JMIR's Fast-Track Experiment (Innovations in Scholarly Publishing: Part 1)

As (to our knowledge) the first journal in the world, the Journal of Medical Internet Research (JMIR) started in 2007 to offer a "paid fast-track" (FT) option, where authors pay an extra fee if they require an extra-speedy handling of their manuscript.
JMIR's fast-track package consists of two components:

• a) we make an initial editorial decision within (currently) 3 weeks after submission
• b) after acceptance, we publish the paper within 4 weeks

FT can be purchased at any time during manuscript handling process.
As we made part of the the source code available for OJS, some other journals have started to adopt similar policies, although the details of their policies vary widely.

We see several advantages of this model. First, authors often have deadlines to meet, such as a grant submission deadlines, end-of-grant deadlines (by which grant money needs to be spent), deadlines for promotion & tenure applications, PhD defense deadlines, etc. From our authors who have used the FT option we know that the FT track is widely appreciated, and almost 25% of all authors make use of it. Guaranteeing a rapid decision by the journal is a considerable advantage over the current system, where authors are subjected to unpredictable journal turnaround times.
Secondly, even for authors not in hurry or with insufficient funds who are not opting for the FT, the FT revenue stream helps to keep other fees down. All authors pay a lower Article Processing Fee than what we would have to charge without the FT option.

Thirdly, we think that our FT offering may create a competitive environment where journals become more accountable in regards to their turnaround times, and not only compete for the highest impact factor or the best authors, but on other metrics such as the shortest turnaround times. All this would - in our opinion - help to transform the often sluggish process of scholarly communication and accelerate scientific progress.

Obviously, speeding up processes must be done without sacrificing quality and integrity. Some of the principles we have implemented are

• all reviewers have the same instructions, reminders and turn-around times (2 weeks) for all manuscripts - fast-tracked or not
• reviewers are blinded, i.e. do not know whether or not a manuscript is fast-tracked
• on the decision page, where editors see the reviewer comments and make a decision, the editor also does not see if a manuscript has been fast-tracked or not
• fast-tracking at the decision-making level (promise a) is achieved by sending aggressive email reminders to the editor to assign more reviewers. Editors are asked to make sure that within the first week of submission, at least 2-3 reviewers have agreed to review the paper, so to achieve a rapid decision editors spend more time monitoring reviewer responses and assigning more reviewers if needed.

As other experiments of scholarly innovations which we are undertaking, the experiment is closely monitored, and (to enhance public trust) our peer-review statistics are fully transparent (these are real-time statistics, so they change on a daily basis. The following data cited below are based on the peer-review results as of 2011-07-12, a snapshot is available at WebCite).

To summarize what these data - based on 689 submissions (incl 156 FT submissions) and almost 1000 completed reviews - tell us:

