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.

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* 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...

How to cite twitter, how to cite tweets, how to archive tweets

As twitter and microblogging is gaining momentum as a social phenomenon, a number of researchers start wondering how to cite tweets (for example here) and how to cite a whole thread (series of tweets).
A related issue is how to digitally preserve and archive tweets. For example, using twitter search, one can currently only search a few months back, older tweets are not retrievable. And while it is difficult to imagine that twitter won't be around for a while, it is not certain that the site still exists in 5, 10 or 20 years, making it impossible for future scholars to access the same information the author accessed.
A third related issue is dynamically changing content on twitter. For example, it doesn't make much sense to cite a search URL like http://search.twitter.com/search?q=twitter, because obviously the content is changing all the time.

For all these reasons, the WebCite tool comes in handy (http://www.webcitation.org) [3]. WebCite, which is endorsed by hundreds of scholarly journals, is a member of the International Internet Preservation Consortium (other members include for example the Internet Archive/Wayback machine) and works with libraries to make scholarly important digital material (including cited webpages, websites, online datasets etc) permanently accessible and "citable".

Here is how I use the WebCite tool to cite and archive tweets:

1. If I want to search all tweets by a given user, or tweets matching a hashtag or keyword, I use the search interface at http://search.twitter.com/ (or advanced: http://search.twitter.com/advanced) to generate a query searching for the username, a given hashtag etc, for example http://search.twitter.com/search?q=eysenbach


If I want to cite a specific tweet, I simply enter the entire tweet into the search interface, for example "http://search.twitter.com/search?q=Wondering+about+copyright+and+twitter.+Who+owns+intellectual+property+%2F+ideas+posted+on+twitter%3F+".
This is a workaround, as archiving the direct URL of the post (http://twitter.com/eysenbach/statuses/1457158115) currently seems to fail (http://www.webcitation.org/5foQZ3stR) (WebCite is working on this).


2. Copy and paste the search URL ( http://search.twitter.com/search?q=eysenbach) into the archive form of WebCite under "URL to Archive [url]:" and enter your email adress under "Your (citing author) E-mail Address [email]:", so that WebCite can email you a success/failure notice.



If you use WebCite regularly to cite other webpages etc., add the "WebCite this" bookmarklet to your browser. You can then archive any URL by just clicking the bookmarklet on your browser without having to navigate to the archive form of WebCite.


3. You're done! Cite the tweet or tweet thread as follows:


Eysenbach G (03-04-2009). wondering about how to archive my tweets (and friends' tweets) locally - any solutions out there? Retrieved from twitter.com, archived at http://www.webcitation.org/5foXLx2sm

or

[Multiple authors]. How to cite tweets. Search result retrieved on 2009-04-05 12:08pm from http://search.twitter.com/search?q=how%20to%20cite%20tweets, archived at http://www.webcitation.org/5foMuVHgy

As a side note, forget the APA or NLM styles [2] on how to cite blogs and websites. These citation styles leave out the most important aspect of citing a webpage or blog (which can change every minute or - in the case of twitter - every second), which is to archive it and to cite a permanent, archived snapshot - at least if the intention is that the reader sees the same as the author when he cited the tweet or series of tweets. In addition to the original URL, always cite the WebCite URL which links to a stable snapshot of the cited page.

For example, a URL like http://search.twitter.com/search?q=twitter is showing a different result every second. Only by "freezing" and archiving the result, (http://www.webcitation.org/5foXx28BB) the URL can and should be cited.

Limitations
Currently, the WebCite team is working on a few fixes, to make archiving and citing of tweets easier.

A current limitation is that the "show conversation" links in search results do not work if the search results are archived by WebCite (see e.g. http://www.webcitation.org/5foMuVHgy), presumably because javascript is used to retrieve that additional information.

Secondly, archiving the direct URL of a microblog (http://twitter.com/eysenbach/statuses/1457158115) seems to fail (http://www.webcitation.org/5foQZ3stR), as does webciting the twitter homepage of a user, e.g. http://www.webcitation.org/5foR9anu2. (any hints on why this is - my guess is some javascript magic on these pages-, and whether there are alternative URLs which can be archived, are welcome). Thus, use the workaround of using the search interface as described above.

Thirdly, the twitter search interface currently only allows the display of max 100 microblog entries on one page, so that one WebCite snapshot has to be taken per search results page.

