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Physician websites evolve

Daniel Palestrant, M.D.
Daniel Palestrant, M.D.

By Christopher Guadagnino, Ph.D.

The challenge of keeping up-to-date with the staggering growth of medical information has never been an easy one. As physicians work longer hours to meet increasing overhead costs, busy schedules make it even more challenging to stay current with peer-reviewed clinical journals, conferences and other traditional venues.

New Web-based technologies are being adapted specifically for use by physicians that may transform the manner in which information is disseminated in the physician community, offering a level of efficiency and interactivity that has never before existed. These innovative online trends and technologies – which many refer to using the buzzword “Web 2.0” – go beyond static text and document links, and are characterized by greater user participation, multimedia content, distribution of user-generated content across online social networks in seconds, integration of content across Web sites, and content that is accessible across a range of portable media devices.

Private, for-profit companies are emerging as Web site “platforms,” offering these functionalities exclusively to physician users, with some focusing primarily on clinical information exchange, some brokering broader medical news and social content, and others featuring video segments on an array of medical topics. Business models vary among these private Web sites, with some accepting sponsored content and traditional advertising, and others forging “information arbitrage” – a form of data mining partnerships with medical industry, research and financial communities.

These new technologies may, however, complicate the traditional ways of judging the credibility of medical information, e.g., looking at source credentials in peer-reviewed journals or a conference papers, or scrutinizing the research methodology of studies. While these Web 2.0 technologies facilitate rapid access and exchange of medical information, democratizing the promulgation of that information requires more vigilance to vet its credibility and potential bias, as sources may be anonymous and/or have commercial ties to industry that are not immediately apparent.

Medical specialty societies are also starting to roll out Web 2.0 technologies for their members, offering many of the same interactive content features as the commercial Web sites, while touting the added credibility of Web portal content that carries the imprimatur of a professional medical society. The private companies maintain that self-policing of physician users – credibility through corroboration – will ensure the quality of medical information promulgated on their Web sites, while touting the revolutionary capacity of social networking to facilitate discussions of individual clinical cases – or any topic – among thousands of physicians across the country.

As the marketplace of informational physician Web sites expands, the implications of that growth become increasingly important, e.g., how these sites are used; how they should be used; what, if any, real value they add to the multitude of existing information sources for physicians; what the quality is of information available from them; and what impact any commercial bias of their sources will have on physicians.

Private Sector Web 2.0

Web site developers who target a physician audience focus on how physicians are using online video, blogs (commentary diaries), and podcasting (distributing digital media files over the Internet using syndication feeds for playback on portable media players), according to Physicians and Web 2.0, a white paper released in 2007 by health care market research company Manhattan Research, LLC. A survey by the company estimated that 508,000 physicians are using online video, suggesting an evolving shift from text and image-based content online to that of full-motion video as a preferred format already used by the majority of physicians. The survey also revealed that almost 300,000 physicians are using blogs, and over 25,000 are actively using blogs with professional content.

Podcasting, in contrast with one-time downloadable content on a Web site, uses RSS (Really Simple Syndication – a family of Web feed formats) to allow users to keep up with their favorite Web site content in an automated manner rather than having to check for it manually. Manhattan Research’s survey revealed a growing segment of loyal physician podcast users in 2007 – almost 100,000 strong – almost all of them listening to professional content via the podcasts. Content that physicians find most attractive are timely clinical news, specialty updates and podcasts from the journals they already trust and read, Manhattan Research notes.

Narrowing the definition of a “Web 2.0 physician” to one who posts professional content online or who participates in online communities with other physicians, Manhattan Research’s survey revealed a segment of 245,000 physicians. “Clearly we are beyond the age of the early adopter with regard to physicians and Web 2.0, as physicians are already engaged online in ways far beyond the average consumer today,” Manhattan Research writes.

As Web 2.0 services and applications continue to expand, Manhattan Research predicts features such as smarter and more relevant search engines and syndicated feeds, and sites and social network applications that enable physicians to aggregate relevant journal content, views of what their “trusted” colleagues are talking about online, and filtered clinical news and updates tailored to their level of experience or identified knowledge gaps.

