From: Subject: ICT4E816 Date: Thu, 19 Feb 2004 10:36:15 -0500 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0009_01C3F6D4.338B1B40"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1165 This is a multi-part message in MIME format. ------=_NextPart_000_0009_01C3F6D4.338B1B40 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.jrc.es/home/report/iptsreport/vol81/english/ICT4E816.htm ICT4E816

Skills and Competencies for the Future of eHealth
Anastasia=20 Constantelou and Vasiliki=20 Karounou, National Technical University of Athens,=20 Greece

Issue: An important = prerequisite for=20 the widespread introduction of new technologies in the heath sector is = the=20 acquisition of new types of skills by citizens, patients, doctors, = nurses and=20 other healthcare professionals. These skills translate to new abilities, = competencies and, above all, mindsets and attitudes to new ways of = working that=20 are more responsive to the needs of citizens.

Relevance: = Human=20 resource development through appropriate education and training is a key = factor=20 in coordinating efforts by stakeholders, introducing new working methods = and=20 gradually transforming traditional healthcare service providers into = agencies=20 that provide a wide range of eHealth services. This is particularly = relevant=20 considering the under-investment in training and education that is = endemic in=20 the health sector and which create blockages in the ways knowledge is=20 shared.

Introduction

eHealth is an umbrella term = encompassing=20 a broad range of ICT-driven activities that are transforming the = delivery of=20 healthcare. Such activities normally involve the use of digital data = that is=20 transmitted, stored, and retrieved electronically for clinical, = educational and=20 administrative purposes, whether at a fixed location or remotely. The = important=20 implications of eHealth are becoming more and more apparent to patients, = health=20 workers, administrators, and practitioners as new applications allow the = provision of medical support remotely at any point in time and = facilitate access=20 to, and exchange of, pertinent health information on = demand.

eHealth is an umbrella term = encompassing a broad=20 range of ICT-driven activities that are transforming the delivery of=20 healthcare

The introduction and effective = delivery of=20 eHealth concerns all players in the healthcare sector. These include = hospitals=20 and other healthcare facilities, public and private insurance firms,=20 organizations developing and applying technological solutions, as well = as a=20 variety of user groups - citizens, patients and their environment, = doctors,=20 nurses and allied healthcare professionals. The growing body of = literature on=20 eHealth has extensively dealt with the rise of new technologies and the=20 bottlenecks and challenges facing eHealth strategies in the 21st = century. Less=20 attention has been given to ways of increasing awareness and general=20 understanding and utilization of ICT-driven activities among all the = parties=20 directly involved. For this, it is important to recognize that = technology alone=20 cannot guarantee optimal results. New types of skills, competencies and, = above=20 all, mindsets and attitudes to novel ways of working are required for = the=20 ubiquitous introduction and effective exploitation of ICTs in = healthcare.=20

New types of skills, and changed = attitudes to=20 novel ways of working are required for the ubiquitous introduction and = effective=20 exploitation of ICTs in healthcare

ICTs and the changing nature of skills in healthcare = delivery

For over two decades now, ICTs = have been=20 gradually introduced into the healthcare system creating turbulence in = its=20 traditional structure and organization and requiring all those working = in the=20 area to keep pace with new technologies. As early as 1990, the European = Council=20 issued Recommendation No R(90)21 which alerted governments of member = states to=20 "=85ensure that, as soon as possible, those staff involved in healthcare = receive=20 appropriate, multidisciplinary training, both theoretical and practical, = for=20 health information systems within an overall public context" (Grimson,=20 et. al., 2000). At that time, the predominant ways in which ICTs were = introduced=20 and applied within the healthcare system related mainly to = administrative,=20 managerial and financial functions. The integration of some of the = =91back office=92=20 components of the healthcare system that was made possible with ICTs = required=20 health practitioners to transcend the strict boundaries of their = profession and=20 acquire a new set of skills that may have been unnecessary a few years = ago.=20 These were mainly leadership competencies - such as strategic and = tactical=20 planning, persuasive communication, negotiating skills, financial=20 decision-making, team building, conflict resolution and interviewing - = as well=20 as some basic ICT-related technical skills (Schwartz,=20 R., 2000). Even at that time the need for increased information = technology=20 =91upskilling=92 created an additional burden on the already demanding = schedule of=20 healthcare professionals. The latter viewed ICT training as peripheral = to their=20 activities, or at worst, as an unnecessary burden which consumed = valuable time=20 (Grimson,=20 et. al., 2000).

