisation also involves the idea of continuing development and revalidation, in order to stay professional (whether this is through a formal registration process or not), there may be requirements to stay current and up to date in your area of expertise. 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). For medical educators, this includes 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. Managing development in both these aspects can be very demanding particularly for clinical educators who also have to deliver the health service. However, regulatory and professional bodies increasingly require doctors and other health professionals to be able to provide evidence of professional development relating to teaching as well as clinical competence. The ageing population demands increasing attention from medical personnel, resulting in a reduction in the time that can be devoted to teaching activities. In addition, the trend towards decreasing lengths of patients stays in hospitals reduces the possibilities for medical students to observe the treatment process. Medical educators work within a linked university, health service and regulatory organisation context. Even if they work in either a university or a healthcare organisation, students move from one setting to another and the curriculum for undergraduates is delivered jointly. Postgraduate trainees need to fulfill external body assessment requirements at certain points in their training although they may primarily learn, work and be assessed in a healthcare setting. Understanding the requirements from the different bodies involved in medical education is hugely challenging. Other writers identify a range of challenges for clinical teachers, some of which are common to all teachers, others which are unique to clinical educators: Managing time Teaching amidst busy clinical workloads and service pressures

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 Feelings of isolation and lack of support Patients rights and changing expectations about the quality and safety of health care Increasing numbers of medical and other healthcare students Changing expectations from medical students and trainees Involving patients meaningfully in medical education Interprofessional education Keeping pace with new scientific and clinical knowledge Keeping up to date with educational requirements and advances in teaching, learning and assessment The impact of technology, including e-learning and simulation Quality assurance requirements from funding bodies, professional regulators and statutory bodies (Spencer, 2003; Swanwick & McKimm, 2010). Many universities have departments of medical education which provide a focus for academic activities, including research and professional development programmes. Other opportunities in medical education include becoming involved in the wider community of practice. Internationally and more locally, there are a number of high profile conferences, journals and other activities that focus specifically on medical education as a subject discipline. Attending and presenting at conferences helps to keep knowledge up to date as well as providing opportunities for networking with like-minded individuals. For teachers who are interested in the broader aspects of medical education, becoming involved with assessment, curriculum development and quality assurance activities (such as on behalf of accrediting bodies or medical Colleges) can be highly rewarding and interesting. Just as opportunities relating to subject content and teaching, learning and assessment methods are increasing, so are those relating to educational leadership. 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. 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 courses is a real necessity. Learning strategies are focused on engaging students actively through structured activities and realistic tasks to encourage learning by doing, with opportunities for reinforcement and consolidation through reflections shared and feedback from tutors and peers. 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. "Continuing professional development" is a very important concept for most professions, no matter what activity we're talking. Very rapid evolution of society, technology and human needs of today require professionals to seek the best ways to be permanently connected to the latest findings that, in this way, and may carry out professional work to effectively and properly standards. 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. The rapid pace with which the data change constantly within the problem and the many challenges that doctors face daily must make continuous training and "connecting" constantly at everything new to become essentially required for that profession, regardless of area of specialization chosen.

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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. The reasons that make "e learning" so appreciated and used at international level can be summarised as follows: very fast access from anywhere in the world to the precise information, effortless access (through a simple Internet connection) and which involves a much lower cost than required by traditional training methods offering CME credits (travel, time spent, cost subscriptions, etc..), which is very important especially in the current economic climate in Romania and abroad. In addition, due to increased level of interactivity owned by "e learning" (online courses, etc.) professional development via the Internet proved, compared to traditional methods of education, to have a higher degree of efficiency in terms of easy acces and the ability to put into practice by physicians of newly available information. Increasing demands on continuing medical education (CME) are taking place at a time of significant developments in educational thinking and new learning technologies. Such developments allow today's CME providers to better meet the CRISIS criteria for effective continuing education: convenience, relevance, individualization, self-assessment, independent learning, and a systematic approach. e-learning - definitions Brown (2007) drove attention that in the policy documents there is no generally accepted definition of e-learning. This point is illustrated clearly by the way e-learning, online learning and distance learning seem to be synonymous. Often the conception of elearning is very broad and in many cases, no explicit definition was provided in policy documentation. The idea of blended learning also appears more recently in some policy texts but there is a danger of seeing this concept as largely business as usual.

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In the article The Impact of E-Learning in Medical Education (2006) the authors provide an introduction to e-learning and its role in medical education by outlining key terms, the components of e-learning, the evidence for its effectiveness, faculty development needs for implementation, evaluation strategies for e-learning and its technology, and how elearning might be considered evidence of academic scholarship. E-learning is commonly referred to the intentional use of networked information and communications technology or Internet technologies in teaching and learning, aiming to enhance knowledge and performance. A number of other terms are also used to describe this mode of teaching and learning. They include online learning, virtual learning, distributed learning, network and webbased learning, computer-assisted instruction, or Internet-based learning. Fundamentally, they all refer to educational processes that utilize information and communications technology to mediate asynchronous as well as synchronous learning and teaching activities. On closer scrutiny, however, it will be clear that these labels refer to slightly different educational processes and as such they cannot be used synonymously with the term e-learning. The term e-learning comprises a lot more than online learning, virtual learning, distributed learning, networked or web-based learning. As the letter e in e-learning stands for the word electronic, e-learning would incorporate all educational activities that are carried out by individuals or groups working online or offline, and synchronously or asynchronously via networked or standalone computers and other electronic devices Historically, there have been two common e-learning modes: distance learning and computer-assisted instruction. Distance learning uses information technologies to deliver instruction to learners who are at remote locations from a central site. Computer-assisted instruction (also called computer-based learning and computer-based training) uses computers to aid in the delivery of stand-alone multimedia packages for learning and teaching. These two modes are subsumed under e-learning as the Internet becomes the integrating technology. A concept closely related to e-learning but preceding the birth of the Internet is multimedia learning. Multimedia uses two or more media, such as text, graphics, animation, audio, or video, to produce engaging content that learners access via computer. Distance Education, then, is often referred to as those delivery modalities that seek to reduce the barriers of time and space to learning, thus the frequently used phrase anytime, anywhere learning. Advantages of e-learning E-learning technologies offer learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives. In diverse medical education contexts, e-learning appears to be at least as effective as traditional instructor-led methods such as lectures. Students do not see e-learning as replacing traditional instructor-led training but as a complement to it, forming part of a blended-learning strategy. Quantitative and qualitative studies of collaborative learning in medicine have shown higher levels of learner satisfaction, improvements in knowledge, self-awareness, understanding of concepts, achievement of course objectives, and changes in practice. Faculty, administrators, and learners find that multimedia e-learning enhances both teaching and learning. These advantages can be categorized as targeting either learning delivery or learning enhancement. These advantages can be categorized as targeting either learning delivery or learning enhancement. Learning delivery is the most often cited advantage of e-learning and includes increased accessibility to information, ease in updating content, personalized instruction, ease of

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distribution, standardization of content, and accountability. Accessibility refers to the user's ability to find what is needed, when it is needed. Improved access to educational materials is crucial, as learning is often an unplanned experience. Updating electronic content is easier than updating printed material 9: e-learning technologies allow educators to revise their content simply and quickly. Learners have control over the content, learning sequence, pace of learning, time, and, often, media, which allows them to tailor their experience to meet personal learning objectives. Internet technologies permit the widespread distribution of digital content to many users simultaneously anytime and anywhere. An additional strength of e-learning is that it standardizes course content and delivery; unlike, for instance, a lecture given to separate sections of the same course. Automated tracking and reporting of learners' activities lessen faculty administrative burden. Moreover, e-learning can be designed to include outcomes assessment to determine whether learning has occurred. Advantages in learning enhancement are a less well recognized but potentially more revolutionary aspect of e-learning than are those related to learning delivery. E-learning technologies offer educators a new paradigm based on adult learning theory, which states that adults learn by relating new learning to past experiences, by linking learning to specific needs, and by practically applying learning, resulting in more effective and efficient learning experiences. Learning enhancement permits greater learner interactivity and promotes learners' efficiency, motivation, cognitive effectiveness, and flexibility of learning style. Learning is a deeply personal experience: we learn because we want to learn. By enabling learners to be more active participants, a well-designed e-learning experience can motivate them to become more engaged with the content. Interactive learning shifts the focus from a passive, teacher-centered model to one that is active and learner-centered, offering a stronger learning stimulus. Interactivity helps to maintain the learner's interest and provides a means for individual practice and reinforcement. Evidence suggests that e-learning is more efficient because learners gain knowledge, skills, and attitudes faster than through traditional instructor-led methods. This efficiency is likely to translate into improved motivation and performance. E-learners have demonstrated increased retention rates and better utilization of content, resulting in better achievement of knowledge, skills, and attitudes. Multimedia e-learning offers learners the flexibility to select from a large menu of media options to accommodate their diverse learning styles. Other opportunities are emerging as the medical curriculum expands to include a wider range of topics such as communication skills, professionalism, medical ethics and law and research skills. As curricula become increasingly integrated, teachers with experience and interest in the social and behavioural sciences and public health are required as well as in more conventional topics. E-learning presents numerous research opportunities for faculty, along with continuing challenges for documenting scholarship. 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. Components of E-Learning In the university sector, medical education is slowly becoming regarded as a specialty in its own right, stimulating a wide range of roles and career options to support teaching, learning and assessment activities. Most undergraduate medical programmes require

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students to study in a blended learning model which includes face to face laboratory, classroom and lecture sessions, e-learning and simulated activities and clinical placements or apprenticeships. Other modes of learning, such as Problem Based Learning (PBL) or Team Based Learning (TBL) provide interesting opportunities for teachers to extend existing teaching skills and learn new ways of working. A developing infrastructure to support e-learning within medical education includes repositories, or digital libraries, to manage access to e-learning materials, consensus on technical standardization, and methods for peer review of these resources. Creating e-learning material involves several components: once content is developed, it must be managed, delivered, and standardized. Content comprises all instructional material, which can range in complexity from discrete items to larger instructional modules. A digital learning object is defined as any grouping of digital materials structured in a meaningful way and tied to an educational objective. Learning objects represent discrete, self-contained units of instructional material assembled and reassembled around specific learning objectives, which are used to build larger educational materials such as lessons, modules, or complete courses to meet the requirements of a specified curriculum. Examples include tutorials, case-based learning, hypermedia, simulations, and game-based learning modules. Content creators use instructional design and pedagogical principles to produce learning objects and instructional materials. Content management includes all the administrative functions (e.g., storing, indexing, cataloging) needed to make e-learning content available to learners. Examples include portals, repositories, digital libraries, learning-management systems, search engines, and ePortfolios. A learning-management system, for example, is Internet-based software that facilitates the delivery and tracking of e-learning across an institution. A learningmanagement system can serve several functions beyond delivering e-learning content. It can simplify and automate administrative and supervisory tasks, track learners' achievement of competencies, and operate as a repository for instructional resources twenty-four hours a day. Learning-management systems familiar to medical educators are WebCT or Blackboard, but there are more than 200 commercially available systems, a number that is growing rapidly. Content delivery may be either synchronous or asynchronous. Synchronous delivery refers to real-time, instructor-led e-learning, where all learners receive information simultaneously and communicate directly with other learners. Examples include teleconferencing (audio, video, or both), Internet chat forums, and instant messaging. With asynchronous delivery, the transmission and receipt of information do not occur simultaneously. The learners are responsible for pacing their own self-instruction and learning. The instructor and learners communicate using e-mail or feedback technologies, but not in real time. A variety of methods can be used for asynchronous delivery, including e-mail, online bulletin boards, listservs, newsgroups, and Weblogs. In addition to establishing, managing, and delivering content, a fourth component is part of the e-learning equation. It is becoming increasingly clear that standards are needed for the creation of new e-learning material. Such standards promote compatibility and usability of products across many computer systems, facilitating the widespread use of elearning materials. Several organizations have been engaged in creating broad e-learning standards. Although not specifically designed for medical education, these standards offer medical educators important advantages. The most well-known set of standards is the Advanced Distributed Learning: Sharable Content Object Reference Model (SCORM). SCORM is a group of specifications developed through a collaborative effort of e-learning organizations funded by the United States Department of Defense. SCORM specifications prescribe the manner in which a learning-management system handles e-learning products. E-learning material built to SCORM specifications will interact with a conformant learning-management system, allowing for the prescription of the learning