• Fast-tracking works (line 1.3). Fast-tracked articles are on average (median) published over 100 days earlier than non-fast-tracked articles (median time from submission to publication for FT articles 182 days, non-FT: 303 days). Note that these times still may appear long, but these figures include the time authors need to revise their manuscripts (which is on average 3 months per revision)
• No evidence for lighter peer-review of fast-tracked articles (line 4.3a): While cynics have speculated that money-greedy publishers/editors may take shortcuts and favor fast-tracked articles and make decisions in the absence of a sufficient number of reviews, the data at JMIR speak a different language. In the past 4 years or so we sent a total of 519 manuscripts for peer-review, with FT articles receiving MORE peer-reviews (1.96 reviews per article) than non-FTed articles (1.88 reviews). Come to think of it, this is not so surprising, because editors work harder to assign a sufficient number of reviewers, assigning 5.29 (FT) versus 4.50 (non-FT) reviewers to each submission (line 4.1)
• No evidence for preferential treatment of fast-tracked articles (line 3.1): There is also no evidence for an editorial bias - the acceptance rate of articles which have been sent out for peer-review are virtually the same for both tracks: 63% (FT) versus 61% (non-FT).
• FT articles are not rated better by reviewers (line 4.7): If reviewer recommendations (which are made on a scale of A-E) are converted to a numerical scale 1-5, then the mean reviewer recommendation of FTed articles is 2.8 - exactly the same as "normal" articles (it should be stressed that reviewers are blinded regarding the FT status).
• FT articles are more often sent out for peer-review (line 2): Articles which are not within the scope of the journal are not sent out for peer-review - 85.9% of FT articles and 72.3% of nFT articles were sent out for peer-review, indicating a higher proportion of articles which are "out of scope" among the "normal" submissions. Again, it is probably not surprising that FT'ed articles are more often within scope (if someone pays a FT fee he is more likely to make sure that the manuscript is within the scope of the journal, often through pre-submission inquiries). Also, at JMIR it is possible to request fast-tracking of an article after acceptance (to speed up the production process), which also biases these numbers (obviously, all accepted manuscripts were peer-reviewed). Some authors may also wait until the "within scope" decision has been made and peer-review has started before they fast-track the paper.
• The quality of the peer-reviewers is the same (line 4.8a): After peer-review has been completed, the editor may rate the quality of the review on a 5-point scale. There are no differences here: The mean rating is 4.19 for FT'ed article reviews, and 4.10 for non-FTed. We recently also started to ask authors to rate the quality of reviews, but with only 4 ratings in the FT track the sample size is too small to draw any conclusions at this time.

These are preliminary data, but overall they confirm that it is possible to accelerate the publication process without compromising quality, introducing biases, or affecting the integrity of the process. Further evidence could be generated by directly comparing quality metrics (e.g. the number of citations) between FTed and nFTed articles (we don't have time for this, but if anybody is interested in this, we are happy to share the list of FTed articles).

As a next step we are planning to refine the system so that peer-reviewers who have submitted a review on time will receive credits which they can use for the FT fee if they submit something to JMIR or iJMR (we did experiment with paying reviewers directly but the overhead costs for administering these micropayments is too high). This will create a microeconomy with incentives for reviewers ("if I review your paper on time, I'll be guaranteed a more speedy decision-making for my paper when it's my turn to get reviewed") which we hope will accelerate knowledge dissemination and scientific progress.

Next (coming soon): Innovations in Scholarly Publishing Part 2: Preliminary Results of JMIR's Open Peer Review Experiment

Impact Factors of Medical Informatics Journals 2011

(Toronto, June 29th, 2011) The new JMIR (Journal of Medical Internet Research) Impact Factor for 2010 (released in June 2011 by Thomson Reuters Journal Citation Reports) has further increased to an unprecedented 4.7 (5-year impact factor: 5.0). Never before in the history of the impact factor had a journal in the medical informatics category such a high impact factor. JMIR remains the leading journal in the health informatics category, clearly outranking other journals like the runner-up, the J Am Med Inform Assn (JAMIA) (IF 3.1, 5-yr IF 3.9), the Int J Med Inform (IF 2.2, 5-yr IF 2.2), the J Biomed Inform (IF 1.7, 5-yr IF 1.2), or Method Inform Med (IF 1.5, 5-yr IF 1.2).


JMIR also remains the #2 journal in the health sciences & health services research category, with the top journal in that discipline (Milbank Q) having almost the same impact factor as JMIR (IF 4.8). JMIR outranks journals such as Health Affairs (IF 3.8) or Med Care (IF 3.2).
JMIR also outranks established public health journals such as Am J Prev Med (IF 4.1) or the Am J Public Health (IF 3.9) - this is an interesting observation because JMIR has a clear "public health" angle due to the large number of studies evaluating web-based or mobile behavior change programs.
Finally, as an open access journal, we also take pride in the fact that our papers receive more citations than open access articles published in a "generic" open access outlet such as PLOS ONE (IF 4.4). JMIR's impact factor is also higher than all 35 BMC journals except the two BMC flagship journals BMC Med (IF 5.7) and BMC Biol (IF 5.2), which are ranked 12th and 8th in their disciplines. Except for two PLOS Biology journals (PLOS Biol and PLOS PLoS Computational Biology), JMIR remains the only open access journal taking the #1 spot in its discipline.