The need to equip health-care = professionals with=20 better ICT skills has been on the agenda for over a = decade

The current widespread use of ICTs in the health = sector has=20 important implications not only for the support of administrative and = functional=20 tasks but also for the actual delivery of healthcare. eHealth = applications offer=20 the potential to cut costs, increase the efficiency with which care is = provided,=20 deliver healthcare services remotely, simplify diagnostic and = therapeutic=20 processes, and enable better care to be provided in the patient=92s = personal=20 environment. At the same time, they can increase patients=92 levels of = awareness=20 and understanding about their own health and encourage a degree of=20 self-care.

The modernization of public service = provision=20 with the use of ICTs is a challenge to existing forms of organization in = the=20 health sector and implies some kind of organizational = change

The modernization of public service provision with = the use of=20 ICTs is a challenge to existing forms of organization in the health = sector and=20 implies some kind of organizational change. In fact, technical = innovation to a=20 large extent depends on organizational innovation in order to achieve = real=20 improvements in efficiency and quality of service. On the other hand, = the=20 translation and implementation of new modes of service provision into = practice=20 is always a serious challenge to management. Still, the potential of = eHealth may=20 fall flat without the active involvement of healthcare professionals and = citizens in the choice, deployment, and assessment of relevant = technologies. For=20 these user groups to participate in a meaningful way in these procedures = they=20 have to be empowered and informed about the benefits ICTs can bring to=20 healthcare delivery.

Appropriate education and training is = a key=20 factor in introducing new methods of work for healthcare service = providers and=20 in empowering citizens to use ICTs to obtain medical=20 information

Human resource development through appropriate = education and=20 training is a key factor in introducing new methods of work for = healthcare=20 service providers and in empowering citizens to use ICTs to obtain = medical=20 information. The nurturing of competencies and skills and the = introduction of=20 new working methods have become key factors in the successful = re-engineering of=20 service suppliers as they transform into agencies providing eHealth = services.=20 Changes to strategies, structures and methods of service delivery are = dependent=20 upon a creative and innovative workforce. The latter needs to adapt its = skills,=20 competencies and, above all, mindsets and attitudes to new ways of = working that=20 are more responsive to the needs of citizens.

Although technical skills are = necessary to set up=20 eHealth applications, the delivery of these applications to citizens = also=20 requires strong inter-personal and managerial skills

The availability of an = appropriate mix of=20 competencies and skills is central to the wider diffusion and take up of = e-health. The care provided by specialized professionals requires = adherence to=20 evidence-based clinical protocols, nursing processes, clinical = judgement, and=20 skills/experience in communications, technology, and computers. Thus, = although=20 technical skills are necessary to set up eHealth applications, the = delivery of=20 these applications to citizens also requires strong inter-personal and=20 managerial skills since quite often providers are required to manage = people over=20 the network. While the technical skills are concerned with the = communication=20 technologies used and the clinical processes enabled by those = technologies, the=20 interpersonal skills are concerned with relationships between system = personnel,=20 providers and patients, and the way in which those relationships are=20 organized.

Furthermore, the notion of =91civil servant=92 in the = health sector=20 needs updating to meet the requirements and opportunities of the = Information=20 Society. The public service ethic remains vital in the sector. However, = in the=20 eHealth era it should incorporate customer relations=92 management = approaches,=20 efficiency measures, and modern management techniques.