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experience and tracking of learner performance. In medical education, MedBiquitous, a consortium of academic, government, and health care industry organizations, is working to develop SCORM-compliant specifications and standards for medical education. The Evidence for Effective and Efficient E-Learning The effectiveness of e-learning has been demonstrated primarily by studies of higher education, government, corporate, and military environments. However, these studies have limitations, especially because of the variability in their scientific design. Often they have failed to define the content quality, technological characteristics, and type of specific e-learning intervention being analyzed. In addition, most have included several different instructional and delivery methodologies, which complicates the analysis. Most of these studies compared e-learning with traditional instructor-led approaches. Yet three aspects of e-learning have been consistently explored: product utility, costeffectiveness, and learner satisfaction. Utility refers to the usefulness of the method of elearning. Several studies outside of health care have revealed that most often e-learning is at least as good as, if not better than, traditional instructor-led methods such as lectures in contributing to demonstrated learning. Gibbons and Fairweather cite several studies from the pre-Internet era, including two meta-analyses that compared the utility of computer-based instruction to traditional teaching methods. The studies used a variety of designs in both training and academic environments, with inconsistent results for many outcomes. Yet learners' knowledge, measured by pre-post test scores, was shown to improve. Moreover, learners using computer-based instruction learned more efficiently and demonstrated better retention. Recent reviews of the e-learning (specifically Web-based learning) literature in diverse medical education contexts reveal similar findings. Chumley-Jones and colleagues reviewed 76 studies from the medical, nursing, and dental literature on the utility of Web-based learning. About one-third of the studies evaluated knowledge gains, most using multiple-choice written tests, although standardized patients were used in one study. In terms of learners' achievements in knowledge, Web-based learning was equivalent to traditional methods. Of the two studies evaluating learning efficiency, only one demonstrated evidence for more efficient learning via Web-based instruction. A substantial body of evidence in the nonmedical literature has shown, on the basis of sophisticated cost analysis, that e-learning can result in significant cost-savings, sometimes as much as 50%, compared with traditional instructor-led learning. Savings are related to reduced instructor training time, travel costs, and labor costs, reduced institutional infrastructure, and the possibility of expanding programs with new educational technologies. Only one study in the medical literature evaluated the costeffectiveness of e-learning as compared with text-based learning. The authors found the printing and distribution of educational materials to be less costly than creating and disseminating e-learning content. Studies in both the medical and nonmedical literature have consistently demonstrated that students are very satisfied with e-learning. Learners' satisfaction rates increase with e-learning compared to traditional learning, along with perceived ease of use and access, navigation, interactivity, and user-friendly interface design. Interestingly, students do not see e-learning as replacing traditional instructor-led training but as a complement to it, forming part of a blended-learning strategy. E-Learning as Academic Scholarship The literature regarding faculty development or promotion of e-learning as evidence of scholarly pursuit is almost nonexistent to our knowledge; however, as noted above, elearning requires faculty competencies that go beyond traditional instructional activities. Furthermore, by its nature, e-learning offers learners and instructors the possibility of widespread use, access, and sharing unmatched by other types of instruction. Evaluation

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data from peer review as well as learning-management system tracking and monitoring of e-learning use can provide evidence of its quality and effectiveness. How are faculty members recognized and rewarded for their dedication to this effort? The following activities could be considered evidence of scholarship for faculty promotion: * Publication of e-learning materials in a national online peer-reviewed repository. * Faculty and learner evaluations of one's e-learning material. * Peer-reviewed publications describing the process, impact, and scientific contributions of e-learning to medical education. * Successful grant awards in e-learning. * Participation in national (and international) societies concerned with the development, application, and use of e-learning in medical education. Numerous research opportunities exist in the relatively new field of e-learning. Faculty, administrators, and the public will demand that educators evaluate the impact of elearning on the quality and efficiency of medical education. Extrapolating methods from other clinical and educational research, including comparative studies, is insufficient because such studies often ignore the complexity of the learning process and the methods of delivery characteristic of e-learning. Potential areas for research include assessing contexts for effective use of e-learning in medical education, the differential use of e-learning in preclinical versus clinical years, the adaptation of e-learning to a wide variety of medical specialties and clinical settings, an exploration of methods for simplifying the e-learning creation process to gain wider acceptance and use, the incorporation of e-learning as part of a blended-learning strategy, and the use of a multimedia instructional design process by medical educators. Integrating E-Learning into Medical Education The integration of e-learning into existing medical curricula should be the result of a welldevised plan that begins with a needs assessment and concludes with the 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, we believe it is best to begin with an integrated strategy that considers the benefits and burdens of blended learning before revising the curriculum. In undergraduate medical education, e-learning offers learners materials for self-instruction and collaborative learning. In graduate medical education, the Accreditation Council for Graduate Medical Education has established six core competencies toward which e-learning can be applied (http://www.acgme.org/acwebsite/RRC_280/280_corecomp.asp). E-learning materials suited for each of these competencies can be integrated into the education of residents and fellows, replacing lectures and other synchronous methods of instruction. Asynchronous e-learning can be effectively used during demanding clinical care rotations, especially when duty hours are limited yet curriculum requirements remain high. In continuing medical education, physicians with daily clinical obligations can attend medical e-conferences using e-learning. Evaluating E-Learning Processes and Outcomes Adopting e-learning and its technology requires large investments in faculty, time, money, and space that need to be justified to administrators and leadership. As with other educational materials, there are two major approaches to the evaluation of e-learning: process and outcomes. Process evaluation examines an e-learning program's strengths and weaknesses and how its results are produced, often providing information that will allow others to replicate it. Peer review is one type of process evaluation. Traditional peer review for journal articles verifies the quality of content. E-learning requires the consideration of additional dimensions. For example, is it easy to navigate through the online material? Is the

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appearance conducive to education? Are multimedia elements used effectively? Is the interactivity appropriate for the level of the learner? Are special computer skills, hardware, or software required? These and other questions place new demands on peer reviewers engaged in process evaluation of e-learning. In fact, the AAMC, at the request of the Council of Deans, has begun a peer-review process of e-learning that recognizes these materials as evidence of scholarly activity for faculty promotion and recognition. Outcome evaluation of changes in learners' knowledge, skills, or attitudes allows elearning developers to gauge program effectiveness. The evaluation framework outlined by Kirkpatrick in the 1950s and later adapted to health care education can be used to evaluate e-learning interventions. The Kirkpatrick model defines four levels of evaluation based on outcome: satisfaction, learning, change in learner behavior, and organizational change/patient outcome. Satisfaction measures learners' reactions to the material: was it easy to use, hard to use, fun, boring, and so forth. But satisfaction measures alone do not measure learning. For example, excellent content that learners find difficult to use may be rated as poor. Likewise, a module that is highly entertaining in its use of multimedia but superficial in its content may be rated as excellent. Tracking and monitoring learners' knowledge, attitudes, and skills via a learningmanagement system can greatly simplify the process of evaluating the gains made through e-learning. An approach that combines assessment of skills and attitudes using e-learning technology with facilitator-mediated observation would allow a more in-depth evaluation of skills and behavior. By contrast, evaluating the direct result of an education program by measuring changes in learners' behaviors, institutional changes, and better patient care is often complex, time-consuming, and costly. E-learning assessments can be one valuable component in such overall evaluation of medical school curricula. Standards and accreditation for e-learning (www.elearners.com/resources/ accreditation.asp). 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. 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. The European Accreditation Council for CME (EACCME) was established in January 2000, to act as a clearing house system for international CME accreditation. Its purpose is to facilitate the international transfer and recognition of CME credits obtained by individuals in CME activities that meet common quality requirements. EACCME aims to connect existing and emerging accreditation systems: . between European countries . between dierent specialties . in case of migration of specialists within Europe . between the European accreditation system and comparable systems outside Europe. The EACCME establishes standards and procedure that need to be applied by the accrediting authorities. EACCME delegates the task of review and accreditation to Boards within medical specialties . The accreditation criteria for the EACCME are: . Integral learner support: The learner is provided with an introduction to the course, to include at least the following: the purpose of the course

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 learning objectives the structure of the course estimated required study time estimated elapsed time required to complete the course any materials (books, software etc.) to be supplied by the learner the hardware and software required to use the materials how to get the best from the course. The learner is provided with instructions on using the course, to include at least the following: . Content: Given the support of online tutors, where provided, is sucient to allow the learner to reach the learning objectives. Structured into meaningful sections and arranged into a sequence and/or hierarchy that facilitates learning. Written at a level appropriate to the specified audience. Lively, stimulating and enjoyable. Free of intended or unintended racist, sexist or ageist material. Accurate, up-to-date and free of spelling and grammatical errors. Does not violate existing copyrights. All units include an overview and summary. . Learning design: Uses a variety of approaches designed to satisfy the needs of learners with diferent learning styles. Adequate provision is made in the design for the learner to: reflect on, review and digest new learning apply new knowledge and practise new skills assess their progress. Methods and media are selected appropriately according to their suitability in helping the learner to achieve the particular learning objective. Opportunities for meaningful user interaction are provided regularly throughout the course, whether built into the materials or through communication with other learners and tutors. Where interactivity is built into the materials, questions are set at a level appropriate to the audience. Pre-and post-assessment: tests, exercises or assignments aree-learning for GP educators included to ensure the learner has achieved all of the learning objectives. Where appropriate, the materials include an optional facility for pre-assessment of the learner's existing knowledge, skills or attitudes. Where pre- or postassessments are employed, it is clear where results are stored and how they will be used. Buttons are provided to allow the learner to exit the current section, move upwards within a hierarchy of menus and, from the top level, to exit. Usability: The course conforms to best practice with regard to readability: text is legible against the background and appropriate fonts are selected. Media quality: At the specified minimum bandwidth, the time taken to load any image, animation, applet, movie, sound or document is acceptable given the instructional purpose. The delay should not be greater than 10 seconds. Audio is free from unnecessary hiss, page turns, lip smacks and other extraneous noise and is not clipped at the front or the end. . Technical quality: The program is free of software bugs and broken links. Images display intelligibly at the minimum supported colour resolution. Where delivered as a web application, the program runs without error on all supported brands and versions of browsers and browser add-ons such as plug-ins. The program runs without error on all supported types of computer, at the minimum supported specication. Web-based learning vs computer-based learning e-learning

