MED-NET Conference 1997. Rotterdam, the Netherlands.
Proceedings 2.2.

Compiling an international database on medical education: Experiences with the 'European Medical School Information System' (EMSIS)

G. Eysenbach (Erlangen, Germany)

Summary

We report our experiences from five years of international effort to compile a database on undergraduate medical education in Europe. The project was launched in 1992 by the IFMSA (International Federation of Medical Students Associations) with the financial support of the ERASMUS-programme and the WHO Regional Office of Europe. The project aims to provide an overview and to enable a comparison of the curricula of Medical Schools in Europe, to facilitate the co-operation between Medical Schools in Europe and to allow medical students to plan their studying period abroad. Today the database contains the curricula and other information of about 200 medical schools from 40 different countries and is accessible via the World Wide Web (http://yi.com/emsis). The database contains the addresses of medical schools, general information about each medical school (number of students, hospital beds available for teaching etc.), exchange information (exchange networks the medical school is participating in) and extensive curriculum information, consisting of more than 10.000 course descriptions. All information has largely been entered by the medical schools themselves. Medical schools may update the database directly via the Internet at any time. Users may perform simple queries e.g. by country or city, or may perform more complex searches such as "show all medical schools teaching gynaecology in the 4th year".

Introduction

Movement of European doctors and students dates back as far as to the times of Hippocrates. In 460 BC Hippocrates was born on Kos and since then Kos was a magnet for aspiring physicians in the 5th century BC. Later, in the 17th and 18th century, European medical students travelled to famous centers such as Leiden, Padua, Bologna, and Ferrara. Probably many of the difficulties ancient and medieval scholars experienced were similar to the problems medical students going abroad are facing today - such as language barriers and financial problems -, but at least these ancient exchange students did not have to worry too much about credits, recognition and how to fit the courses into their curriculum.

Today, medical students and educators need more detailed information about the medical education system of foreign medical schools before going abroad, in order to avoid overlapping of subjects or gaps in their education.

Few resources are available allowing to analyse and compare different curricula and educational approaches in Europe at a glance. The few resources known to the authors are largely paper-based and provide a more general description of the educational system in each country (1-3) rather than a detailed description of each medical school. The standard reference volume "World Directory of Medical Schools" (4) contains some key data about each medical school, but no details about the curriculum. In addition, some information packages prepared by individual medical schools participating in SOCRATES/ERASMUS/TEMPUS/INSERT-MED programmes are available (for example (5)).

In view of the growing mobility of students and recognising the increasing need for information, in 1991 the Standing Committee on Medical Education (SCOME) of the International Federation of Medical Students' Associations (IFMSA) launched the idea of compiling the curricula of the Medical Schools in Europe. Later, the World Health Organisation Regional Office for Europe (WHO-ROE) and the European Union were gained as partners, providing logistic and financial support, respectively. The initial project was called "Survey on curricula of medical schools in Europe" and consisted of a paper-based questionnaire sent to each European medical school. In a second step, the returning data were entered into an off-line-database (EMCAD - European Medical Curricula Access Disk) and the medical schools were given a second opportunity to enter or update their data. Recently the database was revised and for the first time made accessible via the Internet using the World Wide Web (WWW) technology (for details about the Internet and medical applications see for example (6, 7)). The on-line database is now known as "European Medical School Information System" (EMSIS) and is available under the Internet-address http://yi.com/emsis.

The main objectives of this project can be summarised as follows:

• to permit an overview and a comparison of the curricula of the Medical Schools in Europe;
• to facilitate the co-operation between Medical Schools in Europe (e.g., for building up and maintaining exchange programmes);
• to allow medical students, by consulting the system, to plan their studying period abroad.

At present, the resulting database contains not only medical curricula with more than 10.000 subject (course) entries, but also addresses, exchange details and other information about 200 European medical schools from 40 European countries, representing approximately 50% of medical schools in the European region.

With the database being on the World Wide Web (WWW), EMSIS is now publicly available from everywhere in the world with a user-friendly interface and represents a unique and useful resource for medical educators, policy makers and medical students.