For citizens/patients, the ability to = benefit=20 from developments in eHealth critically depends on their familiarity = with=20 technology, their interest in ICTs, andin the Internet in=20 particular

Similarly, for citizens/patients, the ability to = benefit from=20 developments in eHealth critically depends on their familiarity with = technology,=20 their interest in ICTs, and in the Internet in particular. People with = no=20 experience and no interest in computers and electronic devices are = unlikely to=20 be able or willing to seek medical information from Internet sites or = receive=20 care and support at a distance. By contrast, people who already use = computers or=20 are keen on learning about technology and wish to gain some basic = computer=20 skills are more likely to have a positive attitude towards eHealth = applications=20 and benefit from their wider deployment.

Box 1. What competencies and skills are needed for = eHealth?=20 Evidence from survey findings

Skills and competencies in new = healthcare=20 delivery models and new professional roles have been identified as being = crucial=20 to the delivery of even the simplest eHealth services. A number of = surveys have=20 looked into the particular types of competencies and skills that are = considered=20 as being central to the diffusion and take-up of eHealth. Some of the = key=20 findings of these studies concerning healthcare professionals and = citizens are=20 highlighted below.

In the US, the Michigan telepsychiatry = research=20 project identified confidence building to senior administrative staff = regarding=20 capabilities and use of technologies as an important issue in providing = eHealth=20 services (Whitten,=20 P. & Rowe-Adjibogoun,=20 J., 2002).

In the UK, a survey on Primary Care Staff's use of = the=20 Internet in Scotland found that time constraints and concerns that they = lack the=20 necessary skills were highlighted as the most common reasons for not = accessing=20 the Internet (Wilson,=20 1999).

A survey on nurses=92 responses to telemedicine found = that nurses=20 need to obtain technical skills, on how to install, calibrate and = operate=20 equipment, as well as to recognize and fix technical problems. Also, = they need=20 training in team building so that project nurses are able to build and = develop=20 problem-solving skills as a group (Dansky=20 et al.,1999). Furthermore, awareness on a nurse=92s new role as = "e-nurse" needs to=20 be built among senior management and key nursing managers in order for = them to=20 gain good appreciation and true understanding of what nurses are doing = over the=20 telephone and accept their new role (Larson-Dahn=20 2002). The care provided by the nurse requires adherence to = evidence-based=20 clinical protocols, nursing process, clinical judgement, and = skills/experience=20 in communications, technology, and computers (Richardson,=20 R.J., Schug,=20 S., Bywater,=20 M., Williams,=20 D.L. 2002).

Leadership skills are also recognized as being very=20 important, since the role of a "champion" is considered critical for = getting a=20 new eHealth project off the ground and sustaining interest among = participants=20 when problems occur. (Larson-Dahn=20 2002, Norris 2001). Survey findings suggest that the development of = people-based=20 skills such as cooperation, leadership, and creative thinking are just = as=20 important as - if not more so - than actual technology developments (Ball=20 & Lillis,=20 2000; Silber=20 2003).

In Europe, the SeniorWatch1=20 survey took into account information gathered about computer usage, = skills=92=20 self-assessment and attitudes towards new technologies and came up with = a=20 typology of citizens=92 computer involvement. According to this typology = the=20 majority of older citizens (over the age of 50) (69.7%) have either = advanced IT=20 skills or are familiar with the use of computers, or they are keen to = learn=20 about technology, whereas 31.3% do not use a computer or are not keen on = familiarizing themselves with this technology. The proportion of users = drops=20 with age and so does the proportion of computer-literate = individuals.

The=20 evidence from the Flash Eurobarometer survey (2003) shows that among = computer=20 users only a small proportion (23.1%) of people within the European = Union use=20 the Internet to get information about health. A positive attitude about = the=20 Internet is a given amongst young people in contrast to older people = (55.7% in=20 the 15-24 age group vs 26% of people over 55).