While everybody in the publishing industry recognizes the limitations of the impact factor as a metric for quality of a journal, these numbers (in addition to our other metrics such as views or tweets, published at http://www.jmir.org/stats/overview) provide an important validation of our editorial work, and of the work of the authors deciding to submit their best work to JMIR to achieve maximum exposure, visibility, and recognition.
We also know from emails and conversations with fellow scientists that JMIR has been and continues to be an inspiration for those seeking to establish new journals independently of large publishers. With the creation of iJMR and other journal-spin offs, JMIR will broaden its publishing activities in 2011 and beyond.
Thank you - once again - to all authors, reviewers and editors for helping us to maintain our status as the leading journal in our fields and one of the the leading open access publishers!


ABOUT THE JOURNAL OF MEDICAL INTERNET RESEARCH (http://www.jmir.org)
----------------------------------------------------------
The "Journal of Medical Internet Research" (JMIR; Medline-abbreviation: J Med Internet Res), founded in 1999, was the first international scientific peer-reviewed Open Access journal in eHealth and Health Informatics and has quickly established itself as the leading journals in this field.
The journal has now more than 50.000 readers per month, is subscribed by more than 45.000 TOC alert subscribers, and publishes about 50-60 high-quality papers per year. Leading ehealth research institutions and departments are institutional members of JMIR (http://www.jmir.org/membership/viewall), enabling their faculty and students to publish in JMIR free of charge, while other authors pay our article processing fee from their grants (similar to how they budget for conference presentations and travel).
JMIR focusses on patient/consumer-centered, participatory approaches, innovative methods, and applications with public health impact, as opposed to hospital information systems and clinical informatics. With a 2010 ISI impact factor of 4.7 and a 5-year impact factor of 5.0 JMIR has established itself as THE leading peer-reviewed journal in the field of "ICT in health". As of 2011, JMIR is listed #1 in the medical informatics category and #2 in the health services research category of Thomson/Reuters Journal Citation Reports (JCR 2010, released June 2011).
Due to its open access policy, the journal has a broad readership, including policy makers, health care practitioners, academic researchers (including medicine, social sciences, and engineering), and even patients/consumers.
JMIR will publish applied research in the areas of consumer health informatics, mobile communication, and public health informatics, in particular if mobile or web-based methods are employed. A rigorous evaluation preferably with clinical outcomes is usually a prerequisite for acceptance - technical papers with only formative evaluation or other papers not fitting the scope of JMIR should be submitted to iJMR (interactive Journal of Medical Research) instead.
As one of our unique features JMIR tries to publish in "Internet speed", achieving minimal editorial turnaround times of sometimes only a couple of days or weeks between submission and publication. Selected papers are published for open peer-review before formal acceptance.
The journal is freely available at http://www.jmir.org.

ABOUT THE IMPACT FACTOR
The Impact Factor, published annually by Thomson/Reuters in the Journal Citations Reports, is the most widely used metric for the influence and importance of a scholarly journal. The impact factor 2010 was calculated by counting the number of citations received in 2010, citing articles published in 2008 and 2009, divided by the number of articles published in that journal in 2008 -2009. In other words, an impact factor of 4.7 means that on average an article published in JMIR in 2008 or 2009 received 4.7 citations in 2010. The five-year impact factor takes articles published between the years 2004-2009 and is the average number of citations received in 2010. In other words, articles published in JMIR in 2004-2009 were cited on average 5.0 times in 2010.

