Electronic medical publishing: We’re not in Kansas anymore

Some day, we might say it all started at the BMJ.

Beginning with the first issue of 2010, clinical research articles in the BMJ print version are limited to structured 1-page summaries. The full text of these articles are available online and are accompanied by a host of additional features including tables and figures, commentaries, blogs, videos, rapid response tools, and podcasts.

For the readers, this is an abrupt shift, but Dr Fiona Godlee, BMJ Editor, says the change process was cautious and paced. “We have known for some time that the needs of authors and readers are different. Authors want length and lots of space, while print readers are likely to read only research abstracts.” Thus, the BMJ editorial staff concluded that original research belongs online, in an open-access format, with no word-limit restrictions, and alongside extensive backup content – a publication strategy that frees up more space in the print journal for educational content, columns, and reviews.

Is the BMJ approach an anomaly, or the start of a new trend in medical publishing? Albeit an unscientific sample, we interviewed several editors and publishers, who suggest that print versions of most journals, except perhaps for certain speciality journals, will remain intact for the foreseeable future. However, there was universal agreement among those interviewed that journals are substantially expanding the amount of content provided online. According to Dr David Hughes, Managing Director of Expert Reviews in Pharmacoeconomics and Outcomes Research, “There is an increasing need to augment articles in a more interactive way – to make the terrain less flat.” At the same time, he notes that a fixed role remains for print journals, for example in underdeveloped nations.

Dr Christine Laine, a member of the Secretariat of the International Committee of Medical Journal Editors (ICMJE) and Senior Deputy Editor of the Annals of Internal Medicine, notes that the publishing world is watching closely to see if the BMJ experiment takes off. Says Laine, “This change certainly fits with the realities of practising physicians, whose biggest pressures are related to limited time, including limited time to read medical journals.” The change also reflects current ‘green concerns’ related to paper, printing, and transportation (the reduction of which, serendipitously, translates into financial savings for journals likely to be deprived of print advert revenue). Although Laine and others have found that readers still want to ‘hold the paper’ when they perform in-depth reading, they also think that e-readers like the iPad will become the next norm. According to Laine, “People tend to use print when they are sitting down reading something in-depth, and electronic information when they are looking in a more hurried manner.” In other words, we have not yet found the e-technology that will force that final step away from the printed page.

However, Hughes believes that BMJ’s ‘hybrid’ content is well-suited to its new publication plan. That said, he indicated that format might be unfavourable for other publications or article types – such as the comprehensive reviews favoured by Dr Hughes’ publication, which would not translate well in abbreviated form.

Dr Gregory Curfman, Executive Editor of the New England Journal of Medicine (NEJM) believes that rapid turnaround is one absolute benefit that online publication offers to both researchers and journals. Says Curfman, “To keep information from the health care community simply because the printing press has not yet run does not make a lot of sense to me.” However, Curfman also believes that a ‘tipping point’ has not yet been reached where researchers will be satisfied with online publication only; authors still want the sensory experience of being able to see and hold their published work.

Christopher Carswell, Editor-in-Chief of PharmacoEconomics, offers a more cautious view of fast-track publication. He is concerned that it would be impossible for editors and peer reviewers to adequately review or revise a clinical study or health economics model under extremely tight timelines. Along similar lines, Laine warns of the need for increased editorial vigilance once online content grows and word limits disappear. If journals publish articles online without sufficient editorial input, says Laine, “this will do a disservice to the readers, who really need to understand the methodological details of the study.”

Laine cites the authorship burden imposed by space limitations when dealing with complex research methodologies such as meta-analyses or systematic reviews. Carswell agrees, and emphasizes that online access enables readers to more closely review and understand the design and content of health economics models. Says Carswell, “Whether it is a standard Markov decision tree or a regression, you just cannot include that level of detail in a printed paper. This is an effort to increase transparency.” Of interest to HOC readers, Carswell also mentioned that the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has recently implemented a task force to develop standardised guidelines for health economics and outcomes research publication preparation and submission.

Excluding these caveats, however, publishing professionals agree that making more content easily available online is a positive step forward. Curfman and others note that online readership is swelling, even as print readership shrinks somewhat. The BMJ experiment is into its fourth month, and Godlee notes that, despite some concerns expressed during the transition period of the last couple of years, not a single complaint has been registered since the new format’s introduction.

What’s next for BMJ online? How about brief commentaries from authors, as well as full access to the peer reviewer-to-author communications? In addition, the BMJ editors hope to provide authors with the bandwidth required to publish all of their data online.