Towards a typology of eHealth competencies and skills

The findings of the survey alluded to above suggest = that the=20 required skills and competencies for eHealth can be grouped into the = following=20 broad categories:

  • Basic computer skills: these skills include use of computers, = use of=20 web technologies for accessing portals and for using personalized = services,=20 together with eHealth applications for delivering simple telecare=20 services.
  • Organizational and managerial skills: including the so-called = =91soft=92=20 type of skills similar to the leadership competencies identified = earlier in=20 the paper, which are necessary for the effective development and = delivery of=20 eHealth services. These skills are necessary for dealing with new=20 organizational structures, new service delivery models, changes in = working=20 methods, new job roles, etc.
  • In-depth understanding of the functional capabilities of eHealth=20 technologies and applications: this encompasses the ability to = have a=20 thorough understanding of how eHealth applications such as = integrated=20 patient management and electronic health records, epidemiological = networks,=20 telecare and independent living devices and services, etc., fit into, = and are=20 an integral part of, the formal healthcare delivery system.
  • In-depth understanding of legal, ethical, and economic issues = surrounding=20 eHealth: this refers to the necessary knowledge and capabilities = that need=20 to be acquired in order to manage the relations between the different=20 stakeholders in an eHealth environment, such as identifying their = rights and=20 obligations, defining service level agreements, understanding the = problems=20 surrounding the security and confidentiality of personal and health = data, ways=20 of preventing and/or dealing with malpractice, etc.

Note that the proposed grouping intentionally does = not include=20 advanced technical skills such as information management, health = informatics,=20 software design, etc. These skills can be obtained formally and nowadays = are the=20 subject of specific postgraduate courses designed specifically for the = needs of=20 healthcare professionals.

The above grouping places particular emphasis on the = =91soft=92=20 types of skills required as opposed to the more formal =91hard=92 type = of advanced=20 computer and technical skills. This is because, as often demonstrated in = surveys=20 and case studies, the former are often accountable for the weak = communication=20 links and information flows among actors within the system. In addition, = the=20 above categorization of skills and competencies suggests that some types = of=20 skills, such as basic computer skills, the understanding of = complementarities of=20 eHealth and traditional healthcare practice, and their legal and ethical = implications, should be generic for all user groups, while other types = are more=20 specific to individual application areas of eHealth.

eHealth competencies and skills are = particularly=20 necessary in relation to four major eHealth application areas: public = health=20 policy, information services, patient management and telecare/ = independent=20 living services

eHealth competencies and skills are particularly = necessary in=20 relation to four major eHealth application areas (including their = application=20 sub-areas):

  • Public Health Policy & Prevention: this refers to the = collection of=20 healthcare event, environmental, and socio economic information that = enables=20 data mining for healthcare strategy planning. Essential skills for = healthcare=20 professionals involved in this area include the ability to understand = the=20 functional design and use of personalized web services as well as the = ability=20 to understand the structure and information needs of Public Health = Policy and=20 Prevention in order to come up with new algorithms to fit in new types = of=20 data.
  • Information services to citizens: these encompass activities = providing=20 information to citizens on issues such as good health and lifestyle = advice and=20 empowering them to know when professional help is required, and where = and how=20 to obtain it. Essential skills for healthcare professionals involved = in this=20 area include the ability to contribute to the structuring and updating = of=20 citizen information services and to the functional design and use of=20 personalized web services.
  • Integrated Patient Management & patient health records: these = concern=20 activities surrounding the efficient and secure sharing of information = between=20 health and social care professionals and the establishment of an = environment=20 to provide support for integrated client case management. Essential = skills for=20 healthcare professionals involved in this area include the design and = use of=20 evidence-based eHealth clinical protocols, the ability to understand = the=20 structure and functional capabilities of integrated patient management = systems=20 and patient health records, the operation, updating and maintenance of = Integrated Health records, and the efficient management of personal = and health=20 information security and confidentiality.
  • Telecare & Independent living services. These comprise=20 tele-consultations, telehomecare, vital signs monitoring, and services = for the=20 elderly and disabled that support independent living. Essential skills = for=20 healthcare professionals involved in this area include basic technical = knowledge on how to operate telecare and independent living services, = ability=20 to form telecare and independent living Service Level Agreements with = third=20 parties, ability to evaluate the equipment and services delivered, and = also=20 the management of personal and health information security and=20 confidentiality.