A Call to Arms from Wikipedia Doctors

A group of doctors, scientists and medical students who write Wikipedia's medical articles and are involved in the Wikiproject Medicine have issued a "call to arms", calling on their peers to join them in their efforts to provide consumer-friendly medical knowledge free to the world at large.

In a paper published on January 31s, 2011 in the peer-reviewed, openly accessible Journal of Medical Internet Research (JMIR, the leading journal in health services research and health informatics), they argue that the possibilities to use Wikipedia as a tool for worldwide health promotion are under-appreciated, citing its unique global reach and examples of how the Internet encyclopedia is used in humanitarian projects [Heilman et al. Wikipedia: A Key Tool for Global Public Health Promotion. J Med Internet Res 2011;13(1):e14].

The 19 authors are all members of Wikipedia's project that manages the health-related content. They note that both doctors and patients commonly seek health information online. Patients usually turn to search engines like Google for health-related queries, and previous research by these authors has shown that Wikipedia appears among those results in around 75% of cases.

Wikipedia's medical content broad and fairly accurate

Based on a review of existing studies of Wikipedia's medical content, the paper concludes that Wikipedia has articles on an incredibly wide range of medical topics with few factual errors, although most of Wikipedia's articles are only in the earliest stages of development and the readability needs to be improved.

"With more than 20,000 articles on health and more than 6,000 drug-related articles, there has never been more freely accessible health information on the Internet thanks to Wikipedia. But now we need more experts to expand these articles and to make them more accessible to the general public at the same time," says Dr. Michaël Laurent, the article's corresponding author.

Although critics have questioned Wikipedia's open editorial policy and examples of errors have been widely published, the authors point out that the encyclopedia has developed multiple strategies to prevent damage to its articles (including the use of vandalism fighting software, automated correction scripts, page protection, edit filters, blocking and banning).

Calling all doctors to contribute

Since WikiProject Medicine was founded by one of the authors (Dr. Jacob F. de Wolff) in April 2004, more than 200 editors (ranging from laypeople and students to doctors, nurses and professors) have registered at the virtual 'doctor's mess', where Wikipedia's medical content is discussed and coordinated. Over the years, the project has developed guidelines about writing good medical articles and finding reliable medical references. "Wikipedia lends itself very well to evidence-based medicine," the article notes.

The group suggests that physicians may contribute to Wikipedia for several reasons, including the intellectual challenge to summarize a medical topic for the general public and the satisfaction that comes from editing an important source of medical information, watching the articles grow and rise among Google results, often outperforming review articles in leading medical journals.

Citation:
Heilman JM, Kemmann E, Bonert M, Chatterjee A, Ragar B, Beards GM, Iberri DJ, Harvey M, Thomas B, Stomp W, Martone MF, Lodge DJ, Vondracek A, de Wolff JF, Liber C, Grover SC, Vickers TJ, Meskó B, Laurent MR
Wikipedia: A Key Tool for Global Public Health Promotion
J Med Internet Res 2011;13(1):e14
URL: http://www.jmir.org/2011/1/e14/
doi: 10.2196/jmir.1589
PMID: 21282098

Source: Journal of Medical Internet Research (http://www.jmir.org)

This is a JMIR press-release and can be freely redistributed under the Creative Commons by-nd 3.0 License. This means you can copy & paste the text above into any medium you like (if paper based, you need to preserve the hyperlinks by spelling out the URLs), as long as you give credit to the source, create no derivative works (which includes editing or changing the press release), and include these license conditions, i.e. this license text must be included.

Open Access Week: webinar about the Journal of Medical Internet Research

To celebrate Open Access weeks, we have created a Webinar (slideshare presentation with audio track), chronicling the 12 year journey of the Journal of Medical Internet Research, one of the pioneers in this area. The talk focusses on the publishing innovations contributed by the JMIR team.
Enjoy!

Slideshare presentation

Open Access Publishing - The Journal of Medical Internet Research

View more webinars from eysen.

