Evaluation of Continuing Medical Education ( CME ) Systems across the 27 European Countries

The EU Research Project Tell Me aims to create a common communication channel and joint intervention strategies to respond to potential pandemic influenza events. This aim can be supported by using e-learning, which is an increasingly popular approach for continuing medical education. It is characterised by practical and theoretical advantages related to its flexibility, accessibility, adaptability, reduced time and costs and the potential to rapidly disseminate and update educational resources. The aim of this article is to review and identify the policies of continuing medical education systems in Europe. We will specifically focus on e-learning, which may be useful to understand whether there is a favourable evidence and context for the development of a common European continuing medical education e-learning framework. We conducted a survey to collect information about the Continuing Medical Education (CME) system’s policy of 27 European Union countries using electronic databases. A CME system is present in 26 of the27 EU countries. Most of the countries have 1) similar CME system requirements (16), 2) the same accreditation unit (21) and 3) recognize CME distance learning (E-learning) (22). There are still some differences between continuing medical education systems of European countries; however, there is a favourable evidence and context for the development of a common European continuing medical education e-learning framework.


Introduction 1.EU Tell Me Project
The EU Research "Transparent communication in Epidemics: Learning Lessons from experience, delivering effective Messages, providing Evidence project" (Tell Me project) aims to create a common communication channel and joint intervention strategies to respond to potential pandemic influenza events that would reduce the heterogeneity in tackling the problem between European countries and then optimize the use of available resources.These results can be achieved in particular with e-learning, one of the tools on which the project is centered, and is more cost-effective than classical training.
The EU Tell Me research project involves experts in social and behavioural sciences, communication and media, health professionals at various levels and specialities and representatives of civil society organisations to develop an evidence-based behavioural and communication package to respond to major epidemic outbreaks, notably flu pandemics (Tell Me project, 2012).In order to reach this goal, Tell Me must meet a number of objectives, including the development of an e-learning tool for health workers to rapidly spread information in case of a pandemic situation through all 27 European countries.

Continuing Medical Education and Professional Development
Health operators are constantly required and reminded to update their theoretical, technical and communication skills in order to keep up with the continuous development of medicine and biomedical knowledge, and adhere to requirements for good medical practice (UEMS, 2012).
Hence, it has become essential to support health professionals with lifelong learning initiatives such as continuing medical education (CME) and Continuing Professional Development (CPD) (UEMS, 2012).
As a result, several countries have developed national CME systems to ensure that health professionals would fulfil compulsory learning requirements in order to be able to practice medicine and maintain a high standard of health care.

European Accreditation Council for Continuing Medical Education (EACCME)
Several European countries have developed individual CME systems which may be harmonised via an European initiative.The first step to collate and group these different systems to improve the quality of specialist medical care in Europe was taken by the European Union of Medical Specialists (UEMS, 2012).The UEMS is a non-governmental organisation representing national associations of medical specialists in the European Union and associated countries which has set up the European Accreditation Council for Continuing Medical Education (EACCME).The main aim is to structure and facilitate the mutual recognition of accreditation of CME/ CPD activities through the awarding of European CME credits (ECMECs) to individual medical specialists (UEMS, 2012).However, differences between the CME systems in European countries still persist notwithstanding the recent efforts by UEMS.

CME E-Learning
Internet based e-learning is becoming an increasingly recognised approach to CME for practical and theoretical reasons.Compared with traditional face-to-face programs, e-learning platforms offer greater flexibility in training schedules, improved accessibility and dissemination, reduced costs and time, greater adaptability to individual learning styles and easier access to educational material and updates (Fordis, 2005;Cook, 2010).Therefore, e-learning may represent an ideal tool to achieve the primary aims of the EU Tell Me project (see below): to develop a system capable of efficiently disseminating information to health workers across all 27 European Union countries in case of an infectious disease emergency.

Objective
The aim of this article is to review and identify the policies of continuing medical education systems in Europe.The data will inform policy makers and health professionals on the feasibility to develop a common European e-learning tool.