Fourthly, there is an urgent need for a tool allowing researchers to prospectively monitor and archive feeds from twitter, which is also something WebCite is working on (there are relations to the Infovigil [3] project, which allows advanced analytics such as trendanalysis, geographical coding, and links to polls).

Copyright
Ok, this question always comes up.. Using and archiving webpages should be covered under fair use clauses if the intent is scholarly communication. Twitter itself raises some interesting copyright issues, including the question if tweets reach the standard for copyrightability.

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References
1. Eysenbach G, Trudel M. Going, Going, Still There: Using the WebCite Service to Permanently Archive Cited Web Pages. J Med Internet Res 2005;7(5):e60 URL: http://www.jmir.org/2005/5/e60
2. Patrias, K. Citing medicine: the NLM style guide for authors, editors, and publishers [Internet]. 2nd ed. Wendling, DL, technical editor. Bethesda (MD): National Library of Medicine (US); 2007 [updated 2009 Jan 14; cited Year Month Day]. Available from: http://www.nlm.nih.gov/citingmedicine
3. Eysenbach G. Infodemiology and Infoveillance: Framework for an Emerging Set of Public Health Informatics Methods to Analyze Search, Communication and Publication Behavior on the Internet. J Med Internet Res 2009;11(1):e11 URL: http://www.jmir.org/2009/1/e11

Article Processing Fees and Open Access journals

Stephen [WebCite] has just blogged about the Libertas Academica table on Article Processing Charges [WebCite] (which by the way seems to be swiped -without attribution- from the Biomed Central comparison table [WebCite]).

What I am missing in both tables is an overview of what journals are actually offering for these costs. For example, PLoS One* has no copyediting process, and also seems to skip the final proofreading step common at most other journals (galleys are not sent to the author for final approval).
As a result, some authors decry the quality of their published work. For example, John Logsdon [WebCite] writes

There was no opportunity given for making corrections to proofs. I have already identified an issue with one of the tables that would have been corrected in proof had there been an opportunity.

On the same page, Banoo Malik offers an insightful comment:

I contacted the production staff and they mistakenly gave it the citation year of "2007" not 2008. Thus, my first primary-authored paper will likely NEVER appear in anyone's eTOCs,
(...)
Obviously you get what you pay for. Cheap production costs yielded some production oversights. I can appreciate how many hours and effort a copy editor and production staff spend on these seemingly small details now since I followed up on a few points myself. [WebCite]

On the same page, Andrew Staroscik writes:

I am unhappy with parts of the BMC process. I agree that the pros outweighed the cons but I also had an issue with proofing. The BMC process did not have a copy editing step! There are typos in the published version of our paper that I and the other authors did not catch until it was tool late.

Is having a competent copy editor look over the proofs really a particularly costly step in the process? [WebCite]

The answer to the last question - at least from my perspective as publisher of JMIR - is a clear "yes". JMIR charges a $1500 Article Processing Fee, but spends most of this budget - hundreds of dollars - for every article to clean it up before publication, to standardize the reporting, and to improve language issues. Bringing an article into the final form, including checking all the references, crosslinking them to DOIs, PMIDs, PMCIDs etc. is - even though a semi-automatic process - a very timeconsuming and expensive undertaking.

This is what authors often don't realize when looking at APF comparison tables such as those published above: There are considerable differences between journals on how much time and costs they spend on the actual production process, which justify different article processing fees.

The notion that the "ONLY major cost in running a journal is the time spent by the editorial team and reviewers" [WebCite] is - at least for how I run my journal - not accurate.

In fact, JMIR is spending most of the article processing charges on external contractors - copyeditors, XML typesetters etc. There are several copyediting and proofreading steps in the production process, which not all journals seem to employ. I invite authors to critically assess what they get for the money instead of just looking at the article processing fee. JMIR staff and external contractors spend on average 10-20 hours to bring a manuscript into its final form.

And open access journals not charging any Article Processing Fees are almost guaranteed to skip these steps. Many won't even have XML versions of the articles (i.e. no submission to PubMed Central), because creating them is very expensive.

So I would encourage academic authors considering to submit articles to an open access journal to not only ask how much the article processing fee is, but also what they get for their money.

