Open Peer Review - Trials and Tribulations

In its dual role as a dissemination medium for peer-reviewed ehealth research on one hand, and as a “e-publishing lab” for pushing the boundaries of “openness” on the other hand, the Journal of Medical Internet Research (JMIR) and the "e-publishing Innovations Group" which I direct at the Centre for Global eHealth Innovation, attempts to be at the forefront of what I call the triple-O philosophy: 1) Opening access to everything we publish (Open Access), 2) opening up our infrastructure developments (open source contributions – JMIR has been a contributor to the PKP Project), and 3) enhancing the transparency of our editorial processes (open peer review).
Among the three, the latter is perhaps the most underdeveloped, but this will change soon, as JMIR is currently undertaking a "prepublication Open Peer review" trial. On submission, authors are asked whether they are interested in us posting the paper on the web before formal publication to solicit further comments from peers and the public.

Before delving into the challenges of doing an open peer review experiment, I should briefly discuss the semantic confusion around the term “open peer review” - commonly used by so many - which has bothered me for a while. People may actually discuss "open peer review" without realizing that everybody has something else in mind. The term “open peer review” has many (I would argue at least 4) different meanings and “open peer review” comes in vastly different flavours. In brief, my little proposed taxonomy is to distinguish between:

• “named (or: signed) peer-reviews”,
  
• “openly accessible peer reviews”,
  
• “prepublication open peer review”,
  
• and “post publication open peer review”.
  

The first variant is to be open about the identity of the reviewers. This form of “open peer review” is better (and more precisely) called “named (signed) peer review” (“named” being the antonym to “anonymous”). JMIR has been doing this since its inception in 1999, and was probably a pioneer in adopting a policy of complete transparency, revealing the identity of the reviewers alongside with each published article, which we think is an adequate form of acknowledgment given the (sometimes substantial) contributions the reviewers make. We keep the names of the reviewers confidential if we reject a manuscript, to avoid retributions from authors.
Openess is never free from tensions, and even JMIRs mini-step towards openness has its problems. While most peer-reviewers are happy to see their name published alongside the articles they reviewed, we also had one or two cases where reviewers thought the manuscript should not have been published, and were not happy about their name showing up alongside the paper. As reviewers frequently disagree on the merits of a paper (and what they would like to see changed to make it “publishable”), it is not always possible or reasonable to bring a paper into a form that makes all reviewers happy (not to talk about the fact that even reviewers can be wrong).
By and large however we did not observe any “adverse effects”.

Another subflavour of named reviews (which I call signed reviews) has been introduced by the BMJ, which in 1999 announced to reveal the name(s) of the reviewer(s) to the author (regardless of whether or not the manuscript is accepted) together with the review. Contrary to JMIR’s policy however, the name of the reviewers are not published.
The Br J Psych did a randomized trial on signed peer-reviews and concluded that signed reviews increase the quality of the reviews, time to complete, and the probability of recommending acceptance.
Although “named / signed peer review” is a small step towards transparency, we would actually suggest not to call it an “open peer review”, unless the entire process is visible on the web.


A second variant of open peer review, which I call openly accessible peer-reviews, is publishing the actual peer-reviews and pre-publication history (e.g. after the manuscript has been published) alongside with the article, as for example BMC does.

The most radical form of openness in peer-review is however a variant where the peer-review process (or let’s call it more accurately an assessment process) can be monitored in real time and influenced by everybody, i.e. “pre-publication open peer review” or “post-publication open peer-review”, i.e. publishing the entire manuscript online and inviting everybody to comment on it, before the manuscript has been published, or after it has been published. Neither of these variants are radically new approaches: In fact, pre-publication peer-review has been done in some fields (e.g. physics) almost routinely, by authors sharing or self-publishing a preprint (or e-print), and the BMJ has experimented with a preprint server in the late 90ies (http://clinmed.netprints.org/) - with dismal results. The Netprints server was hardly used by anybody and the service has been discontinued.
Post-publication open peer-reviews (e,g. the model of PLOS One, which has abandoned pre-publication peer-review completely) is also not really a new model, as many journals have the possibility for readers to post rapid responses alongside with articles.
However, journal initiated pre-publication open peer-review (as opposed to author-initiated peer-review, i.e. preprints) is still a rarity (I know of the Economic eJournal (WebCite ), the new Scholarly Exchange (WebCite), and most recently also Medical Education Online (WebCite) .