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covers a wide set of applications and processes, such as web-based learning, computerbased learning, virtual classrooms and online collaboration. Web-based learning includes online courses or any kind of educational resource that is on the World Wide Web, such as online classrooms or forums. Computerbased learning mainly encompasses o.ine learning through the use of computers or computer-based technology, such as an interactive CD-ROM. Not all colleges accredit online courses, although these enable greater ability to audit and check than lunchtime lectures or seminars. For example, the Royal College of Physicians will accredit a course if it is on CD, but not if the same course is online. The EACCME does not accredit online courses either. The accreditation criteria for a resource (e.g. a CD course) are as follows. 1 The target audience falls within the remit of the Federation (given medical specialties). 2 The content is concerned with clinical specialty-based issues or with the development of non-clinical skills (e.g. management, teaching, information technology etc.) necessary to work in a modern health service. 3 The package provides educational objectives for the user and a method of assessment to measure whether these objectives have been reached. 4 The package provides evidence of interactivity between the user and material to enhance the learning process. 5 The package is flexible and free from unreasonable geographical and resource (hardware and software) implications and time constraints that will restrict access to use. 6 Any sponsorship or funding has not inuenced the educational programme content, and programme authors are completely independent of any commercial healthcare organisation. 7 The provider's evaluation record for previous events is satisfactory or, where not, reasons for unsatisfactory ratings have subsequently been addressed. 8 The provider agrees to submit, upon request, confirmation of physician participation at any time up to two years after the event has taken place. 9 Information and references should be relevant, up-to-date and where possible encompass the best evidence available, and it should also adequately cover the subject area without any inexplicable omissions appearance and functionality should be userfriendly. 10 There are appropriate methods of assessment included. Feedback for the user should be available in order to improve performance the final assessment and pass rate should be of a standard that is benecial for CPD purposes. 11 Information provided by the producer should include: results of any market research for need of such materials amongst intended users details of any evaluative procedures before and during the package's developmental stage. 12 The package should be a cost-eective and innovative contribution to a physician's learning environment and the range of CPD activities available. Institute of IT Training (IITT) accreditation To be IITT-compliant, the education provider, learning materials and developer (the individual practitioner) levels will be assessed, and current best practice in these areas designed. The standards are reviewed on an annual basis to ensure continued currency and applicability. The standards cover four main areas: 1 Code of practice for e-learning providers: e-learning providers must adhere to the terms of this code of practice and continually demonstrate that they do so to be eligible for accreditation by the Institute. Through this, the Institute will maintain and monitor a register of approved providers of e-learning. The following areas are included in the code of practice: publicity and promotion

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 course information learning materials standards third-party standards developer competencies tutor competencies external controls complaints procedure. 2 e-learning provider accreditation programme: Institute accreditation requires rigorous assessment by expert practitioners and applicants commit to ongoing compliance with the Institute's code of practice. 3 Standards for e-learning materials: For e-learning to fulfil its promise, learning materials have to be designed so as to facilitate learning within a simulating whilst enjoyable environment. The standards focus on key areas: integral learner support content interactive design navigation usability media quality technical quality. 4 Competencies for developers of e-learning materials: Best-practice competencies are evidence of which has to be shown by individual practitioners applying for membership of the Institute.

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7. e-Learning and Europe - the best practices concerning current elearning methodologies in medical education in EU
Curent state of art. The Council of the European Union drive attention to the need to advance in bringing about the modernisation of Europe's universities, addressing their interlinked roles in education, research and innovation, as a key element of Europe's drive to create a knowledge-based society and economy and improve its competitiveness. In these conditions the importance of increasing lifelong learning opportunities, widening higher education access to non-traditional Web-based learning as such is incorporated in the more general educational term e-learning is crucial. It is one of its major subcomponents and represents one of the tools with which education is delivered. The introduction of new learning technologies, the exponential growth of Internet usage and the advent of the World Wide Web have the potential of changing the face of higher education. There are also demands in medical education for greater globalization, for the development of a common core curriculum, for improving access to training, for more flexible and student-centred training programmes including programmes with multiprofessional elements and for maintaining quality while increasing student numbers and working within financial constraints. In academic institutions, web-based learning systems are generally housed administratively in a distance education department alongside other at-distance delivery methods such as correspondence, satellite broadcast, two way videoconferencing, videotape and CD-ROM/DVD delivery systems. All such systems seek to create a new educational environment developed extremely on the basis of the new information and communication technologies and strongly dependant on them. The aim of this type of education is to serve learners at some distance from their learning facilitator. Many such systems attempt to serve learners interacting with the learning source at different chronological times (for example, e-mail). Developments in e-learning and technologies are creating the groundwork for a revolution in education, allowing learning to be individualized (adaptive learning), enhancing learners' interactions with each other (collaborative learning)- terms that will be explained later, and transforming the role of the teacher. As presented further on An evolving emphasis within medical education on lifelong learning and competencybased education has forced educators to reevaluate their traditional roles In this changing paradigm, educators no longer serve as the sole distributors of content, but are becoming facilitators of learning and assessors of competency. E-learning offers the opportunity for educators to evolve into this new role by providing them with a set of online resources to facilitate the learning process. There are currently many e-Learning platforms on the market, either open source or proprietary. More and more software companies and research centers use computersupported cooperative tools to overcome the geographical distance and benefit from access to a qualified resource pool and a reduction in development costs. However, the increased globalization of software development creates software engineering challenges due to the impact of temporal and geographical differences. Every e-Learning platform has implemented a mechanism for assessing the quantity of accumulated knowledge for a certain discipline. A problem that frequently arises is that the system in place may not be fair regarding the ordering of learners according with accumulated knowledge. Usually, there are situations when the distributions of grades is not normal, such that many learners are clustered although there are differences regarding their accumulated knowledge. The main goal of an e-learning platform is to give students the possibility to download course materials, take tests or sustain final examinations and communicate with all involved parties. The usual protocol between clients (users) and server (the e-Learning

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platform itself) is HTTP. This stateless protocol uses only request/response type interactions between clients and server. Every e-Learning platform has implemented a mechanism for assessing the quantity of accumulated knowledge for a certain discipline. A problem that frequently arises is that the system in place may not be fair regarding the ordering of learners according with accumulated knowledge. Usually, there are situations when the distributions of grades is not normal, such that many learners are clustered although there are differences regarding their accumulated knowledge. As a general European feature, increasingly, Medical Education around the world is being supported by online teaching, usually within Learning Management Systems (LMSs) or Virtual Learning Environment (VLEs). Research areas into online medical education are wide-ranging, and include: The roles of the participants (student, teacher, administrators) Content generation, especially in a wide range of media The use of LMSs, VLEs and other systems, and open-source vs. proprietary, methods of interaction Practical applications, virtual patients, 3 D animation, etc Distance learning Assessment Electronic Portfolios (e-Portfolios) Mobile Learning (M-Learning) The Politics and Psychology of e-learning Legal and Ethical Issues Design Issues Standards and Specifications Key terms in e-learning The terminology for systems which integrate and manage computer-based learning has changed over the years. Terms which are useful in searching for earlier materials include: "Computer Assisted Instruction" (CAI) "Computer Based Training" (CBT) "Computer Managed Instruction" (CMI) "Course Management System" (CMS) "Integrated Learning Systems" (ILS) "Interactive Multimedia Instruction" (IMI) "Learning Management System" (LMS) "Technology Based Learning" (TBL) "Technology Enhanced Learning" (TEL) "Web Based Training" (WBT) " On Demand Training" (ODT) Virtual Learning Environments (VLEs). A virtual learning environment (VLE) is a system that creates an environment designed to facilitate teachers in the management of educational courses for their students, especially a system using computer hardware and software, which involves distance learning. In North America, a virtual learning environment is often referred to as a "learning management system" (LMS). Learning Management Systems (LMS) A Learning Management System (LMS) is a software application or web-based technology for managing the administration, documentation, tracking, reporting, and delivery of training programs, continuing education, professional development, credentialing, online events, and e-Learning programs. It provides organizations with a centralized and

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consolidated method for the delivery of online training programs. Built-in assessment and reporting tools allow for automated certificate generation. A Learning Management System (LMS) manages student records, distributes courses to students, and provides features for online collaboration and communication. A well-designed Learning Management System (LMS) provides hands-free administration with features such as these: Student self-service features that allow self-registration Course purchasing Automated notifications Online assessment (test) creation Continuing education (CE) tracking Collaborative learningapplication sharing, discussion threads, etc. Training resource management A Medical Learning Management System (LMS), much like general learning management systems, manages learner records, distributes courses and provides for social learning. Organizations use medical learning management systems (LMS) such as the Knowledge Direct MED LMS for continuing medical education (CME), maintenance of certification (MOC), self evaluation programs (SEP), and training. Through the use of a medical learning management system, organizations are able to: Create online content Register, track, test and report on learners Issue certificates Maintain reports and records Learning Content Management Systems (LCMS) A Learning Content Management System (LCMS) typically provides a multi-user environment where administrators, instructors, and content managers can create, store, reuse, and manage learning objects from a central object repository. A learning object can be thought of as a small, self-contained re-usable unit of content that can be used to support learning. Some examples of learning objects include MicrosoftWord or PowerPoint files, PDF files, video, and audio. A Learning Content Management System (LCMS) enables an organization to share learning objects across the enterprise, which saves money, promotes consistent learning, and helps to amortize the cost of eLearning. If you would like additional information e-learning portal A web site that acts as a central directory/repository for various types of learning and training materials used by learners is known as a learning portal or e-Learning portal. Learning portals link to relevant training or learning materials such as pdf documents, training videos, web sites, courses, interactives, etc. The main page of the learning portal (often called the training menu) may also display a list of recommended courses, upcoming events, resource libraries, job aids or discussion boards. Search functionality within the portal, rating systems, and social networking features are also available in some learning portals. Content within the e-Learning portal can either be general training OR customized for the individual learner. Content, tailored for the individual learner, is based on the learners role within the organization, department, or membership level, previous training history as well as professional/personal goals. In cases where the portal is populated with custom content for the learner, administrators use the portals learning management system to assign the most valuable and appropriate courses to the learner based on those roles and goals.

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Web 2.0 eLearning The term Web 2.0 refers to new ways of using the web to deliver a more personalized and collaborative online learning experience through information sharing and interoperability. Examples of Web 2.0 are social networking sites (MySpace, Facebook, LinkedIn), video and photo sharing sites (YouTube, Flickr), wikis, blogs, podcasts, RSS feeds, and folksonomies (Delicious). In the eLearning field, Web 2.0 has revolutionized the way instructors and end-users interact with learning content and each other. In the workplace, the term "tribal knowledge" has taken on a whole new meaning. e-Learning 2.0 comes from the term, Web 2.0, and similar to Web 2.0, is the facilitation of learning through collaboration and sharing ideas and content with other learners. Increasingly, people are using these technologies to share information, get help, find people with similar interests, and learn from one another. M-Learning The term M-Learning, or "mobile learning", has different meanings for different communities. Although related to e-learning and distance education, it is distinct in its focus on learning across contexts and learning with mobile devices. One definition of mobile learning in Wikipedia is: Any sort of learning that happens when the learner is not at a fixed, predetermined location, or learning that happens when the learner takes advantage of the learning opportunities offered by mobile technologies. In other words mobile learning decreases limitation of learning location with the mobility of general portable devices. The term covers: learning with portable technologies including but not limited to handheld computers, MP3 players, notebooks and mobile phones. M-learning focuses on the mobility of the learner, interacting with portable technologies, and learning that reflects a focus on how society and its institutions can accommodate and support an increasingly mobile population. There is also a new direction in MLearning that adds mobility of the instructor and includes creation of learning materials "on-the-spot, "in the field" using predominately smartphone with special software such as AHG Cloud Note. Using mobile tools for creating learning aides and materials becomes an important part of informal learning. M-learning is convenient in that it is accessible from virtually anywhere. M-Learning, like other forms of E-learning, is also collaborative; sharing is almost instantaneous among everyone using the same content, which leads to the reception of instant feedback and tips. M-Learning also brings strong portability by replacing books and notes with small RAMs, filled with tailored learning contents. In addition, it is simple to utilize mobile learning for a more effective and entertaining experience. Blended learning, a fairly new term in education but a concept familiar to most educators, is an approach that combines e-learning technology with traditional instructor-led training, where, for example, a lecture or demonstration is supplemented by an online tutorial. Problem-based learning (PBL) is a student-centered pedagogy in which students learn about a subject in the context of complex, multifaceted, and realistic problems. Working in groups, students identify what they already know, what they need to know, and how and where to access new information that may lead to resolution of the problem. The role of the instructor is that of facilitator of learning who provides appropriate scaffolding of that process by (for example), asking probing questions, providing appropriate resources, and leading class discussions, as well as designing student assessments. Unlike traditional instruction, PBL actively engages the student in constructing knowledge in their own mind by themselves, and thus addresses

