The survey presented here showed that e-learning has reached a high implantation level in the cluster of analyzed mid-European medical schools. However, the use of single tools and the distribution of e-learning offerings in individual disciplines were seen to be inhomogeneous among the institutions. The results also highlight that there is a potential for improvements regarding motivational incentives for the teaching staff which is dealing with the development and implementation of e-learning scenarios.
Concerning the level of e-learning implementation, it can be stated that all of the addressed schools did use e-learning proposals to some extent. E-learning is also established in its basic use as a means to offer support to classic teaching of face-to-face courses. Among these offers, non-collaborative formats (such as podcasts or lecture recordings) are predominantly used as mandatory supplements. Future developments should consist of an integration of mandatory collaborative e-learning tools as a holistic approach that includes digitally driven assessment-formats as well . In this study, gender issues were taken into account for developing e-learning activities in general by less than half of the participating medical schools. The survey did not go into any details, for instance into the use of gender-neutral language, avoiding gender stereotypes or gender medicine as a topic itself.
Among such methods of teaching, many formats seem to be well-known and widely implemented, while tools that focus on online collaboration are less presented especially as mandatory didactic elements. As there can be found successful usage of these—like that of wiki—in the literature , it can be assumed that their implementation depends both on the familiarity of teachers with the tools as curricular implementation and instructional design of the course .
There was an inhomogeneous representation of e-learning offers for the single medical disciplines in this survey. However, the individual number of medical schools which provided offers was also inhomogeneous for every particular discipline, an observation which has already been reported e.g. for radiology . The presented results suggest that there is a lower level of implementation in smaller disciplines, such as otorhinolaryngology or human genetics. Here, implemented examples of successful projects in small disciplines  can be seen as great potential for sharing successful formats between medical schools in the future.
Regarding infrastructure and staff, all participating medical schools had faculty members as responsible contact persons for e-learning matters. For the technological infrastructure it can be stated that LMS were firmly established, with open source platforms predominantly used by the majority of the participants . It is remarkable that the majority of the medical schools observed here preferred an in-house open source model to outsourcing their LMS. Although the use of open source systems is related to altered in-house costs, this might be acceptable to realize a higher flexibility in customizing the systems to the medical school’s needs . Consequently, it can be assumed that a high proportion of the named e-learning staff capacities are allocated to host the LMS. However, it could also be shown that the existence of e-learning staff is positively correlated with the presence of e-learning offers at a medical school. This stresses the use of employing personnel merely dedicated to managing a medical schools’ e-learning portfolio.
Teachers could make use of different programs for the development of contents in the context of their didactic teaching scenarios, depending on the medical school. The vast majority offer trainings or qualification programs for teachers. That this is important was also postulated by Cook and Triola as well as by Kowalczyk and Copley, who stressed the need for faculty development in the use of current tools and ongoing training in emerging technologies [29, 26].
Alongside existing infrastructural services, motivational incentives will be important to encourage especially clinical teachers to deal with the provision of e-learning offers, as this is often time and resource-intensive . In the study presented here, less than one-third of the participating medical schools rewarded the creation or implementation of e-learning tools/courses, and less than one fifth awarded funds or prizes for tasks undertaken in the field of e-learning. A further problematic aspect was that an evaluation of opinions, attitudes and experiences of teachers who are involved in the development of e-learning seems rarely to be taken into account . Although a small proportion of participating centers recognized the implementation of e-learning activities as an additional achievement when looking at admission to a tenure scheme, a larger number planned to adopt their practices in this field—a promising approach, as already reported in the literature .
Quality assurance protocols for e-learning scenarios  were in place at only a handful of medical schools. As such a standardization is intended to ensure the maintenance of medical standards and the attainment of curricular learning goals , addressing this backlog would help to create certified e-learning tools which could be of use for a larger number of medical schools .
Altogether, the findings of this study can be seen as part of a detailed strategy of most of the medical schools to increase the scope and quality of their e-learning programs in the next years. Future challenges for a wide use and cooperation in e-learning aspects among medical schools can in fact build on the high willingness of the medical schools to use and exchange e-learning offerings of other universities when it comes to the education of students and also the training of teachers themselves. An interesting approach for the future might here be the development of a central—maybe even international—database of e-learning contents for medical schools, where an exchange or common use of data could take place [17, 27]. The majority of the faculties stated that professional societies, academic institutions or ministries should support the development of e-learning activities. Here, an inter-faculty discussion platform supported by these institutions could be helpful to answer many of the questions that the individual medical schools have in the field of e-learning—e.g. copyright or financial issues or the establishment of blended learning concepts.
Limitations of the validity of the present documentation which must be highlighted include the finding that responses were not collected from all of the medical schools addressed. Therefore, the results shown here provide insight into the current status of the field of e-learning but cannot be used for definitive statements. This could also contribute to a bias that potential regulatory differences in curricular uses of e-learning between individual countries and federal states were not captured by this survey. In addition, the option of leaving certain questions blank meant that there was variation in the numbers of answers collected. Also, the faculty positions of the addressees were seen to be inhomogeneous, and this may have influenced their understanding and perceptions as a confounding variable in answering the questions. Finally, the questions used can only provide a brief representation of the different situations in individual disciplines at the various universities.
As this evaluation focused only on the status and e-learning supporting strategies at mid-European medical schools, in future studies the focus of analysis should be expanded to meet the conditions in more countries and regions of the world.