Although Hughes expresses some sadness that the increased computerisation of our medical literature might lead to the death of activities such as perusing the actual journals in an actual library, he is happy to acknowledge that the benefits of serendipitous browsing might extend to the online universe.

According to Laine, no matter what course is taken, the top priority for editors should remain the same. “We need to focus on publishing papers with the potential to effect change in how we care for patients, educate physicians, or set the agenda for future research.” At the same time, to hold onto and even encourage greater readership, it is imperative for publishers to try and anticipate how physicians will use information 5 to 10 years from now. Laine says, “We need to try to be more forward looking, as opposed to always playing catch-up.” If this is the case, the next few years in the medical publishing industry should definitely be interesting

Saying it in cyberspace: a guide to successful blogging and twittering

Got opinions to share? Insights? Information? The Web 2.0 revolution makes it easy to get the word out, build a professional profile, and make connections.

If you don’t want space restrictions to cramp your style, free platforms like WordPress or Blogger let you post your thoughts in a cyber-diary format. Looking for a shorter, more interactive way to communicate? Use Twitter to send out brief ‘tweets’ of information, akin to those surreptitious notes you used to pass to friends during history class.

Ready to start? Keep these tips in mind.

Upfront advice

• Decide what niche you want to fill. Don’t twitter or blog just for the sake of seeing your name online. Instead, become a source your readers or followers value, whether it’s for the latest industry news, a quick hit of humour, or your take on emerging trends.

• Get the go-ahead from your employer if you plan to talk shop online. Find out if there’s a corporate policy for employees who twitter or blog. No policy? Use common sense. Don’t disclose confidential information, be cautious in dishing out criticism, and carefully consider the impact your words will have on your company, its clients, and its shareholders.

• Be professional. Blogging and twittering may be relatively casual forms of communication, but typos, bad grammar, and text-messaging abbreviations won’t impress readers. Similarly, cast a critical eye at your profile. What kind of image does your photo or avatar project? What about your bio?

• Provide full disclosure. Are you representing a particular company or organisation? Being paid to hype a particular product? Make that clear in your profile.

• Use good judgement. Remember that what you publish may end up being read by your boss, your company’s competitors, your local reporter or your mother.

Blogging basics

• Set reasonable goals for how frequently you post, and then follow through. If your readers have come to expect daily posts, they’ll feel miffed if a week goes by without something fresh.

• Pay attention to presentation. A dense wall of text looks intimidating, so use shorter paragraphs to create white space. Is your posting more than 300 words? Subheadings can help to break things up.

• Respect copyright. Just because a photo is online doesn’t mean you can use it without permission. Copyright also applies to words. While it’s okay to quote someone briefly (with attribution), never reproduce more than a few lines of an article without the author’s consent.

• Include relevant links. Give credit where credit is due — and enable your readers to get more details — by linking to any bloggers, websites and articles you mention.

• Turn your blog into a dialogue with readers by enabling comments. If you want to screen them before they’re published, check the ‘moderation’ box in your blog settings, and post your policy as well. Won’t publish anything containing obscenities, for example? Let readers know.

• Follow good journalism practices. Check your facts, name your sources, and avoid anything that might be considered libel, hate literature, or a personal attack.

Twitter tips

• Decide how public you want to be. The default setting will make your tweets visible to anyone. Alternatively, you can restrict them to the people who ‘follow’ you — those who sign up to receive your tweets — by clicking the ‘protect my updates’ option under your account settings.

• Similarly, master the distinction between ‘@’ messages, which are targeted to a specific person but visible to others, and direct messages, which are private communications with a particular follower.

• Keep your tweets short. Twitter sets a limit of just 140 characters per message. That doesn’t leave lots of room for context, so re-read your tweet before you hit ‘update’ to make sure it can’t be misinterpreted.

• Don’t swamp your followers with constant tweets. You’ll quickly turn people off if you deluge them with hourly updates.

• Consider including hash tags/pound signs to make your tweet easily searchable.  Twittering about recent industry developments, for example? Include the hash/pound sign (#) followed by ‘pharma.’

• Be selective in who you follow. Time is a precious commodity, so don’t feel obliged to follow everyone who follows you. If you decide to stop following someone, no apology is necessary — unless it’s family or a close friend, of course.

How to hold on to your web visitors

If you Google for ‘website’ and ‘traffic’ you’ll be inundated with miracle cures to increase visitors to your site. It will then take you roughly three days to sort out the ‘useful’ material.

But there are several ways to increase the number of visitors to your site, although that’s only half the battle. The real skill is being able to keep visitors coming back.