Traditional subscription-based journals have always been vividly opposed to consider anything for publication if it has previously been published on the web (“Ingelfinger rule”), citing safety concerns for patients, but perhaps – as I argued previously –primarily rather to preserve their newsworthiness and in an effort not to loose subscribers (who would perhaps not pay for papers which are also found on the web). Hence, Open Access journals are particularly suited to experiment with open peer review and open assessment models, because for them, loosing subscribers and the newsworthiness of publishing something that has already been published online is it is less a concern.

Yet, as I argued already a decade ago, even for traditional journals their role is changing -- the future role of journals is that they “are not longer in the business of revealing new information, but in making existing information understandable and useful for a broader audience.”. Journals will be read not because they “reveal” new information, but because they help readers of a certain scientific community to cope with the onslaught of publicly available information on the web, but not necessarily because it is “new”.

With the role of the web in scholarly communication is still evolving, with seeing all these new developments and buzz around “Science 2.0” I am more convinced then ever that my (and others') early predications along these lines were not far off. My impression is that even subscription-journals are now more relaxed in terms of publishing material even if it has been published on the Web before.


JMIR has always been running a Wiki, which was thought of as an open space to experiment with new ideas. We are now using the Wiki for what we call a “Peeki” – a peer review wiki (also alluding to the fact that it enables readers to “peek” behind the scenes of peer review) – posting selected submitted articles and their peer-reviews comments as well as anything readers may want to add or correct (since 2007 we have been asking submitting authors to give us permission to do this). In particular, we plan to post all articles which are preliminary accepted on the Peeki.

However, there are also huge barriers and challenges associated with pre-publication peer-review.
The first major concern is that most early experiences (including our own) point to a lack of participation from readers [see Nature experiment (WebCite)]. Why is this? Perhaps because there are lack of incentives to comment on / assess unpublished articles, perhaps because of lack of citability (of the comments) and “credit points” for tenure”? The quality and quantity of comments from the community remains a concern.

A lot of journal editors (including myself) who have been contemplating a similar approach have been discouraged by the Nature experiment, which showed that very few readers actually participated, and that the comments were not very helpful.

An unresolved research question include which factors determine active reader input. Another issue is whether concerns regarding authors to login with a fake identity and to comment positively on their own paper are justified.

Another challenge is that (as preliminary results from the JMIR experiment confirm) not many authors are excited about these possibilities, perhaps due to authors’ concerns that somebody may “steal” their ideas.
Ex-BMJ editor Richard Smith (and the world's best editor - now unfortunately doing other things which nobody understands) wrote a couple of years ago that “openness [disclosing reviewer names to authors] should eliminate some of the worst abuses of peer review, where reviewers under the cloak of anonymity steal ideas or procrastinate.”. In fact, the main argument against open peer-review is perhaps that it reintroduces the quasi-anonymity of the peer-reviewer (even if login is required, we all know how quickly a hotmail email address and a false identify is created).

Associated with plagiarism concerns are authors’ concerns regarding the (perceived) lack of citability of their unpublished draft versions, and perceived lack of having created an archival (“historic”) record to prove priority of ideas – both however problems which my group actively tries to address with the WebCite project (see Eysenbach, Gunther. The paradox of the current state of scholarly communication in the age of Web 2.0 Posted at http://gunther-eysenbach.blogspot.com/ Jan 18, 2008. Archived at http://www.webcitation.org/5Ux2jEb70).
Authors also may be concerned about the paper not being “publishable” somewhere else if the comments are negative. Even if the comments/the paper is removed, there may still be traces somewhere e.g in the Internet Archive or other archiving projects such as WebCite.

There are also many unresolved questions regarding what policies journals which experiment with open pre-publication peer-review should implement, e.g. should comments/papers be deleted after rejection, or after acceptance, or both, or never? How should all the different versions and the comments be indexed and cited?

Given all these questions it is surprising that funding agencies do not show more interest in funding research around these areas. Last year, I have been sending out various grant proposals to various foundations who are traditionally interested in scholarly communication issues and/or openness.
One proposal to develop a generic “Peeki” platform to enable open peer-review (as a plugin for OJS), which I submitted to the Mellon Foundation. It was turned down with the explanation that “support for biomedical publications does not fit within the current funding priorities of the Foundation's Scholarly Communications program.”. Explaining that this is not for a specific publication, but a generic platform to enable open peer-review which could be used by other journals (or even non-journal venues), were countered with the argument that “there is no credible evidence in what you submitted to indicate that any other journal than the Journal of Internet Medical Research would actually use software that is proposed.”
The same proposal submitted to the Open Society Institute was turned down with the argument implying that the project does not differ from other open peer review projects. The project officer wrote “PLoS One is the best example of open peer review which I know of, but others have also experimented with it, including Nature, which unfortunately found that it didn't work within their community.“. Well... in my humble opinion I agree that PLOS One is great, but unfortunately PLOS has morphed from an Open Access advocacy group to a competitive business which currently doesn’t make any software available under an open source license, and there is little evidence or research that the PLOS One model is the one we should all adopt - after all, it means to abandon any kind of pre-publication peer-review.