First PKP award for editors to Gunther Eysenbach, publisher of JMIR

In my capacity as founding editor and publisher of the Journal of Medical Internet Research (JMIR), and open access advocate since over a decade, I am proud to have been honored with the first-ever Public Knowledge Project Community Contribution Award for editors.
The award was given to me (totally surprising - I didn't now anything about it!) at the 2nd PKP Scholarly Publishing Conference in Vancouver, July 2009, by John Willinsky, initiator of the PKP (Public Knowledge Project), for editorial/publishing excellence and the significant contributions I and the team at the epublishing and open access research group at the Centre for Global eHealth Innovation made to open science and open access publishing. Contributions of my group include not only major code development over the past 7 years, laying the foundation for many OJS plugins as well as the Lemon8 XML typesetting software, but also leadership, advocacy, innovation, and excellence in open science, reflected by the prominent standing of JMIR as one of the leading independent open access journals.
OJS originally suffered (and to a certain degree still suffers) greatly from the fact that it was developed without the real life input of publishers/editors, so when I decided to use OJS as a publishing platform in 2002, a tremendous amount of work was required to fix bugs and to customize the platform. Over the years, I invested around $350.000 in developer salaries to make this happen. Two of my former staff members (MJ Suhonos and Juan Alperin), who gathered their first experiences in publishing in my lab, developed publishing plugins and tools to support the new business processes I created, and fixed some of the more severe OJS usability issues. They are now both working for PKP.
It is good to see that my efforts as champion for openness in science & medicine (also reflected in my capacity as a founding member of the Open Access Scholarly Publishers Association and the services my lab to new journal startups, which include hosting, copyediting and article XML production) are recognized by others, especially if this recognition comes from someone whom I deeply admire (John Willinsky).
Big players in the open access field (which shall not be named) are in the news all the time, but what is often forgotten is that there are pioneering open access journals out there which were created long before these giants entered the scene. And none of the big players has bothered to share much of their code with the open access publishing community. The plaque he gave me will have a special place on my office wall, right next to my Tom Ferguson award.

Meanwhile, we continue to customize OJS and have developed some novel approaches which completely integrates the XML production process into the OJS platform (we are the only journal where this has been achieved). These changes go beyond a simple plugin structure, and unfortunately we do not have the funding or manpower to support documentation and sharing of these changes as open source. What we do offer is however to host journals on the modified platform and to support the article production process for new journals, especially those requiring NLM-XML markup (interested editors/publishers should contact me).

Open Access journal JMIR rises to top of its discipline

I am still shaken and thrilled by yesterdays' big news: The Open Access publication Journal of Medical Internet Research (JMIR), which I created 10 years ago, has now established itself as THE leading peer-reviewed journal in the field of ehealth, or as I prefer to put it, for "health and health care in the Internet age". Yesterday, on June 19th, 2009, the Impact Factor rankings for 2008 were published by Thomson Reuters (Impact Factors are the most important metric for the influence of a journal, reflecting the average number of citations to recent articles). The Impact Factor for JMIR in 2008 is now an amazing 3.6 (up from 3.0 last year, and 2.9 the year before). This has to be seen against the background that medical informatics journals are typically not cited very well and have typical impact factors between 1-2.
Perhaps the biggest news due to its high symbolic value is that JMIR is now the top, number one ranked journal in its discipline, and has finally officially overtaken JAMIA, the official Journal of the American Medical Informatics Association (2008 IF 3.4), which has been on the #1 spot in this discipline for decades. For a small, independent, low-budget journal this is a major achievement and truly a David vs Goliath situation. AMIA is probably the most influential scientific society in the medical informatics field, and its journal JAMIA enjoys significant backing by the association. JAMIA is owned and published by Elsevier. I may be wrong on this (leave a comment!), but to my knowledge this is the first time in history that an independent Open Access journal takes the top spot in its discipline, overtaking the long-term top journal in a JCR (Journal Citation Reports) category. I am surprised by this myself - I would have never thought that JMIR could overtake the venerable JAMIA in terms of impact. I know that the Impact Factor has its problems as a metric, but Impact Factors continue to be a valuable measure of a journal’s quality for authors, librarians and societies, and the high impact of JMIR sends a clear message to traditional publishers as well as to societies in terms of what Open Access publishing means for impact.
JMIR is now ranked the top (#1) journal in the medical informatics category (out of 20 journals), and second (#2) in the health sciences & services category (out of 62 journals), by Impact Factor.