If you think this is a job for the tech-guys in your company, then think again. Getting web visitors to come back to your intranet site is just as important as your external internet, if not more so. Your department’s intranet is a key medium for communicating to your staff and it should be the first place they visit when looking for resources and information about your company and the products and services it offers.

I’ve set up blogs for heads of departments, created a presentation and sales aid library for pharmaceutical personnel, developed an interactive online training course and even created a photo gallery for a staff party. Here’s what I’ve learned and some of the services your website can provide:

• Presentations or videos of new products or initiatives
• Newsletters and articles
• RSS feeds or blogs
• A calendar of upcoming events
• Daily weather reports and stock quotes
• Feedback mechanisms – forms, forums and debating facilities
• Podcasts for iPods, PDAs or Blackberrys
• Thoughts for the day and favourite quotes
• Free fun stuff such as competitions, postcards, video clips and games

If you would like any more information, advice or to talk about how we can develop your intranet site to gain maximum exposure feel free to drop me an email at duncan.dibble@rxcomms.com.

Is there a place for healthcare blogs?

Weblogs, or Blogs, have been around for about a decade. Generally viewed as quirky or even anarchic, they may now be gaining a new respectability and power … as evidenced by their influence in bringing about the defeat in US elections of pro-Iraq-war Democrat, Joe Lieberman.

Blogs are also playing a more mainstream and credible role in healthcare. There’s less of what The Economist calls some bloggers’ “vicious, shrill and sanctimonious” commentary. Indeed, Jerome Groopman, MD, in his popular recent book How Doctors Think, contends that many physicians are guided by stereotypes that may shut out possibilities that might contradict their preconceptions. His prescription: a heavy dose of heuristics – stimulating interest as a means of furthering investigation. It’s a defence against uncertainty, he believes, that creates a culture of conformity and orthodoxy.

Dr. Alan Adler (pictured) agrees. He is among those who believe that physicians and other healthcare professionals should – in that hackneyed phrase – think outside the box. And one way of doing that, he says, is by tapping into the blogosphere, which is just one part of the broader social network that includes such interactive innovations as YouTube and FaceBook.

Adler, a general internist with a master’s degree in administration, is a senior medical director at Independence Blue Cross, a Philadelphia-based health insurer with more than 9000 employees and upwards of 3 million policy holders.

“What I like about blogs,” he says, “is that they give doctors and other healthcare workers an opportunity to hear unconventional wisdom and to interact with it.” Blogs provide the opportunity to interact with additional innovative and creative minds outside the usual work environment. Further, he believes, blogs provide two-way communication in which mainstream healthcare professionals can add to the knowledge of bloggers – thereby creating balance.

While those bloggers don’t stand much of a chance in bringing radical change to a healthcare system that is complicated by agendas, special interests, and hierarchies, Adler believes that they can produce incremental change by forcing those in the mainstream to explore new or unusual tributaries.

At a time when healthcare is indeed becoming less hierarchical, blogs serve to speed up the move towards egalitarianism: patients armed with unconventional wisdom challenging the conventional variety. What will further help those patients sort the wheat from the chaff, says Dr. Adler, is a proposed Healthcare Blogger Code of Ethics.

In an article in Managed Care magazine (July 2007), Dr. Adler noted that “if you’ve only heard of blogs from the consumer press, you might think they consist entirely of blather about pop culture and outrageous fulminations from the political far left and far right. But the fact is, there are many serious, well-written blogs, and the major healthcare issues of the day are discussed on blogs more extensively than they are or could ever be discussed in academic articles.”

There are an estimated hundreds of healthcare blogs. Here is a list of some; and some of these will lead you to others you might want to look into:

• NHS Blog Doctor
• DB’s Medical Rants
• The Antidote: Counterspin for Healthcare
• Blogborygmi
• Trust me, I’m a Doctor
• Health Affairs
• Pharmalot
• Healthcare Policy and Marketplace Review
• The Healthcare Blog
• Medical Blog Network
• Master Blog
• Healthcare Blogger Code of Ethics

Prevention information on the Internet

Benjamin Franklin said “An ounce of prevention is worth a pound of cure”. Perhaps the best way to reduce errors in medicine, then, is to prevent the need for medical treatment in the first place.

Here are some websites dedicated to health and prevention:

A report from the Centers for Disease Control and Prevention (CDC) entitled “An Ounce of Prevention… What Are the Returns?” can be found here. The report outlines 19 strategies and demonstrates how spending money to prevent disease and injury and promote healthy lifestyles makes good economic sense. Each prevention strategy was evaluated based on the health impact and costs of the related disease, injury or disability, and the effectiveness and cost-effectiveness of the prevention strategy.