Several companies are now offering a variety of these functionalities. Perhaps most well-known is Cambridge Mass.-based Sermo, founded two years ago by Daniel Palestrant, M.D., as a way to compensate for what he says is the growing isolation of physicians. Because many procedures are now being performed on an outpatient basis and patient volume is further squeezing physicians’ time to round in hospitals, Palestrant says many physicians no longer enjoy the ability to connect with colleagues, exchange clinical opinions or share bedside observations in the hospital.

The Sermo Web site allows its physician-only members – whose credentials must undergo authentication – to create a post that includes an underlying clinical scenario, a discussion of that scenario, and a survey of what other physicians think is going on in the case, says Palestrant. The social networking feature allows a single physician to send that post to a large physician community – currently 41,000 Sermo members – exchanging insights with that community, challenging or corroborating each other’s opinions, potentially accelerating the discovery of emerging trends and providing new insights into medications, devices and treatments, says Palestrant. Those goals represent the primary focus of the site, although posts may be on any subject, including practice management, politics and others, he says.

The social networking feature also allows physicians to build consensus on issues that matter to them, says Palestrant – for example, a physician asked whether others were aware of a New Jersey bill that would require nephrologists in ambulatory renal dialysis facilities to provide a certain amount of free services to uninsured low-income persons, which prompted an outcry of several hundred physicians who weighed in on the issue (the bill ultimately became law last May).

It came as a surprise to Palestrant that the busiest physicians are Sermo’s heaviest users – those age 45 and older outnumbering younger ones by three to one, and some logging on several times a day. Palestrant believes that it is the ability to re-connect with colleagues that is driving physicians to the site: “There are thousands of journals out there, but physicians are using Sermo, not to find out the latest literature on a subject, but to return to the type of discourse they enjoyed during their training,” he says.

The number of case studies and letters to the editor published by journals is declining because they have a low “impact factor,” or likelihood of being cited by other researchers, and there is a growing chasm between physicians in the trenches treating patients and those in academic research, Palestrant maintains. “Sermo is never going to replace peer-reviewed medical literature, but the traditional research and publication process tends to be slow and depends on knowing what questions to ask,” he says. “Sermo’s rapid growth is a strong reflection of the value of case study analysis, especially when it is occurring at the same time as the appearance of case study reports in peer-reviewed journals is contracting,” he adds.

Users of online physician communities like Sermo typically can reference medical literature in their posts and can link any sort of document – text, image, audio or video. While Palestrant guesses that only 10 or 20 percent currently go beyond plain text, he says that will soon change as the company is exploring partnerships with external content providers to offer links to CME resources, much of which is in multimedia format. Sermo also is exploring partnerships with publishers of peer-reviewed clinical literature to allow physicians to import articles and discuss them, he adds.

By harnessing the “power of collective wisdom,” online physician communities allow physicians to exchange new clinical findings and knowledge the minute it is learned and gain potentially life-saving insights from colleagues as they happen, instead of waiting to read about them in conventional media sources, says Palestrant. “The value and credibility of information comes through the volume of corroboration by physicians,” he says.

On the “backend,” Sermo has the ability to aggregate a growing dataset of case reports and feedback information, identify emerging clinical trends, and sell access to that information to clients in government, research, industry and financial sectors – an “information arbitrage” capacity that defines its business model and funds the company, which is free to physicians and has no advertising or promotion. Sermo says it can couple its data in a de-identified way with information about the specialty, place of practice and other demographic information about the physicians who provided it.

Sermo is in the middle of a six-month evaluation agreement with the U.S. Food and Drug Administration (FDA) to allow the FDA/Center for Devices and Radiological Health to explore ways in which physicians can expedite medical product safety surveillance, for example, allowing the FDA to post questions about an adverse event from a recently-approved drug and get thousands of physician responses about occurrence rates and details in a matter of hours.