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many of deficits of traditional classroom where knowledge is expounded by an instructor. Characteristics of PBL are: Learning is driven by challenging, open-ended, ill-defined and ill-structured problems. Students generally work in collaborative groups. Teachers take on the role as "facilitators" of learning. In PBL, students are encouraged to take responsibility for their group and organize and direct the learning process with support from a tutor or instructor. Advocates of PBL claim it can be used to enhance content knowledge while simultaneously fostering the development of communication, problem-solving, and self-directed learning skills. PBL may position students in a simulated real world working and professional context which involves policy, process, and ethical problems that will need to be understood and resolved to some outcome. By working through a combination of learning strategies to discover the nature of a problem, understanding the constraints and options to its resolution, defining the input variables, and understanding the viewpoints involved, students learn to negotiate the complex sociological nature of the problem and how competing resolutions may inform decision-making. Team-based learning (TBL) possibly relies on small group interaction more heavily than any other commonly used instructional strategy in postsecondary education. The primary learning objective in TBL is to go beyond simply covering content and focus on ensuring that students have the opportunity to practice using course concepts to solve problems. Thus, TBL is designed to provide students with both conceptual and procedural knowledge. Although some time in the TBL classroom is spent ensuring that students master the course content, the vast majority of class time is used for team assignments that focus on using course content to solve the kinds of problems that students are likely to face in the future. In this way TBL is a well-defined instructional strategy that is being employed increasingly in medical education. Developed originally for business schools and other higher learning settings, TBL allows a single instructor to manage multiple small groups simultaneously in 1 classroom. It has raised interest within the medical education community because of its potential to promote active learning without requiring large numbers of faculty facilitators. A number of studies have appeared in the medical literature providing empirical evidence of potential benefits from TBL. Such benefits include increased student engagement, higher-quality communication processes and increased National Board of Medical Examiners shelf examination scores. (Thompson et al, 2007). Adaptive learning uses technology to assess learners' knowledge, skills, and attitudes at the beginning of online training in order to deliver educational materials at the level most appropriate for each learner. In the online environment of elearning, adaptive learning is possible through identification of the learner, personalization of content, and individualization of tracking, monitoring, support, and assessment. Adaptive learning is the ultimate learner-centered experience because it individualizes a unique learning path for each learner that is likely to target his or her specific learning needs and aptitudes. Collaborative learning is a situation in which two or more people learn or attempt to learn something together. Unlike individual learning, people engaged in collaborative learning capitalize on one anothers resources and skills (asking one another for information, evaluating one anothers ideas, monitoring one anothers work, etc.). More specifically, collaborative learning is based on the model that knowledge can be created within a population where members actively interact by sharing experiences and take on asymmetry roles.[4] Put differently, collaborative learning refers to methodologies and environments in which learners engage in a common task where each individual depends on and is accountable to each other.

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These include both face-to-face conversations[5] and computer discussions (online forums, chat rooms, etc.).[6] Methods for examining collaborative learning processes include conversation analysis and statistical discourse analysis.The potential for collaborative learning to break the isolation of learners is realized in e-learning technologies. Advances in synchronous distance education and collaborative technologies like Weblogs, message boards, chats, e-mail, and teleconferencing are making such collaborative learning more readily available Examples of Collaborative Learning Collaborative Networked Learning is a form of collaborative learning for the self-directed adult learner. Youth directed collaboration, another form of self-directed organizing and learning, relies on a novel, more radical concept of youth voice. Computer-supported collaborative learning (CSCL) is a relatively new educational paradigm within collaborative learning which uses technology in a learning environment to help mediate and support group interactions in a collaborative learning context. CSCL systems use technology to control and monitor interactions, to regulate tasks, rules, and roles, and to mediate the acquisition of new knowledge. Most recently, one study showed that using robots in the classroom to promote collaborative learning led to an increase in learning effectiveness of the activity and an increase in the students motivation.[4] Researchers and practitioners in several fields, including cognitive sciences, sociology, computer engineering have begun to investigate CSCL, thus, it constitutes a new trans-disciplinary field. Learning Management Systems is a context that gives collaborative learning particular meaning. In this context, collaborative learning refers to a collection of tools which learners can use to assist, or be assisted by others. Such tools include Virtual Classrooms (i.e. geographically distributed classrooms linked by audio-visual network connections), chat, discussion threads, application sharing (e.g. a colleague projects spreadsheet on another colleagues screen across a network link for the purpose of collaboration), among many others. Collaborative Learning Development Enables developers of learning systems to work as a network. Specifically relevant to e-learning where developers can share and build knowledge into courses in a collaborative environment. Knowledge of a single subject can be pulled together from remote locations using software systems. Collaborative Learning in Virtual Worlds Virtual Worlds by their nature provide an excellent opportunity for collaborative learning. At first learning in virtual worlds was restricted to classroom meetings and lectures, similar to their counterparts in real life. Now collaborative learning is evolving as companies starting to take advantage of unique features offered by virtual world spaces - such as ability to record and map the flow of ideas, use 3D models and virtual worlds mind mapping tools. Collaborative learning in thesis circles in higher education is another example of people learning together. In a thesis circle, a number of students work together with at least one professor or lecturer, to collaboratively coach and supervise individual work on final (e.g. undergraduate or MSc) projects. Students switch frequently between their role as co-supervisor of other students and their own thesis work (incl. receiving feedback from other students). An Online Community of Practice (OCoP), also known as a Virtual Community of Practice, is a Community of Practice that is developed on, and is maintained using the Internet. To qualify as an OCoP, the characteristics of a Community in Practice (CoP) as described by Lave and Wenger must be met. To this end, an OCoP must include active members who are practitioners, or experts, in the specific domain of interest. Members must participate in a process of collective learning within their domain. Additionally, social structures must be created within the community to assist in knowledge creation and sharing. Knowledge must be shared and meaning negotiated within an appropriate

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context. Community members must learn through both instruction-based learning and group discourse. Finally, multiple dimensions must facilitate the long-term management of support as well as enable immediate synchronous interactions. They may include online tools specifically developed to address the needs of communities of practice including members around the world or other types of tools and forums that are available and used for OCoPs. Examples of Online Collaborative Tools Social Networking Sites The first social network site (SNS), SixDegrees.com, was created in 1997. Web 2.0 applications and social networks have increased the ease with which OCoPs are created and maintained. The structural characteristics of a community of practice include a shared domain of interest, a notion of community, and members who are also practitioners. Only with all three characteristics present does a group become a community. A single Internet application, though it may incorporate one of these characteristics, may not be enough to fully support a full community in practice. The continued development of Web 2.0 technologies and the ensuing evolution of vast social networks have easily enabled incorporating these characteristics within an OCoP Examples of social networking sites include the following: LinkedIn Facebook MySpace YouTube Virtual Worlds Virtual worlds, which are online community-based environments, are now being used in both educational and professional settings. In education, these virtual worlds are being used to communicate information and allow for face-to-face virtual interaction between students and teachers. They also allow students to access and use resources provided by the teacher in both the physical classroom as well as in the virtual classroom. In professional environments, virtual training is used to provide virtual visits to company locations as well as to provide training that can be converted from classroom content to online, virtual world content. Virtual worlds provide training simulations for what could otherwise be hazardous situations. Companies are using virtual worlds to exchange information and ideas. [11] In addition, virtual worlds are being used for technical support and business improvements. Case studies document how virtual worlds are used to provide teamwork and training simulations that would not have otherwise been as accessible. Examples of virtual worlds used include the following: Second Life Whyville Information Sharing Online tools are available for the sharing of information. This information can be intended for a wide range of audiences, from two participants to many participants. These tools can be used to communication new thoughts or ideas and can provide a setting necessary for collaborative knowledge building.[6] Activities associated with these tools can be integrated into the presentation of online classroom and/or training materials. Examples of tools that allow information sharing include the following: Wikis Google Docs Blogs

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Types of e-learning products in medicine Electronic learning (elearning) is moving from textbooks in electronic format (that are increasingly enhanced by the use of multimedia adjuncts) to a truly interactive medium that can be delivered to meet the educational needs of students and postgraduate learners. Computer technology can present reliable, reusable content in a format that is convenient to the learner. It can be used to transcend geographical boundaries and time zones. It is a valuable tool to add to the medical teachers toolkit, but like all tools it must be used appropriately. Actualy there is a wide variety of learning products including: 3d animation for surgical procedures, deployment of learning management systems including learning assessments to track results, interactive simulations to create mental models for the user, and marketing collateral for tradeshow events. Full motion graphics in HD for a variety of LMS applications, including walk-throughs and device demonstrations, medical animation studio and developer of visually-driven interactive solutions were developed in different e-learning medical platforms. We will try to synthetise the main aspects, in order to offer a comprehensive view of e-lerning in medicine. Medical databases. Using a multimedia component a database with color medical images acquired by the teachers from different patients in the diagnosis process, so represeningt real cases can be created. A series of alphanumerical information: diagnosis, treatment and patient evolution are added for each image. The multimedia component together with modern search methods: content-based image query and content-based region query is used both in the training process and e-testing one. The content-based visual query uses characteristics that are automatically extracted from medical images (color, texture, regions). Using content-based visual query with other access methods (text-based, hierarchical methods) on a teaching image database allows students to see images and associated information from database in a simple and direct manner. This method stimulates learning, by comparing similar cases along with their particularities, or by comparing cases that are visually similar, but with different diagnoses. A modern concept related to this is represented by topic map in medical e-learning. The topic map is mainly used for visualizing a thesaurus containing medical terms (medical terms from Diseases and Drugs categories). The topic map is built and populated in an original manner, mapping an xml file that can be downloaded free, to an xtm file that contains the structure of the topic map. Only a part of the MeSH thesaurus was used, namely the part that includes the medical diagnosiss names. The student can navigate through topic map depending on its interest subject, having in this way big advantages. With this graphical modality, the learner can view medical term description and its associative relationships with other medical descriptors. The paper presents also how to use the topic map for semantic querying of a multimedia database with medical information and images. For retrieving the interest information this access path can be combined with another modern solution: the content-based visual query on the multimedia medical database using color and texture features automatically extracted.. Combining these possibilities to access a database with medical data and images, allows students to see images and associated information in a simple and direct manner. The students are stimulated to learn, by comparing similar cases or by comparing cases that are visually similar, but with different diagnoses. Animation, modelling and simulations in medicine Methods used in e-learning goes from simple Professional Training Videos to 3 D medical animation, computer modelling and simulations. The benefits of well-produced medical animation have been proven effective over time, and bring a unique benefit to your medical marketing efforts. When you choose Interact Medical to create health animations, you are selecting an award-winning and highly experienced team of medical illustration professionals, medical animators, programmers,