The CDC also maintains The Prevention Guidelines Database. It contains all of the official guidelines and recommendations published by the CDC for the prevention of diseases, injuries and disabilities, and was developed to allow public health practitioners and others to quickly access the full set of guidelines from a single point, regardless of where they were originally published. You can search the database or choose from a comprehensive list of topics sorted by title or by date.

The Office of Disease Prevention and Health Promotion (ODPHP), which is part of the US Department of Health and Human Services, developed a programme called “Put Prevention into Practice” or PPIP. In 1998, the project was transferred to the Department’s Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research). PPIP, which can be found here, is now a part of AHRQ’s integrated programme in clinical prevention, which includes support for the US Preventive Services Task Force (www.ahcpr.gov/clinic/uspstfab.htm) and ongoing research on the costs, outcomes, and quality of preventive care.

A site entitled “A Pocketful of Prevention”, contains a list of publications and guidelines adapted from a report by the aforementioned US Preventive Services Task Force. The latest version of the popular publication “Guide to Clinical Preventive Services” can be found here.

Another interesting site dedicated to health and prevention is www.healthypeople.gov. One page on their website lists the ten leading health indicators, with corresponding sample resources available from the US Federal government.

(And for more quotes by Benjamin Franklin, be sure to check out www.ushistory.org/franklin/quotable/index.htm.)

Coping with information overload

A little more than a decade ago, if you’d used words like google, blog, spam, email, internet, iPod, PDA, instant messaging, Blackberry (unless referring to the fruit) and e-zines, people wouldn’t have had a clue what you were talking about. In fact, this e-zine would have been almost impossible to produce… with its “home” in the United Kingdom and its editor in the United States.

Today, it’s not just that those items simply exist, but that they are growing exponentially – and creating information overload.

Consider for example a study by Professor Peter Lyman of the School of Information Management and Systems at the University of California, Berkeley; and Professor Hal R. Varian, of that University’s School of Information.

They note that the amount of new information stored on paper, film, and magnetic and optical media has doubled in the past three years. Instant messaging generates 5 billion messages a day, they say, and email generates 31 billion communications annually, or double the number in 2003. That’s 400,000 Terabytes of new information worldwide: a mere 2 Terabytes represents the content of an entire academic research library.

And it’s not that all of this overload has simply replaced paper. The researchers note that it takes 786 million trees to produce the world’s paper supply. Not only that, but more than 90% goes to produce office documents. Worse, it’s said that the average office worker is interrupted every three minutes by a phone call or an email.

How to cope with this avalanche of information without being buried in it?
There are several strategies for getting the information you want, and avoiding what gets in the way of finding it:

• Have a clear purpose
• Plan ahead
• Prioritise
• Don’t be tempted to go down blind alleys
• Eliminate noise and interruptions
• Use email filters
• Use search tools effectively
• Use abstracts, synopses, and executive summaries where possible.

Bruce DeBonis, a senior executive with international financial and advisory services company PriceWaterhouseCoopers, has a personal approach to information overload: “I tell the people who report to me,” he says, “about email and voicemail etiquette: put the action item in subject heading; use voicemail more. Pick up the phone and call; don’t be phone-phobic. Email can be cumbersome if it’s not streamlined and specific.”

Remember Sisyphus, who was forced by the gods to push a huge rock up towards a mountain top whence it would roll back down again? Don’t let information overload get you down. Keep focused and keep cool!

The pros and cons of e-publishing

As recently as 1990 the World Wide Web did not exist, and email was still difficult to use. Even the most optimistic experts could hardly foresee how rapidly the technology and the software would advance. Electronic publishing, or e-publishing, uses the internet to deliver scientific articles and other content to readers.

But e-publications are not just electronic versions of paper publications – they can be designed solely and specifically for electronic dissemination. Because the technology allows publishers to get information to readers quickly and efficiently, it is causing major changes to the publishing industry, and even has an impact on the way we read.

Pros:

• Open access;
• Rapid publication;
• Lower costs;
• High visibility and international readership;
• Links to articles referenced and later articles that cite the paper;
• Unlimited space for figures, extensive data and even video footage;
• May reduce publication bias; and
• Articles can be widely promoted on websites and by email alerts, etc.

Cons:

• Perceived lack of credibility compared with paper publications, although this is rapidly changing

• Some e-publication houses do not have an adequate peer review process

• Archiving – will these e-publications still be around years from now or will they be lost forever?

Is the end in sight for paper publications? We’re only just beginning to see the effects of e-publishing, and the advantages seem so far to outweigh the disadvantages.