For the time being I’ve put the Peeki proposal into the drawer, but given the many unresolved research questions (including under which circumstances open peer review works) and the many different variants of open peer review models I believe that more research and development in this area is urgently required. An open source platform for open peer review (one that also engineers and experiments with incentives for peer-reviewers which can be used by them for promotion & tenure purposes, e.g. "karma" points) is urgently needed, so I do not think that this is the end of the story.

Leave a comment if you agree or differ.

Please cite as: Eysenbach, Gunther. Open Peer Review - Trials and Tribulations. Gunther Eysenbach Random Research Rants Blog. 2008-03-12. URL:http://gunther-eysenbach.blogspot.com/2008/03/open-peer-review-trials-and.html. Accessed: 2008-03-12. (Archived by WebCite® at http://www.webcitation.org/5WGnhpf6d)

Developing Open Access Journals: A Practical Guide

I just got the new book Developing Open Access Journals. A Practical Guide by David J Solomon, PhD. ISBN 9781843343394 on my desk. It is a great work, much needed, and contains a number of useful tips for (low-budget) academic publishers and editors of new OA journals. The book also contains case-studies of 5 successful OA journals, among them the journal I am editing (Journal of Medical Internet Research (JMIR)). Other journals discussed in detail include MEO, JEP, Information Research, and First Monday. It is about time that people (including journalists - who reflexively start discussing PLOS and BMC when writing about Open Access journals) realize that Open Access should also be associated with these smaller, pioneering publishers/journals. And "small" means "small" in terms of a "lean and sustainable" publishing model - not in terms of impact. In fact, JMIR beats all but one Elsevier/Springer etc journals in the field of medical informatics in terms of impact (ranked #2 out of 20 journals).
A few issues should - in my view - perhaps be strengthened in a future edition of the book. These include perhaps more information about indexes, tools, XML, marketing, how to deal with libraries and aggregators (EBSCO, Swets etc.), impact factor (and how to increase impact), and e-commerce. But I also realize that - given the wide spectrum of business models and discipline-specific requirements - these are difficult areas to cover in a single book.
In summary, a great book, and a much needed template for "best practices" in this field (see this blog entry and comments).
Too bad that the book itself is not openly accessible. I personally think that this kind of work (and further guidelines/best practices, perhaps focussed on specific fields such as medicine?) should be solicited / paid for and made accessible by foundations who have an interest in fostering Open Access.

Gunther Eysenbach keynote speeches schedule

Here are a few forthcoming events in the next 2 months where I am a speaker or keynote speaker:

• At the invitational NSF/NCI workshop "Cyberinfrastructure in Behavioral Medicine" in San Diego on March 31st I will speak about my infodemiology / infoveillance work


• Health Innovation and Policy Summit, Toronto (WebCite), on May 1st I will deliver the closing keynote on web 2.0 in health


• At the 2008 AMIA Spring Congress, May 29-31, 2008, Arizona Grand Resort, I will deliver a keynote on Personal Health Applications


• I am a keynote speaker at the Symposium "Supporting health by technology", on May 20th organized at the new ehealth Centre at the University of Twente (UT) in Enschede in the Netherlands, where I am a visiting professor,
  

I will also be at the NAS E-Journal Summit on Tuesday, March 18, 2008, at the National Academy of Sciences in Washington, and the General Assembly of the International Internet Preservation Consortium (of which WebCite is a member) in Canberra/Australia in April.

Another plagiarist bites the dust (anatomy of a plagiarizing paper)

Plagiarism is the practice of claiming or implying original authorship of (or incorporating material from) someone else's written or creative work, in whole or in part, into one's own without adequate acknowledgement. Unlike cases of forgery, in which the authenticity of the writing, document, or some other kind of object itself is in question, plagiarism is concerned with the issue of false attribution.

Within academia, plagiarism by students, professors, or researchers is considered academic dishonesty or academic fraud and offenders are subject to academic censure.

Plagiarism is different from copyright infringement. While both terms may apply to a particular act, they emphasize different aspects of the transgression. Copyright infringement is a violation of the rights of the copyright holder, when material is used without the copyright holder's consent. On the other hand, plagiarism is concerned with the unearned increment to the plagiarizing author's reputation that is achieved through false claims of authorship.