Sermo also has a multi-year strategic partnership with the American Medical Association, which says it wants to learn more about the nature of online physician communities, the topics commonly discussed there, and the medium’s potential utility as a focus group. The AMA can also post questions and communicate with physicians using the new medium.

Sermo has a similar relationship with market research clients – including pharmaceutical and medical device companies, as well as investment community clients – all of whom can monitor information trends and survey physicians on the site.

Other physician social networking Web sites permit interfaces with consumer audiences. Physicians’ Web Space, for example, touts the ability to use “the sum total medical expertise of its member constituency” to provide consumers with information on their real clinical situations on a fee-for-service basis, according to the company’s Web site. Questions by consumers are relayed into the company’s online physician community anonymously, while physician members participate in targeted discussions, and consumers are e-mailed the combined information of these discussions within 48 hours. Revenue generated from these activities is disbursed to member participants. The company also receives revenue from sponsors.

Physicians’ Web Space also plans to initiate an online medical student mentoring program, in which a third or fourth year medical student each month will have the opportunity to join selected discussions for a four-week rotation.

Physician social networking Web sites are not restricted to clinical subjects, and some are marketing themselves specifically as capable of fostering professional and personal connections, increasing practice productivity, and delivering career and lifestyle opportunities. One example is Seattle-based iMedExchange, currently in “beta” or test mode, and scheduled for official launch in the next month or so, according to Tina Gonsalves, vice president of marketing.

The company’s founders – health care business and IT consultants who work with physicians on technical projects – said physicians who attended only a conference or two each year wanted to continue to be able to interact with their colleagues. Like Sermo, iMedExchange offers the opportunity for physicians to exchange clinical observations, but the company hopes to distinguish itself by featuring forum categories beyond clinical topics, including business of medicine, health IT, financial marketplace, classifieds, and various interest groups, says Gonsalves.

Physician users drive the content of the site, and iMedExchange has recruited over 200 physician advisors who provide feedback on its developing features, and are compensated through stock options. The company is funded by physician investors and is looking at partnering with other content providers, for example, sponsored podcasts by financial services firms for the site’s marketplace forum, says Gonsalves.

“Competition can come from nowhere in the tech community, and online social networks for physicians is a proven idea,” Gonsalves believes. “But it’s a big playground, and physicians can become members of several sites, whether it be primarily for clinical information, or – like iMedExchange – for more social interests,” she adds.

Another physician Web site in beta mode, New York-based The Doctor’s Channel, hopes to distinguish itself by showcasing professionally-produced one- to two-minute video segments as the focal point of physician forum discussions, “condensing the overwhelming amount of information doctors are forced to navigate each day in a creative, informative way,” according to David Best, M.D., MBA, the company’s president.

Videos on the site will feature expert advice from opinion leaders and fellow physicians in 35 medical specialties, created by company’s editorial team, with additional sponsored content supplied by industry and others in the health care community. Subject matter will include information on the latest medical techniques, practice and lifestyle tips from experts in various fields, and a roundup of health and medical news. Videos will be archived, allowing physicians to view at their convenience, and some will offer CME credit, says Best.

Physicians who register on the site can join discussion groups related to their interests, sending and receiving personalized messages, and storing their favorite videos. When viewing certain pharmaceutical company-sponsored videos, physicians can click a link to request additional information or samples from a sales representative, says Best.

The Doctor’s Channel has an editorial board that vets the medical accuracy of the information, and the company has so far produced videos featuring physician experts from academic medical centers including Temple University, Tulane and University of Chicago, says Best.

“This is the age of media snacking. People are getting their information in short blurbs from podcasts and RSS feeds. An overlooked audience is the physician – why not provide them with messages that offer high science, but in a shortened and engaging format for them to learn quickly?” says Best, who compares the experience to reading a journal article abstract, with the ability to read further by clicking on links to full articles or additional information sources.