For further information see
http://www.jmir.org/announcement/view/24

I want to thank all readers, supporters, authors, reviewers, and editors for their support and/or editorial work they've put into the journal.

The new top position in the field means that we will be getting even more submissions, and that I will require even more help. I thank particularly those who have taken on "associate editor / section editor" responsibilities, actively guiding papers through the peer-review process (published JMIR papers acknowledge the section editor at the bottom of each article).

JMIR is continously seeking more academic section editors. Please contact me if know of any individuals who might be willing to take on editorial responsibilities. For those health informatics researchers at Medinfo2010 in South-Africa next year, we will be holding an editorial board meeting to discuss strategic issues.



For those prospective authors considering to submit a paper to JMIR due to its high impact, I urge you to make the Impact Factor not the sole and driving factor for submitting a paper to us. Our aim is to be selective in what we publish and - as a general rule - we will not consider highly technical, but only those with a considerable impact ("BMJ quality"). Our focus remains on topics related to patient empowerment through ICT (information and communication technologies) and web-based approaches, although mhealth and ubiquitous computing applications are also within scope. We also focus on patient/consumer-centered, participatory approaches, innovative methods, and applications with public health impact, as opposed to hospital information systems and traditional medical/clinical informatics. If your research falls into these categories, or if you plan a review or opinion paper in these fields, then we welcome your submission.

Best wishes

Gunther Eysenbach
Editor/Publisher, J Med Internet Res (JMIR)

"Swine Flu" vs "H1N1" terminology - tweets show that people do not adopt the new term

In a previous post I already gave an example of the kind of research we are doing using the Infovigil system - an infodemiology/infoveillance system, which we are developing in cooperation with public health agencies *.
As described in this article, one of the applications of infodemiology (aside from identifying emerging epidemics) is to measure and track knowledge translation and dissemination. When the WHO as well as public health officials around the world dropped the terminology "swine flu", replacing it with "H1N1", on April 29th 2009, I was interested to see whether and how quickly this terminology would be adopted by the public - and ideal test case for a question which could be answered by infodemiological methods.

Figure: H1N1 term (red) versus Swine Flu/Swineflu (blue) terms in tweets (yellow: both). (c) Gunther Eysenbach, licensed under Creative Commons Attribution license (CC-by V2)

The figure above depicts the terminology used in tweets during the first 3 weeks in May, as a proportion of all tweets containing either "swineflu", "swine flu", or "h1n1" (including hashtags). On May 1st, less than 10% of the tweets contained only H1N1 (but not swineflu or "swine flu") (red), and 7% contained both concepts (H1N1 and [swineflu or "swine flu"]) (yellow).
As could be expected, the adoption of the term H1N1 gradually increased during the first week of May, and peaked on May 8th, when 24% of all tweets contained only H1N1 (and not swineflu or swine flu), while the term "swine flu" (or swineflu) alone was used in "only" 63% of the tweets. However, since then, the "swine flu" term experienced a sudden "revival", with the "swine flu" (or swineflu) term alone again used in 74-79% of the tweets, and "H1N1" hovering around 16-20%, without any clear trend of the term's use increasing.

We are still analyzing what happend around May 8th/9th to cause the trend to reverse (suggestions welcome). One working hypothesis is that interest in the epidemic (and the number of tweets) has declined significantly since around that date, so the nature and content of tweets has changed as well.