(Source: Wikipedia [WebCite]

I've always been interested in plagiarism - perhaps because I tend to be quite "open" about my ideas and intellectual products, releasing them on the web immediately as they arise. Being open about ideas however does not mean that I am always thrilled to see my ideas, words, phrases and products reused without proper attribution, which remains the cornerstone of scholarship. In fact, plagiarism is probably the #1 enemy of openess. (Having been burned a couple of times, readers of this blog will notice that I am particularly anal about pointing out how blog entries should be cited. Feel free to use anything posted here - but for god sake don't just copy & paste anything - if you use copy & paste, add some quotation marks and a reference to this blog, preferably using WebCite).

I have seen plagiarism in all shapes and forms, I know how prevalent it is, and I am not afraid to speak out and to blow the whistle, because I see it as a major threat to scholarship and openess.

In 1999, in a high-profile case that was also reported in Nature (Dalton R. Professors use web to catch students who plagiarize...and author gets similar paper retracted. (WebCite), one academic author copied & pasted extensive sections from my website, and reused it in a (subsequently retracted) peer-reviewed publication. A detailed account of this incident was also published in JMIR (Eysenbach G. Report of a case of cyberplagiarism - and reflections on detecting and preventing academic misconduct using the Internet. J Med Internet Res 2000;2(1):e4), which helped to coin the term "cyberplagiarism". This JMIR editorial also contained some considerations of what journals should do to avoid this plague, which is to use automatic software to check for signs of plagiarism. One of the epublishing innovations I am proud of is that JMIR was (to my knowledge) the first (and remains the to date the only?) journal that has implemented a policy of checking submissions routinely for plagiarism, using the TurnItIn plagiarism checker, a now very successful product and company, founded by John Barrie (Barrie JM, Presti DE. Digital plagiarism - The web giveth and the web shall taketh. J Med Internet Res 2000;2(1):e6).

These experiences also inspired me to do a little bit of research in that area on the prevalence of scientific misconduct, with some worrying results (Eysenbach G. Medical students see that academic misconduct is common. BMJ 2001;322:1307).

Since then I have been plagiarized many times again, and - while still a nuisance - I've almost learned to accept it as the most sincere form of flattery. I've encountered plagiarism in all forms and flavors: web-to-paper plagiarism (somebody who writes a paper lifted something from my webpage without attribution), web-to-web plagiarism (somebody lifted an idea and text from a website I created and recreates the same site without attribution - see this blog entry), software-to-software plagiarism (another research group takes open source software developed in my group, removes the copyright statements, and rebrands it as a project/idea initiated in their group without giving attribution), and also paper-to-paper plagiarism (words and ideas from my papers are being reused in other publications without proper attribution).

The latest case of paper-to-paper plagiarism was just pointed out to me three days ago. A watchful student sent me an email alerting me of the fact that one paper which was published in a medical informatics journal (not JMIR!) seemed to contain some paragraphs taken from my BMJ article on "Consumer Health Informatics", which was not cited (see this ithenticate report page - boxed paragraphs marked with [6] are from my paper). But this was only half the story.
I ran the entire published article through the plagiarism checker software which we use at JMIR (now called ithenticate - thanks to John Barrie's company for making this software available to JMIR!), and the result was quite shocking. Almost 50% of that published article (a review) appears to be cobbled together (i.e. copied & pasted) from various websites, abstracts etc. The excerpt from the report below speaks for itself. Everything displayed in boxes has been recognized by ithenticate as having been lifted verbatim from a website or an abstract. 5% of the paper was copied & pasted from my BMJ article on "Consumer Health Informatics" (which was not cited at all), 7% was copied from a EU call for papers (which was also not cited). A lot of information appears to be copied & pasted from abstracts of various papers, which were cited, but in these cases the author failed to indicate (using quotation marks) that these were direct quotes.
Perhaps even more shocking is that the author is not an inexperienced student, but a rather senior health informatician. What is also worrisome is that it is unclear how this blatant work of plagiarism could slip through the editorial process of that particular medical informatics journal, edited by respected medical informaticians. The plagiarism could have been easily spotted even in the absence of sophisticated plagiarism checking software by just skimming through the paper: One paragraph appears to be stolen from the AMIA Consumer Health Informatics website (again, no reference is made to it) - but it is so obvious that it is stolen from a workshop report because the the plagiarist actually forgot to remove revealing phrases such as "In this workshop, participants will discuss..". It is unclear whether any editor, let alone any peer-reviewer has ever read this paper in the first place.
There are some other juicy details in this developing story, but I have to bite my tongue at this point and wait what the editorial and institutional investigations will reveal.