The history of the project, the acquisition of the data, the creation of the databases and their implementation on the Internet has been described in detail elsewhere (8).
This paper gives a brief introduction into the usage of the information system, discusses some problems of data acquisition and provides an outlook into the future towards an international repository for medical education.

History of the project

The EMCAD/EMSIS project can retrospectively be divided into three phases:

The first phase (1992/1993) consisted of the development and mailing of a paper-based questionnaire to all 385 medical schools in Europe. This questionnaire was mailed to the deans of all medical schools by the WHO-ROE and, in parallel, to the Local Medical Student Organisations by the IFMSA. The questionnaire contained general questions regarding the medical curriculum. Once the questionnaires were returned, a relational database system was used to store the results of the survey. The database was distributed on a diskette, subsequently referred to as the first edition of EMCAD (European Medical Curricula Access Disk). The EMCAD database structure was similar to today's database structure of EMSIS explained below and shown in Table 2.

In the second phase (1994/95) the first edition of EMCAD was sent to all medical schools, together with a separate "input disk". The input disk contained an electronic questionnaire, which was - compared to the first paper-based questionnaire - much more elaborated: It contained additional questions regarding the curriculum, exchange specific questions and inquired general data of the medical school (Tab. 1). This time the answers of the responders could be stored directly on the input disk abandoning the need for additional input of the returning data into a computer. Medical schools were asked to enter or edit their entries in the database and to mail the input disk back to the project co-ordinator. From the old database entries and the returning input disks, the second edition of EMCAD was compiled.

Methods

The on-line database was programmed using the PHP/FI language (9) on a Pentium-133 computer under the LINUX operating system running the Apache server software. PHP/FI is a powerful server-side programming language, where the programming script is embedded inside HTML files. PHP/FI supports Mini SQL (10), which is a database engine designed to provide fast access to stored data in table structures with low memory requirements.

The database structure of EMSIS is very similar to the database structure of EMCAD and is shown in table 2. The data which are associated with each medical school (address, exchange information and general information on the medical school) are stored in the database table "uniadr", while the curriculum is stored subject by subject in the table "curr". Therefore table "uniadr" contains one record per medical school, table "curr" contains one record per subject (course) taught at one of these medical schools. Both tables are connected by a unique identification number assigned to each medical school and stored in the field "uniadr.id"; each entry in the table "curr" points to "its" medical school using the id-number (field "curr.ref_nr" ). This database design is different from the previous database design used for EMCAD, as in the previous version both tables were linked by the entries in the fields "name", "city" and "nation".

Since August 1996 the entire EMCAD/EMSIS database is now publicly accessible via the World Wide Web (http://yi.com/emsis). The database allows various ways to query the database, and allows also to update the entries, making the future mailing of paper-based or disk-based questionnaires redundant.

Results

The third phase of the project was launched in 1996. It consisted of the development of an on-line accessible database containing the EMCAD data, using a World-Wide Web Server connected to the Internet.

The reasons for putting the database on the Internet were

• that there is a constant need to update and check the entries of the database, which cannot be done centrally but must be put in the hands of the respective medical schools
• that - having in mind the diverse nature of questions - it is usually different people from a medical school who can best answer a subset of questions rather than a single person; the web technology offering the possibility for many people to work on the same entry
• that during the last few years the Internet has become an accepted information resource among the medical community.

As the on-line-accessibility of the database abandons the need to distribute it on disk, the project was renamed from "European Medical Curricula Access Disk" (EMCAD) into "European Medical School Information System" (EMSIS).

Database contents

Following the mailing of the first questionnaire from the WHO and the IFMSA to the deans or medical student organisations, respectively, from 385 European medical schools listed in the "World Directory of Medical Schools" (WHO, 1988), 98 deans or their representatives replied to the WHO and 73 medical student organisations responded to the IFMSA. From these data, the curricula and other data of 155 European medical schools were compiled to the first EMCAD edition, covering already a total of over 9.000 subjects (courses). The second mailing to the deans, this time accompanied by an input disk, and the subsequent compilation of the second EMCAD edition extended the coverage of the database to 199 medical schools.