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Correction notice: Edited 25/11/2008. I am taking back (and have removed) my original remark on "superficial" [WebCite] peer-review. More correct and value-neutral would have been to say that some journals have a leaner ("hassle free) [WebCite] peer-review process than others (for example, editors may decide to accept an article without sending it out to external reviewers).

eHealth (web-based behavior change programs) in the Toronto Star

Today, the Toronto Star published an article about Web-based behavior change programs [Pigg, Susan: Monitoring your vices online. Toronto Star, 17.11.2008, URL:http://www.thestar.com/article/537988. Accessed: 2008-11-17. (Archived by WebCite(R) at http://www.webcitation.org/5cOtvqnhO)] - with a picture of me in front of my whiteboard in my office. I talked to the reporter about the pros and cons of online-ehealth programs, such as those which we are currently publishing in the JMIR Theme Issue on Web-Assisted Tobacco Interventions (the Toronto Star article has a broader scope though). I mentioned the problem of attrition - many users are starting to use these programs enthusiatically, but stop using it after a while. But there are ways to tackle the attrition problem: Social networking probably make sites more sticky and engaging, and create peer-pressure to return. In addition, personal health records (and PHR platforms like Google Health and Microsoft Healthvault), sensors, Ubiquitous/pervasive computing, smart appliances and smart home-care devices will make it easier for users to aggregate and manage automatically tracked data (rather than having to enter information in online diaries etc). Of course, this raises certain privacy issues...

As you pour that glass of wine or two when you get home tonight, you might want to think about the price you're paying for the daily ritual of taking the edge off.

That drink – which, admit it, is usually two or three as you ease into the weekend – costs you about $2,000 a year. It's adding up to at least 100 extra calories a day and, if you're an average-sized, 50-year-old woman, about 15 pounds of unflattering weight over 12 months.

In the course of a year, you will have downed some 520 drinks and been under the influence of alcohol 1,161 hours. That means your throat is often inflamed, your liver and pancreas are under stress and you are boosting your chances of developing some cancers.

That's not your doctor talking. That's checkyourdrinking.net.

If you think you may have a problem, rest assured there are thousands of others just like you. They're in cyberspace as well, doing online self-assessments and then spending hours in social networking sites debating with like-minded people. Their concerns? Is there a better way to cope with stress? Do their dark days now rate as full-fledged depression? Is their weight off the scales?

There has been a virtual explosion the last few years in so-called eHealth sites, which help people tackle everything from insomnia to anxiety attacks and gambling addictions. But, increasingly, they are being used by companies – usually as part of employee assistance programs – to boost productivity by reducing absenteeism, sick days and disability claims.

"None of these programs is meant to replace a physician or offer (medical) diagnoses," says Estelle Morrison, director of program development at Ceridian Canada, which runs employee assistance programs on behalf of many major Canadian companies. "They are meant to educate people and make them more self-aware and knowledgeable so they can go to the right people and get the help they need.

"We now see employers understanding that if they don't start to provide some very important support to their employees, they will be in quite a mess in the next few years because of aging baby boomers who are struggling with health issues, in terms of employee absenteeism, in terms of labour shortages, in terms of (the health effects of) people working 24/7.

"These are issues that are impacting the mental health, the productivity and the availability of staff – and employers are now seeing the bottom-line cost of that."

In the U.S., companies are offering "incentives" – gift cards, running shoes, health-club discounts, cash awards of up to $1,000 – for employees who undertake "health risk assessment" surveys aimed at pinpointing and minimizing their risky habits. In Canada, Morrison says, cash incentives are more seen as "rewarding" bad behaviour, so "we've had a lot of iPods."

The assessments usually include 50 to 75 questions ranging from your cultural background to whether you wear seat belts.

"They're being very, very aggressive in the United States about getting these kinds of systems in place," says Dr. David Goldbloom, a senior medical adviser for Toronto's Centre for Addiction and Mental Health.

Goldbloom says he was surprised to see the number and sophistication of "behavioural health" programs during a recent health-care conference in Arizona. "There were tonnes of examples of companies that are working very hard to make this more a part of their workplace, but also competing with each other: who's got the healthier workplace?"

Toronto-based V-CC Systems Inc. launched its online behavioural change programs in Canada in 2000 and now offers its services to many companies. It also has partnerships with agencies such as the Canadian Cancer Society, which uses its online smoking-cessation programs, says Rachel Fournier, the company's director of business development.