The way forward: Recommendations for the future of eHealth=20 education

One of the principal barriers to the adoption of = telecare is=20 the resistance of health professionals - primarily doctors - to the use = of new=20 technologies in their daily practice. Survey findings confirm that the = inability=20 of healthcare staff and healthcare professionals to accept and manage = change is=20 seen as a major blockage in implementing eHealth (Richardson,=20 et al., 2002). Health professionals in general are averse to using high=20 technology equipment when treating patients, especially if treatment = takes place=20 from a distance. Often, they perceive the implementation of the service = as a=20 threat to their authority. From another perspective, health = professionals find=20 that education and training in ICTs do not fit in with their busy = schedule and=20 could in no way substitute for the personal relationships they develop = with=20 patients. In the UK, for example, doctors argue that in the fourth and = fifth=20 years of their medical training and in their first years as junior = hospital=20 doctors there is no time for training in ICTs because priority is given = to=20 clinical work and it is in practice very difficult to fit in training on = =91fancy=20 ICT systems=92 (Mansell=20 and Curry,=20 2002).

One of the primary barriers to the = adoption of=20 telecare is the resistance of health professionals the use of new = technologies=20 in their daily practice

For many years, the inclusion of IT skills in the = training of=20 healthcare professionals has been a low priority in most countries. This = approach has caused significant discrepancies in the health system since = the=20 on-going under-investment in professional education and training has = been=20 occurring in an environment characterized by rapid technological and=20 organizational change. Today, the introduction of medical informatics = onto the=20 curricula of medical schools at both undergraduate and postgraduate = levels is=20 gaining more and more ground, as it is becoming widely recognized that = the=20 ability of physicians to use ICTs is vital for the effective management = of=20 medical information. Courses in this area are designed to equip medical = students=20 and other health professionals with the necessary formal informatics=20 competencies that will allow them to function as users and producers of = medical=20 data. Internet technology is often used in medical training and in the = teaching=20 of health informatics as it allows better communication between = participants and=20 better support for students. The primary goals of such courses include = (Parry=20 et al., 2001):

  • Raising health-care professionals=92 understanding of health = informatics and=20 computer technology, including the effective use of common software,=20 communication tools, and some of the concepts underlying the use of = computers=20 in healthcare.
  • Providing academic recognition of informatics skills by awarding a = diploma.
  • Developing a network of expertise, and
  • Reaching people working in relatively remote environmental=20 settings.

However, =91soft=92 types of skills are equally, if = not more,=20 important for the transformation of the healthcare system into an = eHealth=20 system. Therefore, an important prerequisite for engaging more and more=20 professionals in formal training in health informatics is first to raise = their=20 awareness of the potential of ICTs and adjust existing mindsets and = attitudes to=20 the transforming norms and practices in healthcare delivery. In other = words,=20 apart from basic computer skills, health professionals need to be = provided with=20 the necessary education and training that will allow them to understand = the=20 functional capabilities of eHealth technologies and applications as well = as=20 their legal, ethical, and economic implications in order to have at = least some=20 input into technology choice and assessment. Furthermore, people-based = skills,=20 such as co-operation, leadership, and creative thinking are critical for = inspiring participants and sustaining their interest at turbulent times. =

An important prerequisite for = engaging more and=20 more professionals in formal training in health informatics is first to = raise=20 their awareness of the potential of ICTs and adjust existing=20 mindsets