Research
We have conducted an investigation on the Internet to collect information about the Continuing Medical Education (CME) system in the 27 EU countries.
The Ministry of Health's website and CME websites for each country were examined.
In addition, Internet searches were conducted using the Google browser with the following acronyms, keywords and phrases: "CME", "CPD", "continuing medical education", "continuing professional development", "accreditation", "Europe" or "name of the country".
Internet searches were conducted also using keywords in the countries' native language.Most of the sites viewed had the English version; for those which hadn't the English version was used Google Translate tool and the data that were found have been checked crossing available sources.
The review was carried out also using PubMed combining the same keywords ("Education, Medical, Continuing", "accreditation", "European Union").We included studies published from January 2008 to present.Articles were selected based on their title and abstract.Articles not in English were excluded.Four articles were included in the main analysis (Christodoulou, 2007;Vlassis, 2010;Pardell, 2013;Costa, 2010).
The Health Acts of each European country was examined and relevant information extracted.Members of the European Union of General Practioners (UEMO) were contacted to obtain additional information on UK, Denmark, Hungary, Germany, Malta, Czech Republic, France, Slovakia and Poland.In addition, we attempted to obtain information from countries with insufficient information on CME systems by directly contacting key members of the national competent CME authority.Requests were sent via email to representatives from 12 countries including: Denmark, Bulgaria, Cyprus, Estonia, Finland, Greece, Hungary, Latvia, Luxemburg, Malta, Portugal and Sweden.

Research Targets
The information we searched for each country were: − the presence or absence of a CME system; − the type of CME system (compulsory, voluntary); − the CME requirements (number of credits per year); − the unit of accreditation; − the learning activities recognised; − the end-users of the training; − the participations in UEMS EACCME system; − the name and the website of the competent CME authority of the country; These relevant informations have been collected in tables like Table 1 for each countries.Table 2 summarises the results of the research according to six fundamental categories: 1) the presence or absence of a CME system, 2) the CME requirements (compulsory, voluntary), 3) the number of credits per year, 4) the unit of accreditation, 5) the recognition of e-learning and 6) the target of CME.

Results and Discussion
The 27 countries are full members of UEMS and follow the EACCME directive.While there are various types of CME systems in each country, with some systems still in early development, the results suggest the existence of a common European framework (UEMS).The UEMS represents an important attempt to reduce the heterogeneity across the different CME systems.
A CME system is present in 26 EU countries (96%), but some systems do not have a format based on credits system (11%).
More than half of countries (15 countries, 56%) are characterised by a mandatory participation to their CME system.In the remaining countries participation is voluntary and based on the assumption that CME is a civic duty and, in some cases, participation is encouraged by either tax incentives or financial rewards.
There is a reasonable homogeneity in the type of CME system across countries and for most of them (15 countries) it can be divided into two main types: − CME system with a five years cycle for a total of 200/250 credits (11 countries); − CME system with a three years cycle for a total of 150 credits (5 countries).
The remaining CME systems are somewhat different including for example, a five years cycle for a total of 100/120 credits, and a system requiring 75 credits in seven years (Slovenia).
However, among the countries that provide CME credits (21 countries), the majority of these ( 16) requires healthcare operators to acquire 40 to 60 credits per year.
The case of Sweden is unique since the CME system is not based on credits.Details on the CME system were not available for Luxembourg, Malta, Portugal and Spain.
A large homogeneity on the accreditation unit across countries was observed.Specifically, 14 countries award one credit for one hour of activity and 6 countries award one credit for 45 minutes of activity.Information on accreditation unit was not available for the remaining 4 countries with a system based on credits.In addition, if we assume that 45 minutes are equal to an hour of training, all the countries with a system based on credits (21) utilises the same accreditation unit.
The type of activities accepted for credit across all 27 European Union countries includes: 1) internal/external activities, 2) publications and 3) referee duties.Distance learning (E-learning) was recognized for the acquisition of credits in 22 countries (81%) and not recognized in Greece and Estonia.Three countries (Luxembourg, Malta and Portugal) did not provide information on accepted activities for accreditation.

Conclusions
The results show there is a lack of standardisation between European countries' CME systems and the development of a protocol of e-learning that could be consistently applied in different countries is warranted.
Most countries have CME systems with similar accreditation systems, recognize distance learning and have mutually recognized credits because they adhere to a common system (UEMS).
A potential limitation is that most CME systems are targeted only to medical doctors.However, global events requiring organized actions (which is the primary focus of the Tell Me Project) may require the involvement of different health operators who would be expected to follow specific training recommendations.Numerous health training activities are now operating in different countries which may need to be incorporated into each accreditation system and taken into account in case of a coordinated European action to rapidly spread information in case of a pandemic situation.
Few studies have reported a complete overview of the CME system in the 27 EU countries and this article may provide a useful update of the existing literature.

Table 1 .
Example of a table used for collecting information on the CME system of each country.

Table 2 .
Synthesis of information collected by the research about European CME systems.Most CME systems (17 countries) are targeted to medical doctors (all specialties).Seven countries, Italy included, have a CME system open to other health operators (i.e.nurses, obstetricians, pharmacists and so on).Italy in particular is the only European country in which all health operators are obliged to enrol in a continuing medical education programme.