Today, the EMSIS database contains more than 10.000 subject entries from 199 medical schools in 40 countries (for a list of countries currently in file see Fig. 1); it is noteworthy that altogether the medical schools are using more than 2.600 distinct subject-names for the courses they offer.

Figure 1: EMSIS Main Menu Part of the EMSIS Main Menu (http://yi.com/emsis/index.php), enabling to search for medical schools or curriculum subjects according to different criteria.

Retrieval

A part of the EMSIS main menu is shown in Fig. 1. The system allows for example to search for all medical schools in a given city, can list all medical schools in alphabetic order, can show all medical schools in a given country or can also produce a list of medical schools teaching a given subject at any time during the course of study (Fig. 2) or restrict the search to medical schools teaching a given subject in a certain academic year. From each medical schools listing the user can activate a hyperlink to the respective curriculum (Fig. 3) or can even search the whole Internet for the medical schools name ("Hypersearch").

Figure: 2 EMSIS Screenshot - Subject query Part of the resulting screen after the query for a subject containing the word "history". The screen shows medical schools teaching subjects like "Medical History" or "History of Philosophy". The medical schools are listed with their key data like address, and possibly - if entered - exchange information (not shown). A small menu at the bottom of each medical school entry enables to view the full curriculum, to jump to the entry form in order to update the curriculum or the address and exchange information; a special menu point ("Hypersearch") enables to search the whole Internet for the respective medical school using the "Alta Vista" search engine from Digital (http://www.altavista.com). With this hypersearch function it is very easy to find the homepage or other relevant information about the medical school in the Internet.

Figure 3: EMSIS Screenshot - Curriculum output
Part of a curriculum output, in this case of a medical school in London. Each subject is broken down by the hours, number of students and evaluation method. If a subject subscription or any other remarks would have been entered they would appear here as well.

Updating

One of the main reasons for putting EMCAD on the Internet was the need for continuous and quick updating of the data - using paper questionnaires and diskettes was considered as being old-fashioned and too slow for the rapidly changing curricula. Today, EMSIS allows not only to search, but also to update the data directly through the Internet from anywhere in the world and to make updated data immediately available. The update can be done simply by clicking on the menu points "Edit address / exchange info" or "Edit / enter curriculum" and filling in an electronic form. In order to avoid unauthorised deletion or alteration of data a password is required, which is available on request from the database editor (Email: ).

Discussion and outlook: Towards an international medical school information system
The project started already five years ago, and much has happened since then. Advances in telecommunication, the rise of the Internet and its growing popularity among doctors and medical students results in the fact, that much of the information originally thought to be stored in a central database is now available on the department homepages of the medical schools and can be maintained by the department itself in a decentralised manner. Thus, many details are now much more easily available than five years ago and the database has to be changed accordingly, getting rid of details which can be better retrieved from department homepages and adding fields to provide links into the Internet. During the transformation from EMCAD to EMSIS we already added a database field which contains the address (URL) of the respective medical school department, thus the information system now also serves as an entry point for those seeking the homepage of a given department.

However, we still think that a database on medical education as a central clearinghouse and entry point is necessary and useful, not only because information on the Internet is extremely scattered and difficult to find, but also because department homepages are heterogenously organised and difficult to compare. Only a database allows searches such as "Show me all medical schools in (country) teaching (subject) in the x.th year".

One has to stress that the database is decentrally maintained by all medical schools in Europe. Responsibility for the database contents lies not with the database developer, but the individual medical schools (more specifically, the respective persons in charge of exchange). Unfortunately, the database currently contains only about 50% of all medical schools and much of the information is outdated. Medical schools are urged to check and update their information.

As medical schools may increasingly offer curriculum information on their own homepages, we may develop an Internet "crawler" program ("MEIA - medical education internet agent") for automatic screening of the World Wide Web for information suitable to be included in EMSIS and for automatic transfer of this information into the database, abandoning the need for the medical school to care for their homepages and their EMSIS entry separately. This would require that the medical schools use certain HTML "meta-tags" to be included in their medical school, faculty or department homepages. The syntax of these tags would simply be <META NAME="emsis:fieldname" CONTENTS="fieldcontents"> where fieldname is the EMSIS field name (Tab. 2) and fieldcontents the contents of the field, for example <META NAME="emsis:curr.subject" CONTENTS="anatomy">. If such tags are found in a homepage by the "agent", EMSIS would automatically update the entry in the database. A campaign to make EMSIS better known, especially among the medical schools, is needed and a recent publication in an international journal (8) hopefully is the first step.