For now, I'll let the ithenticate report speak for itself (remember, all boxed paragraphs were found by the software on websites or in other articles. The author used no quotation marks in the entire article). I have removed details on the authors' name and the title of the manuscript at this point.


Figure 1a-d. ithenticate report highlighting stolen paragraphs (boxed) in a published, plagiarizing paper from a medical informatics journal (not JMIR!).

Please cite as: Eysenbach, Gunther. Another plagiarist bites the dust (anatomy of a plagiarizing paper). Gunther Eysenbach Random Research Rants Blog. 2008-03-10. URL:http://gunther-eysenbach.blogspot.com/2008/03/another-plagiarist-bites-dust-anatomy.html. Accessed: 2008-03-10. (Archived by WebCite® at http://www.webcitation.org/5WDlfpXAB)

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UPDATE 27/05/2008:
The editor of the journal in question has informed me that the plagiarizing paper will be retracted. The following statement will be published as retraction notice:

The author of the article
[CITATION OF THE PLAGIARIZING PAPER]
has verified that he used a substantial fragment of text without attributing it to
Eysenbach G. Recent Advances: Consumer Health Informatics. BMJ 2000; 320:1713-16.

The author of the article including the unacknowledged material states that his failure to attribute was unintended and the result of hurried completion of his paper. He extends his deepest apology to the author of the original text and the readers of the [SERIAL] for this plagiarism. The editors of the [SERIAL] apologize to the non-cited author of the original article and to the readers of the [SERIAL] for not detecting and excluding this plagiarism from publication. They thank those who brought it to their attention. It is the policy of the [SERIAL] that all articles comply with professional standards of publication to avoid plagiarism. This requires that only short fragments of text from original sources be quoted (enclosed in quotation marks) and be immediately followed by an accurate citation of the source from which the fragment was taken. Because the fragment in question was neither short nor cited for its origin, the author has asked that his paper be withdrawn, and the editors hereby publish this retraction.

I'll let the reader decide whether the retraction statement above is appropriate or downplays the extent of the plagiarism - given that (as shown above) this is not just a failure to attribute a single citation. It also remains unclear why the paper was not reviewed in the first place, even though the SERIAL claims that its contributions are peer-reviewed.
The plagiarizing author is by the way also an official (a working group chair) of a scientific society (SERIAL is the official publication of that society), and the editor of the SERIAL is the president of that society. And to my knowledge, there were no consequences for the author from that society (while I resigned from my position within this society).
I guess this case is as embarrassing for the editor(s) of that journal as it is for the author, which is why there is a common interest in keeping this case "low profile".

Online PHR + Google AdWords/AdSense = A Privacy Disaster

Much is being written and blogged these days about Google Health, and as a general advocate of what I call "PHR2.0" (PHR: Personal Health Record) I am generally all excited about these developments.
I am also chronically annoyed by the privacy zealots who sometimes seem to want to protect consumers from their own choices ( "I think we've all consented to things online we haven't meant to simply by failing to check or uncheck a box," (Archived by WebCite®) - ok, but this shouldn't be a valid argument to protect consumers from having access to or entering health data in the first place).
Matthew Holt also doesn't see any privacy problems whatsoever (Archived by WebCite®), which is perhaps also a bit simplistic.

I see one particular privacy threat which I haven't seen discussed anywhere. The privacy threat is created whenever a personal health record (or any other sort of dynamic, private information) is combined with Google Ads, because Google Ads are created by third parties, and Google Ads are keyword/context triggered. Any combination of Google Ads with any sort of personal health information spells a privacy disaster.
Why? Imagine I am a bad guy who wants to compile a database of people with the condition "Amyotrophic Lateral Sclerosis". It is now a matter of five minutes to set up an ad at Google AdWords which is triggered by the keyword "Amyotrophic Lateral Sclerosis". Google AdWords also lets me define a target site, so I could define health.google.com or any other online PHR site such as myPHRsite.com as the sole target site where the ad (context-triggered) should appear. Now, whenever a user on that site would review his personal health record with integrated Google Ads, my ad would be triggered only if the word "Amyotrophic Lateral Sclerosis" shows up in my record. The consumer of course does not know this and if the ad is something innocuous such as "Click here to receive a free gift basket" he might click on the ad and - bingo - all I (as the bad guy) have to do is to link to a questionnaire pretending to send a gift to the consumer, asking for his/her personal information - name, address etc. Thus, I have a list of people who have the keyword "Amyotrophic Lateral Sclerosis" showing up in their Personal Health Record.
Yes, it is that simple.