Continuing medical education activities need to = endorse this=20 approach. In the same way as other professionals (e.g. engineers,=20 industrialists) deliberately enrol in postgraduate training in order to = develop=20 the key technical, organizational, and administrative competencies that = they=20 need in order to be able to deliver value-added services to customers, = health=20 professionals also need to empower themselves with the necessary = knowledge of=20 health informatics as well as with an essential understanding of the = broader=20 functional, legal, ethical, and economic implications of eHealth. More = training=20 programmes addressed to all groups of health professionals - doctors, = nurses,=20 allied healthcare professionals- should be designed along these lines. = The=20 importance of eHealth and the variety of eHealth services need to be = explained=20 through concrete examples so that the full benefits are appreciated and = key=20 messages are delivered to multi professional groups. Multimedia and = web-based=20 technologies can effectively support the delivery of such training = schemes and=20 establish a user friendly interoperable systems infrastructure for = eHealth=20 education.

Keywords

E-health,=20 skills,=20 competencies,=20 education,=20 training,=20 patients,=20 healthcare=20 professionals

Acknowledgements

This paper is based on research funded by the IPTS/ESTO Project on=20 =91Prospecting eHealth in the context of a European Ageing Society. = Quantifying=20 and qualifying needs=92.

We would like to thank our project partners for their informative = input and=20 advice.

Note

1. The SeniorWatch project launched a pan European survey of elderly = people=20 in Europe relating to eHealth and telemedicine issues. Fieldwork was = carried out=20 by national organizations in all European Union Member States. = Geographically=20 and socio-demographically stratified random sampling was used, with=20 computer-assisted telephone interviews. The interviews were conducted in = June=20 and July 2001. Altogether 9661 interviews were performed. The cases were = weighted according to the share of the population the respective age = groups=20 represent of the older population in each European = country.

References

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Contacts

Anastasia Constantelou, University of the Aegean, Chios, Greece

Tel.: +30 227 10 354 61, e-mail: a.kostantelou@fme.aegean.g= r

Vasiliki Karounou, National Technical University of Athens, = Greece

Tel.: + 30 (210) 77 214 50, e-mail: karounou@netmode.ntua.gr<= /A>

Marcelino Cabrera, IPTS

Tel.: +34 95 448 83 62, fax: +34 95 448 83 39, e-mail: marcelino.cabrera@jrc.es<= /A>

About the authors

  • Dr Anastasia Constantelou holds a PhD in Science and = Technology=20 Policy Studies from SPRU, University of Sussex. She has been = consultant to the=20 OECD and Research Fellow at the Institute for Computer and = Communication=20 Systems (ICCS), National Technical University of Athens. She has = recently been=20 appointed as Assistant Professor of Innovation Management at the = University of=20 the Aegean. Her research interests focus on the economics of science = and=20 technology, innovation policy, and the socio-economic implications of = the=20 information society.
  • Vasiliki Karounou has degrees in Business Administration, = Applied=20 Statistics and Systems Analysis. She has been actively involved = in=20 various projects and has held job positions with responsibilities in=20 information systems development in the private and the public sector. = Since=20 1992, she is working in the area of health informatics as a research = associate=20 at the National Technical University of Athens. Currently she is = working as=20 independent consultant on e-health issues for the Greek Ministry of = Health,=20 the Healthcare Region of Ionian Island and the Hellenic Infectious = Diseases=20 Control.