V-CC is one of the few eHealth sites that offer some free behaviour-change surveys and programs around drinking, obesity, anxiety, smoking and depression, as well as access to its online forums. (Far more comprehensive programs are available through company assistance programs for employees.)

What makes the programs so popular, say experts, is that they are anonymous and available 24 hours a day in the privacy of your home. With traditional assistance programs that offer counselling, there is always the fear the information will leak back to your boss.

Rick H., a recovering alcoholic and drug addict, uses the V-CC site most days, offering personal perspective and advice online. "I think it's very helpful to people who are starting off and trying to find a path. It gives them some tools to get them started, but I don't think it's for maintaining long-term sobriety. They tend to hang around a month and then move on.

"I like to think that some of them make it, but I know, from being a member of Alcoholics Anonymous for two years, that only about 5 per cent make it to five years sober on the first try.

"But there's always value if somebody has hope."

What started as online self-assessments and expanded into online self-help groups is evolving in a new generation of eHealth programs. These are so tailored to individual circumstances that they could significantly reduce at least some serious outcomes, such as, say, drinking or poor diet escalating into costly diabetes and cardiovascular problems or depression – which costs an average per case of $10,000 and 40 lost days at work – spiralling out of control.

"I think it's very important that we continue to do research and evaluate the impact of these programs," says Dr. David Ahern, a U.S. physician who is doing just that kind of research on behalf of the Boston-based Health e-Technologies Initiative.

"But I am much more of an optimist about the benefits of these programs than the downside. I think they have tremendous potential to help improve health and the quality of health care."

The downsides, says Canada eHealth expert Dr. Gunther Eysenbach, include getting people to stick to the programs, especially if they have to keep tedious daily online logs of their habits and behaviour. There are also the privacy risks of cyberspace, he notes.

While the smoking programs have proven among the most successful – some research shows about a 10 to 12 per cent quit rate – weight loss is trickier, says Eysenbach.

"With weight loss, there's just an intrinsic paradox that you make people sit down at a computer to lose weight when you should actually be sending them out onto the street to do some exercise."

A more active intervention is starting to happen, with programs that can now be used on mobile devices and "smart devices" that, in time, Eysenbach believes, will make it much easier for people to keep track of behaviour that poses a risk to their health.

He predicts it won't be long before your car will keep track of how much you have driven and whether you should, for the sake of your heart, start riding your bike. Or your fridge will be telling you it's time to stop snacking.

Or put down that drink.

Also mentioned - in a sidebar to the article - is JMIR:

Dr. Gunther Eysenbach runs the Toronto-based Journal of Medical Internet Research and has spent 10 years monitoring and studying the value of online health initiatives and behavioural change programs. See jmir.org.

Open Access journal JMIR funded by SSHRC's Aid to Scholarly Journals competition - finally!

The Social Sciences and Humanities Research Council (SSHRC) in Canada has just announced that the Journal of Medical Internet Research (JMIR) (which I publish) will receive a $90.000 grant over the next 3 years. In the decision letter the agency writes that the adjudication committee "recognized the quality of the journal and saw that it was making an impact on the field." It "judged the editor-in-chief to be highly competent, the reviewers to have been well-chosen and the publication plan presented to be entirely sound and reasonable."
The SSHRC is funding 142 journals over the next 3 years under their Aid to Scholarly Journals 2008 competition, selected among 186 funding proposals.
In 2007, JMIR has already won a SSHRC grant for Open Access journals.

The editorial board and publisher is thrilled about this decision. Only 4 years ago, at the last SSHRC competition, JMIR was discouraged to submit a proposal, because it was an Open Access journal - 4 years ago, SSHRC did not consider to fund journals with no "subscribers" (the number of paying subscribers was seen as a quality criterion for an academic journal).
The policy change at SSHRC - to fund Open Access journals - is partly a result of intense lobbying of JMIR and others - see for example the submission by Gunther Eysenbach in response to the SSHRC-CFHSS Consultation on Open Access to Publicly Funded Research (2005) (Archived by WebCite® at http://www.webcitation.org/5cP2FNrRb)

Google Uses Searches to Track Flu’s Spread (and forgets to say where this idea came from)