Comment: As a public health researcher, I am sympathetic of the reason for the name change and disappointed (but not surprised) by the publics' (in particular journalists') reluctance to adopt the name change. Studies have shown over and over again, that terminology matters: one of my favorite studies shows that changing the diagnosis "chronic bronchitis" to "smokers lung" actually encourages people to stop smoking (Brandt et al., 1997). The WHO had good reasons for suggesting a terminology change: The inherent threat in using the term "swine flu" is that people translate this into the wrong preventive behaviour (such as avoiding pork). If opinion leaders (in particular the media) would have adopted the name change, then - I assume - the public would have had an easier time to follow.
But I guess it is true what people say about change: Only as babies in our wet diapers we embrace change. It is the same reluctance to change which prevents new medical and scientific evidence to penetrate into medical practice and into the consciousness of the public in a timely manner (it takes years to change medical practice even if new research findings are out). And it is this reluctance to change which we hope to visualize with our line of infodemiology work which focuses on knowledge translation questions.

---

* Infovigil is NOT funded by Google and has no relationships to Google Flutrends - they gladly took our ideas but didn't collaborate.

Reports on Twitter Fueling H1N1/Swine Flu Fear and Misinformation Are Vastly Overstated

Is Twitter fueling panic and misinformation? (Image Source: Posible caso de influenza, (C) Hello32020, licensed under CC-by license)

Recent media reports (e.g. on CNN and USA Today) suggest that microblogging sites such as Twitter are fueling an epidemic of misinformation, disseminating rumor and speculation about the H1N1 (Swine Flu) outbreak.
As infodemiology scholar these media reports struck me as largely anecdotal, not based on systematic evidence.
Using the infovigil system (which allows archiving and analysis of tweets and other sources on the Internet) we decided to address this issue more systematically.

Number of Tweets collected by the Infovigil system between May 1st and May 18th, 2009, containing the keywords or hashtags H1N1, swineflu, or Swine Flu (Image Source: Gunther Eysenbach, University of Toronto, licensed under Creative Commons Attribution license V2.0 CC-by)


My student Cynthia Chew and I just finished a preliminary content analysis of 400 randomly selected tweets (sent during the first weeks of the outbreak), and found that her data do not support the notion of twitter spreading misinformation. As she wrote in her abstract submitted to the Medicine 2.0'09 conference in September in Toronto, she found only 7/400 (1.75%) cases of misinformation in tweets.
News posts were the most common type of information shared (46%) followed by public health education (19.18%) and H1N1-related humour (18.25%). 36.75% of all posts quoted news articles verbatim and provided URLs to the source.
Take that, CNN and USA Today!


Gunther Eysenbach MD MPH
Senior Scientist, Centre for Global eHealth Innovation, Director, Consumer Health Informatics, Public Health Intelligence & Infoveillance Group

Patient empowerment and power distance, health care safety and plane crashes

I just finished reading a fascinating book chapter "The ethnic theory of plane crashes" in Malcolm Gladwells book Outliers. Malcolms argument is that

The single most important variable in determining whether a plane crashes is not the plane, it's not the maintenance, it's not the weather, it's the culture the pilot comes from. Planes are flown safely when the pilot and co-pilot are in open and honest communication. And in cultures where it is difficult for a junior person to speak openly to a superior, you have lots of plane crashes.
(Source: CNN Interview with Gladwell)

As summarized by Rob Verger:

Gladwell explores two plane crashes—one Colombian (Avianca Flight 52) and another, South Korean (Korean Air Flight 801)—and how the culture of the pilots perhaps contributed to each disaster. He focuses on how well the pilots communicated with each other and with air traffic control. Poor communication in these examples, he argues, has to do with something called a culture’s Power Distance Index (P.D.I.)—the term and concept come from psychologist Geert Hofstede—which is a measurement of “how much a particular culture values and respects authority,” as Gladwell defines it. Countries with a high P.D.I. generally value being more deferential towards authority, and thus not contradicting a superior (the U.S. and New Zealand both have a low P.D.I.). Gladwell argues that since both Colombia and South Korea rank towards the top of the P.D.I. list, the subordinate members of their cockpit crews were unable or unwilling to speak up as assertively as they should have about safety concerns.