Contents=20 Report 81

About The=20 IPTS Report

Subscriptio= ns

E-Mail: ipts_secr@jrc.es

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charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.jrc.es/home/report/iptsreport/vol81/english/interior.css A:link { FONT-WEIGHT: bold; COLOR: #4583c0; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-DECORATION: none } A:visited { FONT-WEIGHT: bold; COLOR: #0396dc; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-DECORATION: none } A:hover { FONT-WEIGHT: bold; COLOR: #3366cc; TEXT-DECORATION: none } A.location { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.location:link { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #333366; TEXT-DECORATION: none } A.location:visited { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #003366; TEXT-DECORATION: none } A.location:hover { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #ffffff; TEXT-DECORATION: none } A.location:active { FONT: bold 11px Arial, Helvetica, sans-serif; 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FONT: = bolder 12px Verdana, Arial, Helvetica, sans-serif; VERTICAL-ALIGN: = middle; COLOR: #d28048; BACKGROUND-REPEAT: no-repeat; WHITE-SPACE: = nowrap; TEXT-ALIGN: left; TEXT-DECORATION: none } .head4tables { PADDING-RIGHT: 5px; LIST-STYLE-POSITION: outside; LIST-STYLE-IMAGE: = url(../images/bullet0.jpg); PADDING-BOTTOM: 3px; MARGIN: 2px; FONT: = bolder 12px Verdana, Arial, Helvetica, sans-serif; VERTICAL-ALIGN: = middle; COLOR: #336699; BORDER-BOTTOM: #cccccc 1px solid; = BACKGROUND-REPEAT: no-repeat; WHITE-SPACE: nowrap; TEXT-ALIGN: left; = TEXT-DECORATION: none } .head5tables { BORDER-RIGHT: #a6c4e1 1pt solid; PADDING-RIGHT: 3px; BORDER-TOP: = #a6c4e1 1pt solid; PADDING-LEFT: 3px; PADDING-BOTTOM: 3px; MARGIN: 2px; = FONT: bold 11px Verdana, Arial, Helvetica, sans-serif; TEXT-TRANSFORM: = none; BORDER-LEFT: #a6c4e1 1pt solid; COLOR: #3366cc; TEXT-INDENT: 0px; = PADDING-TOP: 3px; BORDER-BOTTOM: #a6c4e1 1pt solid; BACKGROUND-COLOR: = #e9f1f5; TEXT-ALIGN: center } .listanormTablas { BACKGROUND-POSITION: 5px center; PADDING-LEFT: 25px; BACKGROUND-IMAGE: = url(../images/bullet2.jpg); FONT: 11px Verdana, Arial, Helvetica, = sans-serif; MARGIN-LEFT: 7px; TEXT-TRANSFORM: none; CLIP: rect(auto auto = auto auto); COLOR: #336699; BACKGROUND-REPEAT: no-repeat; TEXT-ALIGN: = left } H1 { BACKGROUND-POSITION: -4px -2px; MARGIN-TOP: 9px; PADDING-LEFT: 5px; = FONT-WEIGHT: bold; FONT-SIZE: 15px; BACKGROUND-IMAGE: = url(./images/h1.jpg); TEXT-TRANSFORM: none; WIDTH: 650px; COLOR: = #336699; BACKGROUND-REPEAT: no-repeat; FONT-STYLE: normal; FONT-FAMILY: = Verdana; FONT-VARIANT: normal; TEXT-DECORATION: none } H2 { FONT-WEIGHT: normal; FONT-SIZE: 13px; WIDTH: 550px; COLOR: #336699; = FONT-FAMILY: Verdana; TEXT-DECORATION: none } H3 { BACKGROUND-POSITION: 2px 0px; PADDING-LEFT: 20px; FONT-WEIGHT: bold; = FONT-SIZE: 13px; BACKGROUND-IMAGE: url(./images/h3.jpg); WIDTH: 550px; = COLOR: #336699; TEXT-INDENT: 0px; BACKGROUND-REPEAT: no-repeat; = FONT-FAMILY: Verdana; TEXT-DECORATION: none } H5 { BACKGROUND-POSITION: 1px 50%; 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= FONT-WEIGHT: bold; FONT-SIZE: 11px; BORDER-LEFT: #a3c6e9 1pt solid; = COLOR: #006699; BORDER-BOTTOM: #a3c6e9 1pt solid; FONT-FAMILY: Verdana, = Arial, Helvetica, sans-serif; BACKGROUND-COLOR: #e0ebf5; = TEXT-DECORATION: none } SELECT { BORDER-RIGHT: #006699; BORDER-TOP: #006699 1pt solid; FONT-WEIGHT: = bold; FONT-SIZE: 11px; RIGHT: 1px; LEFT: 1px; BORDER-LEFT: #006699; = CLIP: rect(1px 1px 1px 1px); COLOR: #006699; BOTTOM: 1px; BORDER-BOTTOM: = #006699; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; TOP: 1px; = BACKGROUND-COLOR: #d9e1f0; TEXT-DECORATION: none } TD { FONT-WEIGHT: normal; FONT-SIZE: 11px; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-DECORATION: none } .darktable { FONT-WEIGHT: normal; FONT-SIZE: 10px; COLOR: #336699; FONT-FAMILY: = Verdana, Arial, Helvetica, sans-serif; BACKGROUND-COLOR: #e1e9f0; = TEXT-ALIGN: center; TEXT-DECORATION: none } .darktable2 { FONT-SIZE: 10px; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = BACKGROUND-COLOR: #e9f1f5; TEXT-DECORATION: none } .darktable3 { FONT-WEIGHT: bold; FONT-SIZE: 11px; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #ffffff; TEXT-ALIGN: center; = TEXT-DECORATION: none } .darktable4 { FONT-SIZE: 10px; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = BACKGROUND-COLOR: #f8fbfc; TEXT-DECORATION: none } .darktable5 { FONT-WEIGHT: bold; FONT-SIZE: 12px; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #e1e9f0; TEXT-ALIGN: center; = TEXT-DECORATION: none } .bordetablacontenido { VERTICAL-ALIGN: middle; BORDER-LEFT: 1pt; LINE-HEIGHT: 13px; = LETTER-SPACING: 1px; BACKGROUND-COLOR: #dddfca; TEXT-ALIGN: left } .bordetablatop { BORDER-BOTTOM: #b1ceeb 1pt solid } .menubody { FONT-WEIGHT: bold; FONT-SIZE: 11px; BORDER-LEFT: #b1ceeb 1px solid; = COLOR: #004986; FONT-FAMILY: Arial, Helvetica, sans-serif; = BACKGROUND-COLOR: #eff7ff } A.menu { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu:link { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986; TEXT-DECORATION: none } A.menu:visited { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu:hover { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #cc9900; TEXT-DECORATION: none } A.menu:active { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986; TEXT-DECORATION: none } A.menu2 { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu2:link { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #1379c9; TEXT-DECORATION: none } A.menu2:visited { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu2:hover { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #cc9900; TEXT-DECORATION: none } A.menu2:active { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986; TEXT-DECORATION: none } .menuele { PADDING-LEFT: 10px; MARGIN-LEFT: 15px; BORDER-BOTTOM: #b1ceeb 2px solid } UL { PADDING-LEFT: 27px; MARGIN-LEFT: 20px; WIDTH: 545px; COLOR: #336699; = LIST-STYLE-TYPE: square; TEXT-ALIGN: justify } LI { PADDING-LEFT: 5px; FONT-WEIGHT: normal; FONT-SIZE: 11px; MARGIN-BOTTOM: = 5px; MARGIN-LEFT: 5px; VERTICAL-ALIGN: top; WIDTH: 450px; COLOR: = #336699; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = LIST-STYLE-TYPE: square; TEXT-ALIGN: justify; TEXT-DECORATION: none } .boxalineado { BORDER-RIGHT: #e1e9d9 2pt solid; PADDING-LEFT: 5px; FONT-WEIGHT: = normal; FONT-SIZE: 11px; MARGIN-LEFT: 5px; COLOR: #336699; = BORDER-BOTTOM: #e1e9d9 2pt solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #e1e9f0; TEXT-ALIGN: justify; = TEXT-DECORATION: none } .centrado { PADDING-LEFT: 5px; FONT-WEIGHT: normal; FONT-SIZE: 11px; MARGIN-LEFT: = 40px; WIDTH: 450px; COLOR: #336699; FONT-STYLE: italic; FONT-FAMILY: = Verdana, Arial, Helvetica, sans-serif; TEXT-ALIGN: center; = TEXT-DECORATION: none } H4 { BACKGROUND-POSITION: 2px 0px; 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