Possibly an expansion of the database scope towards developments and reforms in medical education, postgraduate and continuing medical education, as well as towards international (non-European) medical schools would be possible, provided that problems of logistical and financial nature can be solved.

Continuous refinement is required to keep pace not only with the developments in information technology, but also with the developments in medical education and exchange. For example, the general tendency from a subject based curriculum to an integrated and/or problem-based curriculum provides new challenges for the future refinement of the database. Also, the plethora of 2.600 different subject names illustrates the need for a coding system (e.g. a numerical key) for the exact course contents.

Further co-operation with student associations and professional organisations (for example the WHO Regional Offices, WFME, AMSE, ASME, AMEE, CP, FAMSA, AMSA etc.) and their active involvement in the project is highly desirable, as is co-ordination with the recently established MED-NET to avoid duplication of efforts.

References

1. Eysenbach G (ed.). Medicine and Medical Education in Europe. Vol I.
   Undergraduate Medical Education in Europe. Chapman & Hall, London, Glasgow, Weinheim, New York (in print)
2. Eysenbach G (ed.). Medicine and Medical Education in Europe. Vol II. Postgraduate Medical Education in Europe. Chapman & Hall, London, Glasgow, Weinheim, New York (in print)
3. Mebazaa A. Guide de la santé en Europe [Guide to health in Europe]. Impact Médecin, Neuilly. 1992
4. WHO. World Directory of Medical Schools, 6th ed. WHO, Geneve. 1988
5. NeMSIC. ERASMUS/Insert-Med International Elective Programmes. Press & Publicity, Erasmus Universiteit Rotterdam. 1991
6. Eysenbach G. Computer-Manual für Mediziner und Biowissenschaftler. Urban & Schwarzenberg, München, Wien, Baltimore (1994)
7. Eysenbach G, Bittorf A. Das Internet - Grundlagen und medizinische Anwendungen. In: Schaefer OP, Lamers W, Eysenbach G (ed.). Praxis und Computer, 16th edition. Springer-Verlag, Heidelberg, New York (1996)
8. Eysenbach G, Cloos JM, Jacobsen CT, Antepohl W. An international database on medical education: The European Medical Information System (EMSIS). Medical Education (in print)
9. Hughes D.J. (1995). Mini SQL - A lightweight database engine. Published online at: http://sci173x.mrs.umn.edu/~bentlema/db/msql-doc.html
10. Lerdorf R. PHP/FI User Manual. Published on-line at: http://www.vex.net/php/doc.phtml. 1996

Acknowledgements

The database presented here is largely based on the excellent work of my dear colleagues and friends J.-M. Cloos (EMCAD Co-ordinator 1993-95; Secretary General 1995-96, International Federation of Medical Students' Associations), C.T. Jacobsen (IMCC Denmark; PR & Marketing Director Co-ordinator 1993-94, International Federation of Medical Students' Associations), and W. Antepohl (Standing Committee on Medical Education Director 1994-96, International Federation of Medical Students' Associations) and many other IFMSA activists.

The project has been further supported by
Dr. Mila Garcia-Barbero, Regional Adviser for Medical Education and Hospitals at the WHO Regional Office for Europe.
Mr. Mitchell from the Task Force "Human Resources, Education, Training and Youth" of the European Communities (help and advice in getting financial support from the EU for the second edition of EMCAD).
Lars-Bo Friis Karlsen (programming and computer advice regarding EMCAD).

This work has in part been funded by the European Union, under the ERASMUS programme Action 4.2, grant number CME-94-B-1003.

Download the proceedings as PDF file
To be viewed with Acrobat Reader
Download Acrobat software here

Order a copy of this book by sending 
an e-mail to .