“I’ve never been a proponent of text-based information exchange. I don’t believe physicians like to sit and type away,” says Best. “Our goal is to be a repository of medical information in one- to two-minute streaming video segments,” he notes. “Talking heads can be dull. We wanted an edgy look and feel to our videos – with music, graphics, changing camera angles. Doctors are human, and they want to enjoy the learning experience,” he adds.

Professional Society Web 2.0

Medical specialty societies are beginning to offer Web 2.0 functionalities to their members, replacing static text with interactive and multimedia content designed to deliver information in a more efficient and engaging manner, according to Maria E. Randolph, MPH, senior associate for Informatics and Quality Improvement for the American College of Physicians – which she says is launching a redesigned Web portal this month. “Physicians are used to being bombarded with information each day. A screen with condensed modules of information and videos makes for a more attractive medium than a list of links to PDF documents. Physicians can give a quick glance, or drill down into more detail if they wish,” says Randolph.

The American Gastroenterological Association (AGA) is planning to launch a members-only online wiki – a collaborative encyclopedia that allows users to create, edit, and link indexed content representing the core curriculum for the specialty, according to J.B. McGee, M.D., assistant dean for Medical Education Technology, University of Pittsburgh School of Medicine, and an editor for AGA’s online journals. AGA members will be able to incorporate online journal content and other information sources into their wiki postings, allowing them to share personal knowledge of how to integrate research findings with their own practices, rather than wait until the next professional conference or journal article, says McGee.

Blogs, or expert-led commentaries with discussion, will also be rolled-out for AGA members who share similar interests, McGee says. Since gastroenterology is a very “visual” specialty, members will be invited to submit their own videos of endoscopic procedures and images of unusual lesions for discussion, he adds.

AGA’s new Web portal will also allow physicians to put together a “personal learning portfolio” that flags learning goals and topics they want to stay abreast of, and points them to relevant content modules to enable them to earn CME and maintenance of certification credit, says McGee. The portal will also offer a self-assessment component containing questions similar to those found on board certification exams, along with links to journal articles and other information that answers the questions, adds McGee.

To help its members efficiently locate information targeted to their specialty area, the American College of Surgeons (ACS) is in the process of redesigning its Web portal around 12 “communities,” each of which includes access to peer-reviewed journals, discussion forums, and multimedia content vetted by the ACS’s editorial board, according to George Sheldon, M.D., editor in chief of the Web portal, and former ACS president.

When a member logs on, the screen will be “branded” to the community and interest areas they’ve identified, customizing features and RSS feeds that are most relevant to them, such as audio/video podcasts, NIH videocast alerts, and scrolling headlines from PubMed – the search engine for MEDLINE’s database of medical research articles, says Sheldon. A surgeon can quickly find what atlas he or she should look up for a surgery they will perform, and can download a video of the operation onto a portable MP3 device, he adds.

The portal will also offer “selected readings in surgery” – updated literature reviews prepared by ASC’s editorial board and customized for the college’s various communities, adding further efficiency to physicians’ online experience, says Sheldon.

Some surgeons are storing records of their cases on PDAs and may import them to a secure case log on the ACS portal. Perhaps in the future, Sheldon says, the portal will build in the capacity for a surgeon to benchmark his or her case data – e.g., by success, wound infection, and mortality rates – by linking it to national databases and displaying clinical literature relevant to that type of procedure, “closing the feedback loop by putting the reading right there with the numbers,” Sheldon adds.

Bias and Validity Implications

The typical profile of the heaviest physician users of Web 2.0 has important implications, according to Manhattan Research. Physicians who post professional content online tend to be older than the average physician, representing those with something pertinent and relevant to say, while physicians based in academic medical centers are also significantly more likely to participate in online physician communities. These physicians are much more likely to use the Internet between and during patient consultations, while also being significantly more likely to visit pharmaceutical corporate sites, use “e-detailing,” visit service portals, and exchange email with pharmaceutical companies. “Understanding this audience is critical to understanding how to impact the minority that often influences the majority of other physician readers online today,” Manhattan Research notes.