Now, Google has said that Google Health will actually not have any ads (Archived by WebCite®). However, is this also true for other online PHR vendors?
The bottom line is that Google (as well as any other online PHR vendors) will never be able to put any Google Ads on any sort of online PHR, at least not without giving up the keyword/context sensitivity of the ads, which is the backbone of the Google Business model. Whenever you see an online PHR with Google Ads (or any other contextual ads) - run! (and send me an email).

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Please cite as: Eysenbach, Gunther. Online PHR + Google AdWords/AdSense = A Privacy Disaster. Gunther Eysenbach Random Research Rants Blog. 2008-03-08. URL:http://gunther-eysenbach.blogspot.com/2008/03/google-health-google-adwordsadsense.html. Accessed: 2008-03-08. (Archived by WebCite® at http://www.webcitation.org/5WB7C9LS5)

Black sheep among Open Access Journals and Publishers

Please cite as: Eysenbach, Gunther. Black sheep among Open Access Journals and Publishers. Gunther Eysenbach Random Research Rants Blog. Originally posted 2008-03-08, updated (postscript added) 2008-04-21, 2008-04-23, 2008-06-03. URL:http://gunther-eysenbach.blogspot.com. Accessed: 2008-06-03. (Archived by WebCite® at http://www.webcitation.org/5YIqkyRE4)

Definition of Spam: The word "Spam" as applied to Email means Unsolicited Bulk Email. Unsolicited means that the Recipient has not granted verifiable permission for the message to be sent. Bulk means that the message is sent as part of a larger collection of messages, all having substantively identical content.
Source:http://www.spamhaus.org/definition.html. Accessed: 2008-03-08. (Archived by WebCite® at http://www.webcitation.org/5WATKMPhU)

As a publisher and editor of the Journal of Medical Internet Research, a leading open access journal (and the #2 cited health informatics journal), I am (as many of my colleagues) usually very sympathetic to any new open access journal start-ups, and I know that some sort of marketing is necessary to attract submissions from top authors (luckily, JMIR has survived its first 10 years and now naturally attracts submissions from top authors). While JMIR never engaged or engages in any unsolicited bulk emails (we send out content alerts only to users who have opted-in), some other (in particular open access publishers) seem to betray the trust and sympathy bonus they receive by many researchers by relentlessly spamming researchers' email accounts asking for articles / submissions.

Several factors contribute to this plague, including (1) the ease with which author emails can be extracted from PubMed/Medline and other bibliographic databases, (2) the economics of open access publishing, where journals compete for authors (while subscription-based journals compete for subscribers/libraries) (3) the general goodwill of researchers/scientists associated with publishers (most want to keep good relations with publishers, as they know that they have to "publish or perish") and particular towards open access journal publishers.
Some spammers also use flattery as a technique - spam messages from Bentham actually contain the ridiculous note that "This is not a spam message, and has been sent to you because of your eminence in the field" - and some researchers are open to such flattery.

I fear that these practices of some black sheep among OA publishers will damage the reputation of OA journals at-large, so I decided - from now on - to publicly denounce any publishers (and others) engaging in this practice - in form of handing out a virtual spam award.

My first spam award goes to Bentham Publishers, a "publisher" of "over 200" author-pays open access journals. In the past couple of months I have received no less than 11 emails from Bentham, all mostly identical in text and form, all signed by "Matthew Honan, Editorial Director, Bentham Science Publishers" or "Richard Scott, Editorial Director, Bentham Science Publishers", "inviting" me to submit research articles, reviews and letters to various journals (I got one email per journal!), including "The Open Operational Research Journal", "Open Business Journal", "Open Management Journal", "Open Bioinformatics Journal", "Open Ethics Journal", "Open Analytical Chemistry Journal" and so on - all of them sent to me "because of your eminence in the field" (wow, I didn't know I was so eminent in so many fields! As an aside, the claim that "this is no spam because you are eminent" defies any commonly accepted definition of spam - a message is spam if it is bulk and unsolicited, whether the recipients are all Nobel prize winners or not is irrelevant).

All pleas and begging from my side to stop the spamming, as well as clicking on any "unsubcribe" links did not stop the spam plague from Bentham.

The bulk email "invites" me to submit articles and to pay for publication - "modest open access publication costs are usually covered by the author's institution or research funds.".

Buyers beware! There is a (limited) number of "serious" OA journals out there (such as PloS, JMIR, and others), where authors (or authors' institution) pay for the publication costs, but there are also throw-away journals out there from shady publishers trying to cash in on the current surge of interest in open access publishing.
Researchers who are in doubt about the reputation and scientific standing of a journal should check if the journal is Medline-indexed (none of the Bentham journals is actually Medline-indexed, although the spam emails suggest otherwise), and whether the journal receives any significant citations (check Web of Science or the Journal Citation Reports) before submitting to any Open Access journal.
And my recommendation for fellow scientists /researchers would also be to make it a principle to not submit anything to journals that engage in the practice of spamming.