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and scientific experts who specialize in bringing complex technology and 3d animated graphics to life. Through 3D animation, we can reveal not only the spatial relationships of anatomy but also how medical devices interact within that anatomy. We also can show medical devices in perfect harmony with textural overlays, text, graphics and enhanced feature call-outs. A most used concept is Game-based learning (GBL) that can help engage learners by enabling them to interact with the content and apply the learning in an entertaining environment. The game space continuum provides a complement of game based learning (GBL) applications, suited for different learning situations: Embeddedcasual games within the learning content Collaborativereal-time games where learners work together or compete online Simulationlearning within simulated real-world situations and environments Immersivefully realized immersive environments with applied learning skills and strategies integrated into the gameplay. In the last couple of decades, medical education has started to rethink the extent to which practice happens on live patients. With the availability of simulated alternatives for learning, practice, and the inherent learning curve that comes with it, can begin to be shifted to low risk environments which are simulated. Simulation is a technique for practice and learning that can be applied to many different disciplines and trainees. David Gaba, one of the pioneers of simulation technology in medicine, states, "Simulation is a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Immersive conveys the sense that participants have of being immersed in a task or setting as they would if it were the real world." Simulation facilitates learning through immersion, reflection, feedback, and practice minus the risks inherent in a similar real-life experience. The complexity of its use ranges from simple role play scenarios to highly technical, computer-driven models that are designed to respond to trainee actions as a real situation might. In medicine, simulation is gradually becoming a standard part of professional training. Participants of simulation are immersed in these replicas of real-life experience and play roles in scenarios such as cardiac resuscitation teams, procedural performance, delivery of babies, providing anesthesia, surgical operations, dentistry, and nursing care, to name just a few. Computer modeling and simulation techniques are playing an increasingly central role in changing both the way medicine is taught and the way it is practiced. Fundamental to the art and science of modeling and simulation is an underlying assumption that insight into system behavior can be developed or enhanced from a model that adequately represents a selected subset of the system's attributes. Simulation design considerations include: the provision of an appropriate user interface; determining optimal simulation complexity; defining a tutorial strategy; selecting authoring tools; assessing hardware requirements; identifying user needs; defining pedagogical goals; verification and validation; and system evaluation. Significant trends in simulation include the development of improved authoring tools, migration to desktop hardware platforms, and integration of simulation techniques with other types of applications. Virtual patients (VPs) are interactive computer simulations of real-life clinical scenarios for the purpose of medical training, education, or assessment (Waldman et al., 2008). They offer a wide variety of (anonymous) patient-related data including medical history, physical and technical examinations, as well as laboratory tests. In most cases, the goal

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of the student is tofind the right diagnosis and propose a correct medical treatment based on the data presented. Virtual patients provide a training opportunity in a risk-free environment before students are allowed to take part in bedside teaching. They may also be used to document the fact that all students have been exposed to all diseases defined by curricular objectives The degree of webbased learning in medical education across Europe Thanks to the growth of educational technologies and the Internet, the number of elearning resources available to educators has dramatically increased. Within medical education, repositories or digital libraries have been established to manage access to elearning materials. Although few at this time, such repositories offer a vision of expanded access to a large number of high-quality, peer-reviewed, sharable e-learning materials 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. Comprehensive schools Most general education schools make use of web-based learning in a variety of different ways: -Using the World Wide Web (WWW) to support classroom-based education; -Using the WWW to introduce a greater variety of information into the classroom; -It can directly uphold, replace or further consolidate classroom activities; -The WWW makes it possible to share more information, techniques, and materials among instructors. Learning Portals and Virtual Universities A major part of web-based education and learning is occupied by universities which act as providers of both academic and adult education. Unlike school education where webbased learning facilitates and supports classroom teaching through the use of means similar to the ones mentioned above adult education relies particularly on courses for vocational and practical skills. Such courses are usually web-based i.e. they are supplied in the form of Internet educational web pages which guide learners/students step by step all the way through the education phase they cover. A term used in this kind of education is Learning Portals. Learning Portals are web sites that provide a combination of courses, training collaboration and form learner community. Each university strives to attract to its learning portal as many potential students as possible and to be the single place on the Internet for finding training. When academic institutions offering traditional education undertake learning portals, they are generally called Virtual Universities or Open and Distant Learning Universities. In response to these concerns, the American Medical Association (AMA) launched the Initiative to Transform Medical Education (ITME) in 2005. ITME aims to: Promote excellence in patient care by implementing reform in the medical education and training system across the continuum, from premedical preparation and medical school admission through continuing physician professional development. Recommendation 7 indicated *Ensure that the learning environment throughout the medical education continuum is conducive to the development of appropriate attitudes, behaviors and values, as well as knowledge and skills.* In most medical universities the formal curriculum is designed to teach trainees the knowledge and skills to function as competent physicians. Reform must occur throughout the medical education continuum (medical school, residency training and continuing professional development). This could include expanded use of new educational formats, such as performance improvement continuing medical education, study the question of

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increasing e-learning capacity to meet the flexible and distance learning requirements of a Faculty of Medical and Health Sciences. Examples of organisations that provide on line medical education include: the Association of American Medical Colleges' (AAMC's) MedEdPortal, a repository for curriculum and assessment materials organized around core competencies in medical education and populated with up-to-date, peer-reviewed teaching and assessment materials. The End of Life/Palliative Education Resource Center is a free-access repository of digital content for health profession educators involved in palliative care education. The Health Education Assets Library (HEAL) provides high-quality digital materials for health sciences educators and promotes the preservation and exchange of useful educational assets such as individual graphic, video, or audio elements, while respecting ownership and privacy. HEAL has begun a peer-review process for all elearning materials submitted to the library. The Multimedia Educational Resource for Learning and Online Teaching (MERLOT) is designed primarily for faculty and students of higher education. The service collects links to online learning materials, along with annotations such as users' reviews and assignments. MERLOT contains a growing science and technology section that includes health care education e-learning materials. The International Virtual Medical School (IVIMEDS) is an international organization whose mission is to set new standards for e-learning in medical education through a partnership of medical schools and institutions, using a blended-learning approach. IVIMEDS hosts a repository for use by its member medical schools. Most of the materials in this repository are free to use, although some materials have clearly defined conditions for use. In the future, these and other repositories may require a membership or other fees to cover the ongoing expenses of Web-site maintenance. he complexity and breadth of medical education content, together with the scarcity of experts and resources in e-learning, make the creation of centers of excellence in elearning a reasonable proposition. The Federal Interagency Working Group on Information Technology Research and Development has recommended the establishment of centers to explore new delivery modes for educating medical practitioners and providing continuing medical education; e-learning clearly fits that description. Such centers could offer a wide range of services, including system deployment and administration, training of faculty and administrators, assistance in content development, the design of learning pathways and programs, marketing and support, supervision, maintenance, research, and consultation. The Internet2 is a U.S.-based, collaborative, university-led project started in 1996 to develop additional infrastructure for the Internet backbone capable of superhigh bandwidth. The Internet2's vision of extremely fast speed, complex real-time multimedia capabilities, and quality of service would provide educators enormous potential to enhance the learning experience. Larger bandwidth offers the promise of sophisticated immersive simulations and the use of full-motion video in real time, in both asynchronous and synchronous modes of instruction, delivered to any desktop computer. Many medical schools and health care organizations are already producing high-fidelity e-learning materials, such as virtual patient simulations, that could soon be within the reach of any educator and learner Projects. There are plenty of further programmes involving the usage of computerised case-based simulations in medicine that could not be described here in more detail. Worthy of attention are the European NETWORM project a set of virtual patients in occupational medicine (Radon et al., 2006), REViP - an Anglo-German project focussing on the

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embedding of repurposed and enriched Virtual Patients (VPs) within a Paediatrics curriculum (Balasubramaniam et al., 2009), CASEPORT a national platform for virtual patients in Germany (Holzer et al., 2005) and the virtual patient collection managed by the International Virtual Medical School (IVIMEDS) (Harden & Hart, 2002), (Davies et al., 2006). The International Virtual Medical School (IVIMEDS) provides a case study that illustrates how rapid growth of the Internet and e-learning can alter undergraduate education and has the potential to alter the nature of CME. Key components are a bank of reusable learning objects, a virtual practice with virtual patients, a learning-outcomes framework, and self-assessment instruments. Learning is facilitated by a curriculum map, guided-learning resources, ask-theexpert opportunities, and collaborative or peer-to-peer learning. The educational philosophy is just-for-you learning (learning customized to the content, educational strategy, and distribution needs of the individual physician) and justin-time learning (learning resources available to physicians when they are required). Implications of the new learning technologies are profound. E-learning provides a bridge between the cutting edge of education and training and outdated procedures embedded in institutions and professional organizations. There are important implications, too, for globalization in medical education, for multiprofessional education, and for the continuum of education from undergraduate to postgraduate and continuing education. It is in this context that computers to support the learning process by simulation of clinical scenarios may be very helpful, especially in the case of rare conditions. In the area of learning resources on the web, the DIPEx project (DIPEx 2007) was highlighted as it provided a variety of personal experiences of health and illness aimed at clients and practitioners. Users are able to watch, listen to or read transcripts of client interviews and find information on treatment choices and support and this resource can still be considered a good example of what can be achieved in conveying a client experience in order to educate. Similarly, Nestas report on Savannah (Futurelab 2005) continues to highlight an important point an increasing awareness that young people's digital cultures are as likely to be shaped by interaction with mobile and games technologies as they are by PC applications and that all educational settings including Higher Education should start to engage with these tools. This growing recognition that the areas of simulation, online communities and virtual worlds are becoming seen as important learning and teaching tools of the future has also been reflected in this years funding of research grants by Eduserv (2007) and in many papers and reports. An international virtual medical school (IVIMEDS) with a high-quality education programme embodying a hybrid model of a blended curriculum of innovative elearning approaches and the best of traditional face-to-face teaching is one response to these challenges. Fifty leading international medical schools and institutions are participating in a feasibility study. This is exploring: innovative thinking and approaches to the new learning technologies including e-learning and virtual reality; new approaches to curriculum planning and mapping and advanced instructional design based on the use of 'reusable learning objects'; an international perspective on medical education which takes into account the trend to globalization; a flexible curriculum which meets the needs of different students and has the potential of increasing access to medicine. On our project web site http://www.e-edumed.ro/ we have developed special sections reffering to: EU learning projects

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Contains a database of the most interesting EU projects in the field of e-learning in different health topics, developed with the European Comission support in the last 10 years, selected and recommended by the project partners. Innovation in education This topic aimes to provide links to publications and organisations that develop and provide new theories and conceptual frameworks to guide future reform and innovation efforts in higher education Links to European Society for the Systemic Innovation of Education , European Association for International Education and European Association of Institutions in Higher Education are provided. Educational centers in ultrasonography This topic aimes to provide informations about main educational e-learning resources and centers in ultrasonography. A list with most important providers is available and permanently updated.