The potential of Web 2.0 modalities is not lost on the pharmaceutical industry, as online physician social networking can be a potent way to promote an idea among a large number of physicians in a very short time. With declining return on investment from traditional pharmaceutical company marketing channels, industry must find new ways of reaching physicians and patients, and “the big question for pharma is how Web 2.0 approaches can most effectively be used to meet its marketing and communication challenges,” writes eyeforpharma, a marketing strategy company for the pharmaceutical industry, in a Feb. 2007 report, Web 2.0 – A New Frontier for Pharma? “In a dynamic new world where the Internet itself has become the application and user generated content rules the day85companies must monitor, test, measure and – above all else – participate and find value in social networking opportunities,” the report adds.

The eyeforpharma report cites the opinions of several health technology and pharmaceutical company leaders on what role the industry should play in Web 2.0 physician environments, and how its involvement in social media will affect the industry’s reputation. “Thirty seconds of video can be worth 20 pages of one-dimensional text and in the healthcare arena it can have tremendous impact,” relaying not only facts, but a strong emotional component only available through the use of social media, the report notes, quoting Len Starnes, head of European e-business at Bayer Schering. Emotional portrayals of how consumers feel about a drug, how it has changed their life and what it has meant to them, says Starnes, “can be just as, if not more powerful than the factual information. That’s the revolutionary component of social media.”

Pharma should begin with condition-specific online communities, sponsoring content and sharing information that does not necessarily promote products, according to Unity Stoakes, President of Organized Wisdom, a health care-focused social networking site. One key to success, he says, is recognizing and engaging those “evangelist” physicians – which he calls “health connectors” – individuals who become influential online experts through blogging or other social media mechanisms.

Companies should steer clear of fake blogs, or paying others to generate flattering content, which Starnes warns is counterproductive and could destroy what is left of the industry’s credibility.

It is important for industry to monitor physician wikis to keep abreast of what is being said about one’s company and products, to leverage flattering content and to counter criticism, notes Hedwig Scheck, Manager eBusiness for GlaxoSmithKline in Germany.

Sermo and Pfizer have signed a 15-month deal in October giving Pfizer’s physician staff members access to the site, and Palestrant says it is in similar talks with other drug companies. Any posts by Pfizer’s physicians would be marked with the company’s logo, while the deal allows pharmaceutical companies to test how social media can facilitate interactions between doctors and drug companies.

Palestrant is confident that discussion forum posts by industry physicians, by anonymized physicians with commercial bias, or even by the rogue hacker who might succeed in penetrating sophisticated physician authentication protocols will not erode the credibility of online physician communities like Sermo. “Implicit to the medium is the concept that one physician’s vote isn’t the critical event. The critical event is corroboration within the physician community. No single user’s input will influence the outcome – the preponderance of the community is needed,” Palestrant says. Sermo users also rank their peers’ activity on the site, based on frequency and quality of posts, and view each others’ rankings, he adds.

“Tens of thousands of physicians who are direct employees of the pharmaceutical industry, or have financial ties to the industry, have a right to use Sermo. In our terms of service, they are required to tell the community about those ties. Industry physicians often have the best and most timely information, and physicians are fine with that,” says Palestrant.

The University of Pennsylvania’s Center for Bioethics has partnered with Sermo to investigate issues that accompany online physician social communities, including individual and corporate responsibilities, in what is essentially a new field of clinical informatics. Analysis of that investigation will be published in a series of white papers and journal articles.

The validity of medical information disseminated throughout online physician communities still needs to be studied, as users learn the difference between it and information in a peer-reviewed journal, according to McGee. “The majority of clinical research is industry-sponsored. Only a few dozen people look at content in the peer-reviewed print world before it is published – versus thousands of people in an online physician community,” says McGee, suggesting that the latter venue may even possess superior credibility, particularly when it is run by a professional medical society or an academic medical center with an editorial group to monitor content periodically.

To encourage a greater degree of user responsibility and information reliability, McGee says the AGA is proposing that physicians be required to use their real name for the association’s upcoming online community features, rather than anonymous pseudonyms, as permitted on commercial sites.

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