Enough of these - PLEASE! (excerpt from one of a dozen spam emails I received from Bentham)

A couple of years ago, Biomed Central also engaged in quite aggressive marketing techniques, including spam emails (and even sending out emails which contained a preformulated praise of BMC, asking the recipient to send this email to colleagues). After I pointed out the (questionable) ethics of this to them (that was back in 2004), they seem to have stopped it - or was I only put on a blacklist, and others still receive this? Please contact me / comment here if you still receive those spam emails from BMC or if you know of any other spammers in this field.

Other spam examples from publishers

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Postscript (added 21/04/08)

Richard Poynder, a journalist who also commented on this post, has taken up the issue and plans to publish an interview with Mr Honan, a publishing executive at Bentham. In this, Mr Honan denies any wrongdoing, and says "the complaints are unjustified. We are mailing researchers on a limited basis to try and kick-start a number of Open Access journals, as indeed are a lot of other publishing companies. (...) The recipients are able to unsubscribe from these publishers' mailing lists if they want to, just as they can from our list." (Mr Honan, quoted by Richard Poynder, personal communication, 21/04/2008).

To rebut these claims I am uploading screenshots of my (a total of 4) requests to stop spamming (I hate the term "unsubscribe" as it suggests that I subscribed to anything in the first place). The emails all contained my uhnres.utoronto.ca email adr (to which I believe the emails were sent) and were sent from my gmail account, so they had at least those two email addresses. My unsubscribe emails were sent on Oct 24, 2007; Jan 4, 2008; Mar 5, 2008; and Apr 4, 2008. So far I received spam emails on or around Aug 23, 2007; Oct 22, 2007; Oct 24, 2007; Dec 12, 2007; Jan 1, 2008; two emails on Jan 2, 2008; Jan 4, 2008; Mar 5, 2008; Mar 22, 2008, and Apr 8, 2008 (see figures below).


Figure 1: Spam emails from Bentham asking me to submit my papers to their new journals



Figure 2: My 1st request to cease spamming


Figure 3: My 2nd request to cease spamming


Figure 4: My 3rd request to cease spamming


Figure 5: My 4th request to cease spamming

As an aside, the onus is NOT on the spam victim to prove or trace which email addresses they used to spam to, or to send them unscubribe emails.

The law is clear, Bentham has been breaking the law, and their attitude "we haven't done anything wrong and everybody does it" is unbearable. Perhaps they really need a judge to tell them that, if they don;t listen to the community they are claiming to serve (researchers). Their conduct is far from being reasonable - I am not against a limited amount of emails inviting certain experts to contribute to a journal, but not as a bulk (if I do this, I usually know the researchers personally), and their flurry of emails clearly crosses the line (according to their bulk email they even contacted me as an expert for "Analytical Chemistry"). I didn't even have any other previous business relationship with Bentham (the same can not be said for Elsevier, Springer, and BMC, where I had previous business relationships, so I might be more forgiving when I get something from them, and a lenient judge may rule that it is not spam if a previous business relationship existed.

The attitude "everybody does it, so we'll do it too" is exactly what leads to the ever-growing amount of spam from publishers - a vicious circle which I wanted to break with my blog post and giving this issue some publicity. An official apology and pledge not to continue this practice would go a long way. Instead, according to the interview, they seem to hold on to their position that what they are doing is a legitimate way of doing business. It seems to me that they are asking for getting sued.

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Postscript (added 23/04/08)

Richard Poynders' comment & interview with Bentham executive Honan has now been published [URL:http://www.richardpoynder.co.uk/Honan.pdf. Accessed: 2008-04-23. (Archived by WebCite® at http://www.webcitation.org/5XIpNqa1o)]. In the interview Honan claims that researchers like myself who desperately tried to get off the mailing lists of Bentham were simply too stupid to inform Bentham about all their email addresses ("The particular people (...) have multiple email addresses. That means that when they asked to be removed from our list we removed them — as we always do when we are asked — but they continued to receive messages via their other email addresses. We can only completely remove them from our list if they give us all their email addresses."). Taken aside the issue that spam victims are under no obligation whatsoever to do the research on behalf of Bentham what other email addresses the company may have on file, and taken aside the issue that the very process of letting researchers "opt-out" rather than opt-in is illegal, his claim is also simply untrue, as can be seen in the screenshots above. I clearly sent at least 4 different email requests which contained both my gmail and my utoronto email address, yet the spamming continued to exactly those email addresses (no, there was no forwarding from other email accounts). Honan is lying, and is it unfortunate that Poynder let him get away with simply denying any wrongdoing and downplaying the at best unethical and at worst illegal nature of their business behavior. I pity the researchers who have lent their name to Bentham (Archived in WebCite here - and I note that my colleague Dr Furedy is still listed here despite - as Poynder suggests - repeated attempts to get his name removed from the Bentham website). I don't often wish Open Access projects to fail, but I have to say that I am getting increasingly concerned about the role of commercial open access publishers.