See also: Robert Lemos. Sick Searchers Help Track Flu. MIT Technology Review, Nov 12 [Archived in WebCite]
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I am currently in a mild state of shock. A couple of years ago - when Google.org was just created and Larry Brilliant was appointed CEO of Google.org, I was trying to collaborate with them regarding my research on the correlation of searches on Google and Flu symptoms (published in 2006 here: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1839505). My hope was that a visionary guy like Larry would be open to a collaboration to explore my idea, the correlation between Internet searches and disease outbreaks (most notably influenza).
Larry Brilliant explained in his 2006 TED presentation (after which he was made executive director of Google.org) that his TED wish was an early detection system of disease outbreaks through Internet monitoring of published reports. The "idea" to analyze and aggregate media reports was not original - it was directly "inspired" by Ron St John's GPHIN (another project made in Canada) - but at least he gave GPHIN credit. Monitoring and aggregating what people publish (new items, Internet postings etc) is what I called "supply-based" infodemiology / infoveillance. However, what Larry Brilliant was not thinking about at that time, and what was (and is not) a part of GPHIN or other infoveillance system was what I call "demand-based infodemiology" (infoveillance), i.e. automatically analyzing what people are searching for on the Internet. At the time Larry became CEO of Google.org I was already working (and publishing / speaking) about this.
I was hoping that Google.org would perhaps be open to fund this project, or to share data.
What I did not expect is that they just go ahead and do what I proposed themselves, without ever getting back to me!
Today the NYT reported that Google.org has -- mmh, let's say "adopted" my idea, without giving any credits to its origin.
In the past 12 hours, at least half a dozen people who know about my infodemiology work have emailed me and asked "Hey, isn't this what you were doing, why aren't you on that paper?".
The NYT even goes so far to (wrongly) report that "Google Flu Trends appears to be the first public project that uses the powerful database of a search engine to track the emergence of a disease.". Wrong - apparently this reporter didn't do his homework or checked the published literature. In fact, I started doing this line of research about 4-5 years ago - in 2003, and talked about this at the CDC and on various conferences (e.g. at AMIA, in 2006 - where my paper "Infodemiology: Tracking Flu-Related Searches on the Web for Syndromic Surveillance" won the Distinguished Paper Award, and in 2007, on a joint panel organized by John Brownstein from Healthmap.
Healthmap by the way just got a few millions from Google.org.
The google.org team led by Dr Brilliant (according to the NYT article) even managed to get a paper accepted in Nature (while I haven't been as lucky, see below). Their paper
"Detecting influenza epidemics using search engine query data.
Jeremy Ginsberg ,Matthew H. Mohebbi, Rajan S. Patel, Lynnette Brammer, Mark S. Smolinski and Larry Brilliant is here.
Google.org obviously has every right to use and publish their data, and perhaps it is a case of "great minds think alike" (though I have not seen any presentation or publication from them which precedes mine), but I wonder how outside researchers who submit proposals and suggestions to Google.org can be certain that they don't just steal the ideas? Google.org has not the structure and level of accountability as traditional funding agencies or charities - in fact, it is set up as a company. As an academic, my currency is reputation and getting credit where credit is due. It would have been so easy in this case!

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The following is my slidedeck of my "infodemiology" and "infoveillancve" experiments, which I have been conducting since 2004. The slides were presented at various AMIA meetings, at the CDC, at a NCI/NSF workshop, and in other places. For the record: The terms infodemiology and infoveillance were created by me!

Eysenbach: Infodemiology and Infoveillance

View SlideShare presentation or Upload your own. (tags: medicine health)

Here is a presubmission inquiry letter I sent to Nature Medicine in October 2005 (the editor said this is not something they would consider publishing. Apparently, after 3 years and with authors from Google.org and the CDC on the paper, the situation has changed!):

Research Letter


Using Google for Syndromic Surveillance: Web Searches for Flu Symptoms as Predictor for Influenza Outbreaks


Editor,

We are considering submission of a short paper (500-800 words, with 1 figure) entitled