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8. The EU Policy in e-learning The European Union has made a considerable contribution to discussions around and the promotion of the concept of the information society. The knowledge society is considered as the final goal and the justification of former and current EU policy priorities. Europe is attempting to augment its relatively marginal competitive position in varied domains in this connection. Education is to play an important role in this respect. On the one hand there is the aim of creating the necessary secondary conditions for the further development of the information society, while on the other hand reaping the benefits of a highly technological environment through which the chasm between the social and economically stronger and weaker elements in society can be decreased. E-learning, or the use of ICTs for the support of teaching and learning, is often mentioned in the same breath as educational renewal and the construction of the knowledge society. From many varied instances thought has been given to the redevelopment of curricula, study materials and methodologies connected with the use of the media. Throughout the globe virtual universities have been established and students can get their qualifications via electronically determined distance learning. Ideally these new concepts are anchored within the framework of a constructive and well-defined policy structure. It is this which is central to the definition of our present research reported on in this paper. The main issue is To what extent does contemporary European policy integrate ICTs into tertiary education? Politicians at the European level have recognised that education and training are essential to the development of today's knowledge society and economy. The EU's strategy emphasises countries working together and learning from each other. European policy towards educational innovation and e-learning contains general guidelines which are to be further worked out and filled in by the member states. These guidelines do not represent a straightjacket and leave sufficient leeway to national instances to prioritise their own actions. European authorities are also attempting to support certain trajectories for educational innovation and e-learning in the member states through the financing of projects, research into what is available and the subsidising of activities. The European authorities have very ambitious goals which perhaps are somewhat unrealistic. EU education and training policies have gained impetus since the adoption of the Lisbon Strategy in 2000, the EU's overarching programme focusing on growth and jobs. The strategy recognised that knowledge, and the innovation it sparks, are the EU's most valuable assets, particularly in light of increasing global competition. Brown et al (2007) identified a discernible pattern to the development of e-learning policy. The first stage occurs as governments act to make e-learning possible, the second as they work to integrate elearning into the education system, effectively, to mainstream e-learning. In the third stage, a transformative role for e-learning is seen, with changes to views of learning and to the nature and operation of the tertiary institutions and the tertiary system. First and second stage policy objectives are commonly seen together as policy-makers draw on the experience of early adopters of e-learning, or on their experience of previous adoption of technology use in education. Similarly, second and third stage policy objectives co-exist in policy documents as policymakers continue to encourage the mainstreaming of e-learning and enhancement of its quality, while seeing the potential for sector efficiencies and the need for policy alignment. Following this pattern, policy initiatives include: - Strategies to develop physical infrastructure - Focusing on building and ensuring quality in e-learning - Moves to create a system wide approach to e-learning - Embedding e-learning and aiming for sector efficiencies

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To meet better the health needs of the population, significant changes are taking place in medical education all over the world promoting the quality of higher education as essential priority. Integration of basic and clinical sciences, integration of theory and practice, implementation of problem-based learning, e-Learning and continuing all-life learning are important part of these changes, in unison of the recommendations of the World Health Organization , the World Federation for Medical Education, the European Commission (Directorate-General for Education and Culture), the national strategy for higher education and the strategy of the Medical Universities. First steps towards innovation and e-learning policies The role of the European Union in disseminating acceptance that ICT will dramatically change society, confronting it with major challenges, implied for many western European countries an important stimulus for developing initiatives round ICT. The European Commission resolutely opted for intensifying competitiveness through ICT, under the strong belief that its expansion will stimulate the further development of well-being and fit in with the logic of the free-market economy. A new information society is emerging, in which management, quality and speed of information are key factors for competitiveness. In order to achieve some pertinent integration of ICT in education, to generalise good practice and to develop a European dimension, the need was felt by the European authorities to take ambitious initiatives. ICT must service innovation and improvements in education, since they claim that everything over the coming ten years depends on the capacity to be innovative. At the end of the seventies and the beginning of the eighties several initiatives were launched in a number of European countries with the aim of introducing ICT into teaching. At the time ICT was considered as a learning subject. The development of powerful multimedia computers and increasing awareness of the potential of ICT for pedagogic goals led to the initiation of pilot projects and public financing, particularly in the development of educational software. From 1983 onwards the European Commission was a catalyst for encouraging ICT applications in education. In 1986 the COMETT-programme of the European Commission was approved relating to collaboration between universities and enterprises throughout Europe for the development of and training in new technologies. In 1991 the European Commission published its Memorandum on Open and Distance Learning in the European Community. Since then actions connected with ICT have gradually increased. Towards the middle of the 90s there was general consensus that lifelong teaching and learning would help competitiveness and insertion in society, and would also represent the best means for combating social exclusion. This implies that in teaching and learning the needs of the human being would be central.[40] In tertiary education new e-learning initiatives were taken via networks (including the European Association of Distance Teaching Universities). On top of this there were the major teaching and professional training programmes of the EU, Socrates and Leonardo, where there were opportunities for introducing new technologies. In 1996 during the European summit in Florence the European Commission launched the Action Plan called Learning in the Information Society. Member states have undertaken to make multimedia in general and internet in particular an integral part of teaching. The plan contains 4 actions: - to encourage interconnection via electronic networks between schools across Europe; - to stimulate the development of educational multimedia applications; - to encourage the training of teachers for the use of ICTs; - to provide information on the potential of multimedia and audiovisual educational tools.[41]

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eEurope 2002

At the European Council meeting of 23 and 24 March 2000 held in Lisbon was launched the ambitious goal of making Europe the most competitive and dynamic knowledge society in the world, capable of producing long-term economic growth with more and better employment and stronger social cohesion. Access to and use of internet is one of the goals for all Europeans. Every citizen, every school, every enterprise should be connected on line.[42] In The eEurope Action Plan 2002 An Information Society for All approved by heads of state and government at the Feria summit meeting (19-20 June) concrete goals were stipulated for the period 20002002, namely, to bring every European online, to create a digitally literate Europe and to ensure that the process should not engender social exclusion but arouse confidence among consumers. Three main methods represent the goals aimed at: a suitable legal framework; new infrastructure and services; co-ordination and benchmarking. Specific actions are grouped around 3 topics: - cheaper, quicker and safe internet; - investment in people and skills; - stimulating use of Internet. The Commission intervenes via structural funds, teaching programmes, research and development projects based on collaboration between all European institutions, the member states, the private sector, social organisations and social partners.[43] The eLearning Initiative and eLearning Action Plan The eLearning Designing Tomorrows Education Initiative was approved by the European Commission on 24th May 2000. This initiative contains the basis, goals and major outlines of e-learning [44] while its concrete implementation is contained in the eLearning Action Plan (28 March 2001). Whereas in all previous initiatives the European authorities gave priority to familiarising learners and teachers with ICT, in the present document the European authorities have stressed general reflection on renewal of teaching methods and structures. ICT is hence no longer considered as a supplementary aspect but as a possibility for innovation in education. Several core goals were formulated for European cooperation at the level of infrastructures and equipment, training, services and content and the strengthening of cooperation and dialogue. Plans concentrate in the first place on a more rapid introduction inside the European Union of a respectable, affordable infrastructure. The goal is to have all classrooms equipped with fast internet connections and multimedia. Also prioritised are the development of services, platforms and source materials for teaching and research. Then there is the expansion of training possibilities, including through the encouragement of a digital culture for all and a wider range of courses available to learners and teachers in which not only the technology itself finds its place but also its pedagogic use and adoption. Finally there is the goal of intensifying co-operation and dialogue and improvement of links between actions and initiatives at local, regional, national and European levels for all parties concerned: universities, schools, training centres, decision makers and managers, including the social partners whose task it is to choose materials, software, content and services. To this end the European authorities call on the services of the education sector, cultural sectors and socio-economic stakeholders.(45) The European eLearning Summit During the eLearning Summit, held in Belgium on the 10th and 11th of May, representatives from the private sector together with education experts and policy makers developed a set of recommandations related to the measures suggested in the
th

rd

th

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eLearning Action Plan. They set forward 10 recommendations to remove barriers to access and connectivity, support professional development, accelerate eLearning innovation and content development, address the ICT skills shortage, promote digital literacy and lifelong learning, and explore sustainable public private partnerships[46]: 1. connect everyone and everything from everywhere; 2. adopt and participate in the development of open standars for eLearning; 3. focus eLearning research on pedagogy, eContent and user-friendly interfaces and devices; 4. create the conditions to sustain a commercial market for eLearning content development; 5. increase investment in continuous professional development of educators. Enhance theirs status. Help them develop an understanding of and a pedagogy for eLearning; 6. develop flexible curricular and assessment frameworks to provide individuals with the skills needed for participation in the Information Age; 7. expand eLearning communities and forums; 8. provide financial incentives to promote the take-up of eLearning; 9. leverage financial instruments to support eLearning; 10. explore the potential of public private partnerships. The eEurope 2005 Action Plan Follow-up to eEurope 2002 was outlined in May of the same year in the form of the eEurope Action Plan 2005. The goal is to provide a favourable environment for private investment and for the creation of new jobs, to boost productivity, to modernise public services, and to give everyone the opportunity to participate in the global information society. Two categories of action are to be worked out for 2005: (1) the provision of online services, applications and content in several areas, including e-government, elearning, e-health and e-business, and (2) the creation of a broadband infrastructure and secure information networks. Four working tools were chosen by the European authorities for this purpose: - policy measures at the national and European levels; - the exchange of experience, good practice and model projects; - benchmarking; - general coordination of current policy by a steering committee. In the eEurope 2005 plan can be found an element of e-learning. According to the European authorities since 2002 the Information Society Technologies programme (IST), the eLearning initiative and other activities have led to the realization of a series of goals: Most schools are now connected and work is underway to provide convenient access to the Internet and multimedia resources for schools, teachers and students. In order to stimulate this and other e-learning initiatives a series of extra measures have been implemented. The member states should launch actions to provide learners by the end of 2005 with the following: - internet access for all schools and universities by a broadband connection; - a specific eLearning programme for the implementation of the objectives of the eLearning Action Plan; - virtual campuses for all students; - university and research computer-supported co-operative systems; - re-skilling for the knowledge society. [47] The eLearning Programme The eEurope 2005 e-learning plan took shape in 2002 with the eLearning Programme, a multinational programme for the improvement of the quality and accessibility of European education and training systems through the effective use of information and

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communication technologies. The programme was proposed on December 2002, to be adopted in the Education Council of November 2003. This plan covers the period 20042006 . The term e-learning represents a vision of learning via ICTs as an indispensable component of teaching and training systems. The specific objectives of the programme are to explore and to promote ways of using e-learning for strengthening social cohesion and personal development, fostering intercultural dialogue and fighting the digital divide, to promote and develop the use of e-learning as an enabling factor for the implementation of the lifelong learning paradigm in Europe, to exploit the potential of elearning for enhancing the European dimension in education, to facilitate a more structured co-operation in the field of e-learning between the diverse Community programmes and instruments and Member Sate actions, to provide mechanisms for encouraging improvement of quality of products and services as well as for their effective dissemination and for exchange of good practice. To this end four lines of action and a budget of 36 million Euros has been proposed: - fighting the digital divide (around 25% of total budget); - encouraging the development of European virtual campuses (around 30% of total budget); - fostering partnerships between schools in Europe via networking (around 25% of total budget); - promoting e-learning throught Europe (around 10% of total budget). Via technical and administrative help (around 10% of total budget), support in the form of co-operation links, pilot projects, research and development of think tanks on educational innovation and the integration of ICT in teaching, the European decision makers are attempting to achieve the successful outcome of this ambitious assignment.[48] EU Member States and the European Commission strengthened co-operation in 2009 with strategic framework for European cooperation in education and training ("ET 2020") a follow-up to the earlier Education and Training 2010 work programme launched in 2001. The e-Europe and e-Learning initiatives launched by the European Commission have significantly contributed to the increased awareness and commitment of national and regional governments in supporting the development of a knowledge and information society in Europe. The European Commission organised the eLearning 2005 Conference: Towards a Learning Society on 19-20 May 2005 in Brussels, bringing together a cross section of the various stakeholders involved in e-learning in Europe. It was proposed to reinforce stocktaking and consolidate best practices across policy areas and to review and evaluate e-learning results in the broader perspective in 2006. http://www.elearningconference.org Very recently took place a workshop called Mainstreaming e-Learning in education and training. The purpose of the workshop is to mobilise key stakeholders and Member States' representatives to support the mainstreaming of e-Learning in national policies as an agent for modernization of education, for all subjects and skills. The workshop will discuss the current situation of ICT for education and training in Member States, the potential obstacles to full scale adoption of eLearning, and the necessary pre-conditions to mainstreaming it in formal and informal learning processes (ICT infrastructures, teachers' competencies, etc). The expected outcome is a set of priorities and actions encouraging Member States to innovate in their education and training through adopting and integrating e-Learning into teaching and training. It should also include recommendations to the Commission on how to support the Member States in this endeavour. This workshop will represent the "kickoff" of the Digital Agenda action