Gladwell retells the story of Korean Air, which in the 1990s was plagued by a series of plane crashes. Investigators discovered that when Koreans spoke to each other in Korean, they "were trapped in roles dictated by the heavy weight of their country's cultural legacy." That meant that they were hesitant to challenge a superior directly. According to Gladwell, a number of plane crashes are the direct consequence of "power distance", resulting in miscommunication and eventually disaster.

As a health care researcher and patient advocate I was intrigued by the concept of power distance and the notion of measuring relationships between culture and safety.
And of course, being a professor in health policy and ehealth, I started thinking about the relationship between health care culture and quality/safety of care.

I would argue that in health care, the relationship between patient and health care professional is sometimes akin to the relationship between pilot and copilot. Patients need to speak up and need to be engaged to utter concerns or preferences to avoid disaster. Power distance, which is "the extent to which the less powerful members of organizations and institutions accept and expect that power is distributed unequally" is a barrier often impeding patient-doctor commmunication.

I also hypothesized that power distance is an inverse predictor for patient empowerment: The more consumers accept that there is and that there should be a "power distance" between patients and doctors, the less advocacy in terms of patient rights and access to information will take place, and public policy will be slower to adopt an empowered patient model.


To test this hypothesis, I correlated data (total scores) from the Euro Patient Empowerment Index, which scores patient rights, information access and financial incentives on a health policy level, with Hofstede's Power Distance Index - and found a surprisingly high inverse correlation between the two metrics.
Countries with a high Power Distance Index such as Poland also tend to have low Patient Empowerment scores, while countries such as Denmark, where there is less "fear of authority", also score high on the patient empowerment metric.


What does this all mean for health care policy? Well, if you believe Gladwell's argument that power distance is a predictor for aviation disasters, then it is very feasible to make the analogous argument in health care: that high power distance and low patient empowerment is often a cause for miscommunication with disastrous outcomes in health care.
And obviously there is a relationship to my other research area, ehealth, in that the Internet and the virtues of Medicine 2.0 (participation and openness, collaboration and disintermediation/apomediation) are powerful antidotes to reduce the power distance in health care between patients and doctors, but also between health care professionals (e.g. junior and senior doctors).

I am intrigued by these relationships between culture, policy, and health care quality, and I am trying to get my head around how to do further research in this area.

To avoid "ecological fallacies", such studies presumably must be undertaken at the individual level. So perhaps what we need to develop next is a patient empowerment index that can be administered at the individual rather than policy level, and which can be used to study relationships between empowerment and outcomes.

Medicine 2.0'09 Abstract Submission Now Open (and: Awards!)

Today, the Medicine 2.0'09 conference opened its abstract submission system for presentation proposals for this years' conference (Sept 17-18th. 2009, Toronto). The deadline is May 15th, 2009.

Also announced were a few attractive Medicine 2.0 awards for best paper presentations, one sponsored by the International Medical Informatics Association (IMIA), one sponsored by the Journal of Medical Internet Research (JMIR).

The annual Medicine 2.0'09 conference is all about social networking and Web 2.0 applications in medicine health, health care, as well as in biomedical research. Other than some commercially dominated "Health 2.0" tradeshows, this conference distinguishes itself by 1) having an academic focus, with an open call for presentations, published proceedings and peer-reviewed abstracts (although there is also a non-peer reviewed practice and business track), and 2) being the only conference in this area which has a global perspective and international audience (last year there were participants from 18 countries).

The program in 2008 was outstanding, with internationally renowned speakers, a philosophy of "openess", and a very nice atmosphere for networking.

This years' program promises to be even better, so I'll see you in Toronto in September...