Web Searches for Flu Symptoms as Predictor for Influenza Outbreaks

An increasing proportion of people in industrialized countries are using the Internet to seek health information (1), often before they visit a health professional. An interesting question is whether tracking health information seeking behaviour of populations over time can be used for public health purposes, particularly syndromic surveillance, which has been defined by the CDC as “surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response”. While most syndromic surveillance systems rely on data from clinical encounters with health professionals, monitoring for example sick-leave prescriptions, house calls, hospital- or pharmacy-based data (2), we explored whether an automated analysis of trends in Internet searches can be useful to predict outbreaks such as influenza epidemics. We analyzed data from the Canadian flu season 2004/2005 over a period of 33 weeks from week 41/2004 (Oct 3-9) to week 20/2005 (May 15-21), comparing Fluwatch data on the number of influenza lab tests for Influenza A or B conducted in sentinel laboratories (“lab tests”), the number of lab tests testing positive (“cases”), and the number of cases of influenza like illness (ILI) reported by sentinel physicians with clicks in Google on an sponsored link triggered by influenza-related keywords. In our analysis, search engine clicks were a better predictor for flu cases than ILI reported by sentinel physicians. These data suggest that for diseases where consumers are likely to consult the Internet first before they visit a physician, tracking Internet search behaviour may be a valuable method complementing traditional methods of syndromic surveillance.

Response

Decision on presubmission inquiry NMED-PI29222

From: medicine@natureny.com
To: geysenba@uhnres.utoronto.ca
Date: Oct 31 2005 - 2:09pm


31st Oct 2005

Dear Dr. Eysenbach,

Thank you for asking us to consider your proposed article "Web Searches for Flu Symptoms as Predictor for Influenza Outbreaks" (NMED-PI29222). We have given the paper our careful consideration but sadly have decided that submission to Nature Medicine would not be appropriate.

We receive a great many presubmission inquiries and given the very limited space in our journal we are only able to invite formal submission of a few of these. Thus, the competition is fierce. In choosing which to invite we consider the likely broad appeal of papers, the level of advance they offer over previously published work and whether or not they adequately address subjects that will interest and be accessible to both scientists and clinicians within the biomedical research community. In this case we were not persuaded that your proposed article would compete well with the others that we have received. In making this decision we do not intend a criticism of the work -- indeed we are sure that others in your field will find it of significant value -- but merely question its appropriateness for Nature Medicine.

Nevertheless, thank you very much for giving us the opportunity to consider your work. I am sorry that we cannot be more positive and hope you are soon able to interest an alternative journal in your work.

Sincerely,


Clare Thomas, PhD
Associate Editor
Nature Medicine

This email has been sent through the NPG Manuscript Tracking System NY-610A-NPG& MTS

My paper was also turned down at the BMJ, CMAJ, JAMA, Lancet, and Science. In all but one case (CMAJ) the editors did not even send it out for peer-review. Here is the Science rejection letter.

From: Debbie Dennison [ddennison@science-int.co.uk]
Sent: November 4, 2005 7:14 AM
To: geysenba@uhnres.utoronto.ca
Cc: cash@science-int.co.uk
Subject: Decision on your Science manuscript 1122097 Eysenbach

4 November 2005


Dr. Gunther Eysenbach
Centre for Global eHealth
Fraser Elliott Bldg, 4th fl
University Health Network
190 Elizabeth St
Toronto ON M5G2K5
CANADA

Ref: 1122097

Dear Dr. Eysenbach:

Thank you for submitting your manuscript "Tracking Web Searches for
Syndromic Surveillance" to Science. Because your manuscript was not given a
high priority rating during the initial screening process, we will not be
able to send it out for in-depth review. Although your analysis is
interesting, we feel that the scope and focus of your paper make it more
appropriate for a more specialized journal. We are therefore notifying you
so that you can seek publication elsewhere.

We now receive many more interesting papers than we can publish. We
therefore send for in-depth review only those papers most likely to be
ultimately published in Science. Papers are selected on the basis of
discipline, novelty, and general significance, in addition to the usual
criteria for publication in specialized journals. Therefore, our decision
is not necessarily a reflection of the quality of your research but rather
of our stringent space limitations.

We wish you every success when you submit the paper elsewhere.

Sincerely,



Caroline Ash, Ph.D.
Senior Editor


Debbie Dennison
Editorial Assistant
Science International
Bateman House
82-88 Hills Road
Cambridge
CB2 1LQ

Phone: +44 (0)1223 326500
Fax: +44 (0)1223 326501

---

Reference:

1. G. Eysenbach. Infodemiology: Tracking Flu-Related Searches on the Web for Syndromic Surveillance. AMIA Annu Symp Proc. 2006; 2006: 244–248 : http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1839505