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Participants were Member States' representatives (education and training), eLearning industry representatives (solutions providers, publishers, etc.); association of teachers and parents, researchers, as well as representatives of international associations and experts promoting the use of eLearning. There appears to be a mutually sustaining cycle of reaction to the benefits of e-learning in higher education. Although online instruction is seen by many as a major breakthrough in learning and teaching, it has had its share of critics who do not believe it can actually solve difficult learning and teaching problems and who consider that many barriers hinder effective e-learning. On our project web site http://www.e-edumed.ro/ we have developed special sections reffering to EU POLITICS AND INITIATIVES IN E-LEARNING The eLearning initiative of the European Commission The eLearning initiative of the European Commission seeks to mobilise the educational and cultural communities, as well as the economic and social players in Europe, in order to speed up changes in the education and training systems for Europe's move to a knowledge-based society. Important news all around European Union Provide the latest and most important news all around European Union. It contains links from Politics, Finance, Education etc. EU policies and directions The official link of the European Union which covers all its policies and directions. The site is translated into all official languages of the EU. Distance Learning and eLearning in European Policy and Practice The Vision and the Reality. eLearning in 2000 and 2004: Two different pictures and review of the impact of EU eLearning policies. e-Learning - the integration of advanced ICT into the education system e-Learning: In a world increasingly based on knowledge and information, education and training are put at the core of the European agenda. 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. e-Learning - the integration of advanced information and communication technologies (ICT) into the education system - achieves both aims. Information and communication in e-learning A portal about the use of information and communication technologies to improve learning. An initiative of the European Commission

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9. Conclusions
A. Conclusions regarding the general image of the Educational contexts in Medicine in participant countries State of art of Medical studies in participant countries Medical education is education related to the practice of being a medical practitioner, either the initial training to become a doctor (i.e., medical school and internship) or additional training thereafter (e.g., residency and fellowship). Medical education and training in participant countries does not vary considerably as entry level education, postgraduate education and continuing medical education, but differences occur for online medical education. Various teaching methodologies have been utilised in medical education, which is an active area of educational research Entry-level education Entry-level medical education programs are tertiary-level courses undertaken at a medical school. In all partcipant countries admission is linked to high school graduation. Admission conditions and tests vary from one country to another, but biology and chemistry are common. Duration of basic medical studies is 6 years for all participant countries. Initial training is taken at medical school. Traditionally initial medical education is divided between preclinical and clinical studies. The former consists of the basic sciences such as anatomy, physiology, biochemistry, pharmacology, pathology. The latter consists of teaching in the various areas of clinical medicine such as internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and surgery. Increasingly, however, medical programs are using systems-based curricula in which learning is integrated, and several institutions do this. Postgraduate education Following completion of entry-level training, newly graduated doctors are often required to undertake a period of supervised practice before full registration is granted like in Italy; After graduating, new doctors must complete a three-month, unpaid, supervised tirocinio post-lauream ("post-degree placement") consisting of two months in their university hospital (one month in a medical service and one in a surgical service) as well as one month shadowing a general practitioner. After getting a statement of successful completion of each month from their supervisors, new doctors take the esame di stato ("state exame") to obtain full license to practise medicine. They will then have to register with one of the branches of the Ordine dei Medici ("Order of Physicians"), which are based in each of the Provinces of Italy. Registration makes new doctors legally able practice medicine without supervision. Further training in a particular field of medicine may be undertaken. All graduates have to go through residency and specialization exams after that in order to practice. They will then have to choose between various career paths, each usually requiring a specific admission exam: Most either choose to train as general practitioner or choose to enter a speciality training at a university hospital with a duration of 5-year or 6-year course. Increasingly education theory itself is becoming an integral part of postgraduate medical training. Formal qualifications in education are becoming the norm for Medical School educators who are becoming increasingly accountable for their students. Continuing Medical Education In all countries, Continuing Medical Education or CME courses are required for continued licensing. CME requirements vary by country,with regard notably to its compulsory character but also the ways in which it is implemented and organised. For all the countries surveyed the CME are compulsory. The trend is 50 credits/year (with variations on the timescale).

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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 maagement 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. In Hungary the number of CME is also 50 credits/year. The general concept is 1 hour=1 CME credit with maximum 6 credits/day and 3 credits half day. In all participant countries CME are acredited and CME providers are acredited. For Hungary and Romania there is a participation to EACCME system. Only in Italy there is a Website section of CME National authorities on CME accreditation. Very few countries have sanctions for not complying to the requirements (Germany, UK and Romania, in which the sanction is suspension of licence). One of the EU Commision and ACOE point of viwe is that must be an automatic mutual recognition of credits for all countries. The training activities recognised to earn credits are similar in studied countries and include *traditiona*l activities: live CME events (local, regional, international) - In presence training/traditional training courses - Individual Training- Studies Groups, Commissions, Research Activities/projects, workshops, scientific presentations (courses,abstracts, posters, etc) - Publishing activities - Clinic and /or assistance audits

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- Teaching and tutoring - Study scientific literature, peer-review - Producing didactic publications (medical articles, books) e-learning CME E-learning is valid to collect CME points in a growing number of EU countries (18 countries from 27), but is not valid in Bulgaria and Romania. In Italy is valid starting with 2010. (Hemelryck, 2009) Limits of acceptance could be defined for some aforementioned activities. For example, in Italy professionals 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). It is recognised that Distance course for medical education is more suitable but in Republic Bulgaria such kind of education is 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 e-Learning 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.

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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. Ultrasound education and nurses education have mainly common standards and training requirements. National specificities are explained in national reports and chapter 4 of this survey. B. Conclusions regarding Key Issues revealed by the report in order to create the new e-learning platform Analysis has been conducted processing information gathered from documentary and field work researches. Representatives of target group have been touched and interviewed on the phone, by email, or through web. On the other side, institutional Public Health and private and public Higher Education Institutions websites have been investigated in order to collect all the main relevant data. As an general observation we can affirm that the need of Long-life Medical Education is broadly shared either among medical professionals or among Public Institutions, Hospitals, Clinics, etc The questions were choosen in order to 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 our designing elearning module began,in order to estimate the previous experience of using ICT and elearning as students and teachers, and to allow our tutors to prepare for our range of ICT skill levels. 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 is 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 is 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

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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. 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 e-learning 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 e-learning 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 .

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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. 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 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. Professionals Individual Motivation, training needs and legal assumptions represent a flourishing ground to make pilot project on medical distance learning growing up. 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. 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, etc...). Ultrasound for a medical doctor already specialised in a medical field, need to be deepen with many images (3D if possible), case studies, high quality of content, group discussions and practical information. 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. Information Technology is a flexible and powerful tool able to make the difference. 3D images, videos and virtual classrooms will support medical and nursing professionals in training without having the presumption to be exhaustive, but propaedeutical to practice. The collaborative and committed behaviours of medical professionals will represent the core engines of successful learning venture. C. Conclusions regarding the health care systems training needs for partner countries as defined by our research/the training needs of the target group 1. The need of using e-learning in medical education (great interest from all categories in the target group). What we have to underline regatding this issue is that even if there is an evident need for e-learning solutions- at least on the part of students, and the more innovative faculty-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.

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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. When students use technology as a tool or as support for communicating with others, they are in an active role, rather than the passive role of recipient of information transmitted by a teacher, textbook, or broadcast. The student actively makes choices about how to generate, obtain, manipulate, or display information. Technology prompts students to actively think about information, making choices, and executing skills in a manner that is not typical in teacher-led lessons. Each student can be involved in independent or small-group work with the technology. Moreover, when technology is used as a tool to support students in performing authentic tasks, the students are in the position of defining their goals, making design decisions, and evaluating their progress. The perspective and experience of implementing and using technology in further education (FE) through various e-learning coordination and management roles, incorporating strategising and staff development responsibilities explores and provides examples relating to the concept of e-learning as a blend of traditional and newer techniques and tools, encompassing the use of various technologies with flexible, accessible, and inclusive characteristics to support teaching and enhance learning. Diagnostic Ultrasound Professionals must adhere to the specific continuing education and/or recertification guidelines as mandated by the organization from which the certification is obtained. Due to rapid advancement in ultrasound practice, the need for continually staying abreast of evolving standards, techniques, and technology is imperative. Without continuing education and exposure to knowledge beyond the undergraduate experience, no professional can stay current in information and skills necessary to provide high-quality care to patients. Ongoing certification is based on a standard that includes successful attainment of continuing professional education and experience with new technologies and modalities. The issue if medical professionals would like to use e-learning for basic studies or only for continous medical training is still to be discussed 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. 3. The need to increase the perceived level of IT ability and accessibility 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 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 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 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 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 is not free of

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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 Competencies in ultrasound. In formulating our opinion on whether e-learning is suitable for ultrasound we started from the idea that a fundamental feature of ultrasound is the multidisciplinarity. It is the responsibility of the medical doctor to ensure that its practical skills by performing ultrasounds are maintained continuously by CME hours, and by examining a variety of pathologies. Thus we can say that the use of ultrasound online platforms can be useful in the following conditions a. To achieve competence in ultrasound. Given the practicality of the method, in our opinion online education can not be used to obtain credit and full competence but can be used in preparing for the exam and substitution of the theorethical module. Considering the modality of examination that leads to obteaining competence in ultrasound, online 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 e-platform 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. The same adjuvant character remains for ultrasound specializations, noting the added value by the quality and systematisation, prompt accessof materials from anywhere. b. in continuous professional training and obtaining CME credits is a reliable and superior alternative to classic courses that require accommodation, time, etc.. and can be used fully in the development of courses continues credited c. e- learning education in ultrasound and development of interactive learning platforms with an integrated imaging database remains a perfect option for continuing professional development and formal education in the possibilities offered for review and updating knowledge, sharing information and brainstorming recently. D. Further steps in our project

Based on the findings we will draw the technological architecture needed for new platform and make the adaptation and customization of the Virtual classroom environment to new modules (nurses training, echography) paying special attention to the quality of materials, language, accesability, ICT tools Raising the awarness and interest of medical professionals in e-learning by: - Providing informations about e-learning and its benefits, maybe initiation of courses for training of trainers and increased dissemination on all levels (hospitals, universities, professional organisations, decision makers); first steps were made by dedicating an important part in the present report to e-learning and its specific aspects - 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 (second newsletter)

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- 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 can also be 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.

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20. Stanescu, L.; Burdescu, D.; Ion, A.L.; Panus, A.; Univ. of Craiova, Craiova Imagistic Database for Medical e-Learning Computer-Based Medical Systems, 2008. CBMS '08. 21st IEEE International Symposium, 2008; 427 - 429 21. Swanwick, T. See one, do one, then what? Faculty development in postgraduate medical education, Postgraduate Medical Journal, 2008, 84 (993), pp. 339-343. 22. Swanwick, T. & McKimm, J. Professional development of medical educators, British Journal of Hospital Medicine 2010 (in press). Thompson B, Schneider Vi.F, Haidet P, Levine R.E,3 McMahon K. K, Perkowski L.C, Richards B.F., Team-based learning at ten medical schools: two years later, Blackwell Publishing Ltd 2007. MEDICAL EDUCATION 2007; 41: 250257 23. Valcke, M.; De Wever B. Information and communication technologies in higher education: evidence-based practices in medical education. Med Teach, 2006, 28, 1, pp. 40-48 24. Waldmann, U.; Gulich M. S. & Zeitler H. P. Virtual patients for assessing medical students-important aspects when considering the introduction of a new assessment format. Med Teach, 2008, 30, 17 25. Williams, J. B., & Goldberg, M. The evolution of elearning. 2005 http://www.ascilite.org.au/conferences/brisbane05/blogs/proceedings/84_Williams.pdf 26. Wilson, T. Information overload:Myth, reality and implications for health care 2001. http://informationr.net/tdw/publ/ppt/overload/tsld001.htm 27. Walter, G. Comparing online and traditional teaching: A different approach. CampusWide Information Systems, 200320(4), 137-145. REPORTS 28. E-EDUMED ITALIAN National Reportt 29. E-EDUMED BULGARIAN National Report 30. E-EDUMED HUNGRIAN National Report 31. E-EDUMED ROMANIAN National Report 32. Leonardo da Vinci II WBT WORLDRO/02/B/F/PP 141053 2005 Report on the Best Practices in Web-Based Learning across Europe Issued by: European Centre for Education and Training (ECET), Bulgaria 33. American Medical Association- Initiative to Transform Medical EducationRecommendations for change in the system of medical education June 2007 http://www.ama-assn.org/resources/doc/rfs/itme_final_rpt.pdf 34. Report of the Working Party, World Federation for Medical Education Task Force on Defining International Standards in Basic Medical Education (2000), Medical Education, 34, 665-675. OFFICIAL DOCUMENTS 35. Council Resolution on modernising universities for Europe's competitiveness in a global knowledge economy 2832nd COMPETITIVENESS (Internal market, Industry and Research) Council meeting Brussels, 22 and 23 November 2007 36. European Commission. Making lifelong learning a reality for all. Luxembourg: Office for Official Publications of the European Communities 2002 37. Embedding E-Learning in Further Education The EU Health Policy Forum, Strategic Priorities Including Specific Priorities for 2009-2010, February 2009 Brussels 38. Institute of IT Training, Accreditation programme and code of practice for e-learning providers. www.iitt.org.uk/public/accreditation/elearn-prov.asp#Standards. 39. elearners.com, Distance Learning Accreditation. www.elearners.com/resources/ accreditation.asp.

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40. Directorate-General for Education and Culture, [email protected]. Information and Communication Technology in European Education (ICT) Systems. Brussels: EU, 2001, 15-19. 41. Commission of the European Communities, Learning in the information society Action plan for a European education initiative (1996-98). Brussels: EU, 1996, summary retrieved at http://europa.eu.int/scadplus/leg/en/ cha/c11032.htm (25/09/2003). 42. Commission of the European Communities, eEurope. An Information Society for All. Communication on a Commission Initiative for the Special European Council of Lisbon, 23&24 March 2000. 43. Commission of the European Communities, The eEurope2002 Action Plan. An Information Society for All. Action Plan prepared by the Council and the European Commission for the Feira European Council, 19&20 June 2000, retrieved at http://europa.eu.int/information_ society/eeurope/2002/index_en.htm (25/09/2003). 44. Commission of the European Communities, The European eLearning Initiative: Designing Tomorrow's Education. A Communication from the European Commission, May 2000, retrieved at http://www.e learningeuropa.info (25/09/2003). 45. Commission of the European Communities, The eLearning Action Plan. A Communication from the European Commission, March 2001, retrieved at http://www.e learningeuropa.info (25/09/2003). 46. The European eLearning Summit, Extending Educational Opportunity. Accelerating Educational Innovation. Exploring Public Private Partnerships. Summit Declaration, La Hulpe, 18 May 2001, retrieved at europa.eu.int/comm/education/programmes/elearning/ summit.pdf (25/09/2003). 47. Commission of the European Communities, The eEurope2005 Action Plan. An Information Society for All. Communication from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions. An Action Plan to be presented in view of the Sevilla European Council, 21&22 June 2002, retrieved at http://europa.eu.int/information_society/eeurope/2005/index_en.htm (25/09/2003). 48. Commission of the European Communities, Adopting a Multi-annual Programme (2004-2006) for the Effective Integration of Information and Communication Technologies (ICT) in Education and Training Systems in Europe (eLearning Programme). A Proposal from the European Commission to the Parliament, Brussels: EU, December 2002, retrieved at http://www.elearningeuropa. info (25/09/2003). 49. Overviews on education systems in Europe and ongoing reforms) 2010 (http://eacea.ec.europa.eu/education/eurydice/documents/eurybase/national_summa ry_sheets/047_RO_EN.pdf) 50.European Accreditation Council for Continuing Medical Education) EACCME http://www.eaccme.eu/ 51.EACCME accreditation fees for live events and e-learning materials http://www.uems.net/ 52. http://www.accme.org/index.cfm/fa/AccreditationProcess.home/AccreditationProcess. cfm 53. http://wiki.ifmsa.org/scome/index.php?title=Category:Medical_education_systems

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ANNEX 1

Needs Assessment Questionnaire (Academic Medical Staff)

PERSONAL DETAILS (These details are required for communication purposes only and will not be disclosed) NAME:* optional University Department Position: EMAIL:* optional *Tick the box that suits best your situation. 1. What information sources do you use regularly? How regular is your use? Journals Daily Weekly Books Daily Weekly Newspapers Daily Weekly Online resource Daily Weekly 2. What are the main categories of information that do you use them? Clinical issues Ultrasound Legislation Medication Medical events News Publications Science & Research Daily Daily Daily Daily Daily Daily Daily Weekly Weekly Weekly Weekly Weekly Weekly Weekly Monthly Monthly Monthly Monthly you require? How often Monthly Monthly Monthly Monthly Monthly Monthly Monthly

3. Which of the following e-tools are you familiar with and to which extent? Never I have I can I can use I can heard of heard but manage it teach it never but some others to used it help would use it be useful Chat Wiki Audio conferencing Video conferencing Forum e-mail groups Internet Mobile/ mobile learning

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3. How often do you access the internet? Daily 2-3 times a week weekly How do you prefer to receive your information? Electronic Email Intranet/Web CD ROM How much do you Daily 7. use the internet for improving professional formation? Weekly Monthly

6.

How do you prefer to improve your professional formation? Classical courses Workshop e learning

8.

Did you ever benefit from e-learning courses? Yes No

9.

Did you ever kept courses in the e-learning system? Yes No

10.

Are you interested in e-learning? Yes No

11.

Are you interested in mobile learning? Yes No

12.

Have you ever looked for an e-learning course in internet?

Yes No In what domains 13. In what medical domains do you think that e-learning would be useful?

14. What language would you prefer for the course information?

15. If you would apply to the e-learning platform would you be interested in e-courses in ultrasound e-courses for nurses e ECHO-Atlas Yes No Yes No Yes No

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Manuality All issues

Yes No Yes No

Would you be interested in on line courses in real time/Virtual Classroom? Yes No 16. Would you be interested in a Forum on medical topics? in ultrasound in nurses Yes No Yes No

17. Would you be interested in sharing content with images from your own experience? Yes No 18. What information and in which form would you like to use for your students? _______________________________________________________________ 19. How many hours/per year do you think are necessary for medical staff to refresh their knowledge and improve skills and competencies? Doctors Less than 20 h About 25/35 h About 35/50 h Over 50 h Midwifery Medical Assistants Xray/Ultrasound Technicians Nurses

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NEEDS ASSESSMENT QUESTIONNAIRE

(MANAGERS)
PERSONAL DETAILS (These details are required for communication purposes only and will not be disclosed) NAME:* optional Institution Department Position: EMAIL:* optional *Tick the box that suits best your situation. 1. How important is continuous medical education for you and your employees? 2. How many hours and /or ECTS credits do your employees need yearly for continuous medical education, according to your national heath legislation? ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. Are you interested in e-learning? Yes No 4. Are you interested in mobile learning? Yes No

5. Have you looked for e-learning courses on internet? Yes No In what domains---------------------------------------------------------------------6. Employees in your institution are familiar /use an e-learning platform? Yes No 6. In what medical domains do you think that e-learning would be useful for professional formation of your employees? -----------------------------------------------------------------------------------------7. If you would have access to an e-learning medical platform would you promote it within your institution? Yes No 8. If you would have on your disposal an e-learning platform for continuous education would you apply to it for your employees if it is on free basis? for ultrasound education Yes No

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for nurses education for any medical topic

Yes No Yes No

9. If you would have on your disposal an e-learning platform for continuous education would you apply to it for your employees if it is on payment basis? for ultrasound education Yes No for nurses education Yes No for any medical topic Yes No Comments-------------------------------------------------------------------------10. What language would you prefer for the course information? 11. If you would apply to the e-learning platform would you be interested in e-courses in ultrasound e-courses for nurses e ECHO-Atlas Manuality All issues Yes No Yes No Yes No Yes No Yes No

12.Would you be interested in on line courses in real time/Virtual Classroom? Yes No Would you be interested in a Forum on medical topics? in ultrasound Yes No in nurses Yes No

78

NEEDS ASSESSMENT QUESTIONNAIRE

(MEDICAL STUDENTS, RESIDENTS, MEDICAL DOCTORS, NURSES)
PERSONAL DETAILS (These details are required for communication purposes only and will not be disclosed) NAME:* optional Position: student. year of study resident .in.. medical doctor specialization. Nurse specialization member of professional organization name of organization EMAIL:* optional *Tick the box that suits best your situation. 4. What information sources do you use regularly? How regular is your use? Journals Daily Weekly Monthly Books Daily Weekly Monthly Newspapers Daily Weekly Monthly Online resources Daily Weekly Monthly 2. What are the main categories of information that do you use them? Clinical issues Daily Weekly Ultrasound Daily Weekly Medical Legislation Daily Weekly Medication Daily Weekly Medical events Daily Weekly News Publications Daily Weekly Science & Research Daily Weekly you require? How often Monthly Monthly Monthly Monthly Monthly Monthly Monthly

3. Which of the following e-tools are you familiar with and to which extent? Tick the box that suits best your situation. Never heard of it Chat Wiki Audio conferencing Video conferencing Forum e-mail groups Internet Mobile/ mobile I have heard but never used it I can manage with help I can use it

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learning

4. How often do you access the internet? Daily 5 2-3 times a week weekly

How do you prefer to receive your information? Electronic Email Intranet/Web CD ROM

18. How much do you use the internet for improving your professional career? Daily 19. Weekly Monthly

How do you prefer to improve your professional career? Classical courses Workshops e learning

20.

Did you ever benefit from e-learning during university courses? Yes No

21.

Did you ever benefit of e-learning during post-university courses? Yes No

22.

Are you interested in e-learning? Yes No

23.

Are you interested in mobile learning? Yes No

24.

Have you looked for e-learning on internet?

Yes No Inwhat domains 25. In what medical domains do you think that e-learning would be useful for your professional formation?----------------------------------------------------------14. How many hours/per year do you think are necessary to refresh your knowledge and improve skills and competencies? (I add this question to quantify the training need for each ISCO medical category)

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15. If you would have on your disposal an e-learning platform for continuous education would you apply to it for your employees if it is on free basis? for ultrasound education Yes No for nurses education Yes No for any medical topic Yes No 16. If you would have on your disposal an e-learning platform for continuous education would you apply to it for your employees if it is on payment basis? for ultrasound education Yes No for nurses education Yes No for any medical topic Yes No 17.What language would you prefer for the course information? 18.If you would apply to the e-learning platform would you be interested in e-courses in ultrasound e-courses for nurses e ECHO-Atlas Manuality All issues Yes No Yes No Yes No Yes No Yes No

19.Would you be interested in on line courses in real time/Virtual Classroom? Yes No 18. Would you be interested in a Forum on medical topics? in ultrasound Yes No in nurses Yes No 19.Would you be interested in sharing content with images from your own experience for second opinion? Yes No 20. What information and in which form would make your professional development easier? _______________________________________________________________

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