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Postscript (added 03/06/08)
Matthew Honan from Bentham has sent me a formal apology (after I threatened to sue them and demanded dislosure of what personal information about me they have and with whom they share it):

We wish to apologise to you for the inconvenience the email messages we sent to you have caused. We admit we should not have done this especially since you had requested on several occasions not to receive further emails from Bentham Science. It was down to our error for failing to do this in a timely way for which we sincerely regret doing and apologise once again to you. You will never receive messages again from us. We are also going to stop such activity as much as possible from now.

We have no personal data on you on file. The reason for sending you the emails were for soliciting a paper to several of our new open access journals. We certainly would never forward your email details to any third parties or other classes of recipients. The source of your emails were located in the public domain at the following urls http://www.jmir.org/about/contact http://www.hpme.utoronto.ca/faculty/list/eysenbach.htm



We do not have a record of email addresses with specific dates we sent you the messages in the past other than the dates you cited to us. In my interview with Mr. Poynder I would like to make it clear that he did not discuss with me your complaint until several days after the interview and then after I did request him to state an addendum of apology to you from Bentham Science.

For now, this settles the matter for me - unless I am getting further emails from Bentham I will probably not take any legal action.

Meanwhile, I am continuing - partly as a result of the Bentham affair - my efforts to create interest for an Association of Open Access Publishers, which - among other objectives - will make sure that its members (gold OA publishers) adhere to some ethical principles, which includes responsible use of email. A "Bird-of-a-Feather" meeting will be held at ELPUB (see this post).

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Postscript (added 09/07/08)
New spammers: Dove Medical Press and Libertas Academica, both based in Auckland, both published by Timothy Hill or Tom Hill (the same person?), also use relentless spamming techniques, flooding prospective authors with unsolicited emails as a marketing strategy. The issues are remarkably similar to the Bentham case: The marketing is not targeted - I received "invitations" to submit articles for journals which are not in my field (e.g. Bioinformatics and Biology), I have been unsuccessful to get off their mailing list, there are no automatic unsubscribe links (not to talk about the fact that I never subscribed to anything in the first place), and when I finally got through with my emails, publishers were unapologetic (for details see comments thread to this post).
Anybody receiving these kind of invitations should submit a complaint to the New Zealand Spam Complaint System

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Postscript (added June 15th, 2009)

• Bentham continues to be in the news with ethically questionable and unprofessional behavior. In April 2009, a Bentham editor (Professor Marie-Paule Pilen) resigned from her post after a Bentham journal published a controversial 9/11 conspiracy paper. She said she had not seen the paper before it was published.
  
• As reported by The Scientist, Phil Davis, an ex-librarian, open access critic, and author of a study which claims that open access does not lead to improved citation impact, and Kent Anderson, executive director of international business and product development at the New England Journal, sent a computer-generated paper to Bentham, which was accepted in June 2009, with Bentham claiming that it had undergone peer-review (interestingly, Davis said one of the reasons why he did this to Bentham was the persistent spamming from Bentham - so despite my warnings to Bentham they seemed to continue it!)
  
• Bambang Parmanto, a University of Pittsburgh information scientist and editor of the discredited Bentham journal which accepted Phil Davis' fake paper, subsequently resigned from his editorship at The Open Information Science Journal (TOISCIJ), claiming that he hasn't seen the paper
• Luckily (partly as a result of this blog entry and the subsequent discussions), the leading Open Access publishers have now gotten together and created the Open Access Scholarly Publishers Association (I am a founding member and on the Board of OASPA). OASPA membership can be seen as a qualiy seal, as members comit themselves to quality criteria such as peer-review, and OASPA will sanction members that behave unethically or bypass peer-review (Bentham is not a member of OASPA). OASPA responded to the Bentham affair on its blog here.

Medicine 2.0 Congress Website launched (and: Definition of Medicine 2.0 / Health 2.0)

Please cite as: Eysenbach, Gunther. Medicine 2.0 Congress Website launched (and: Definition of Medicine 2.0 / Health 2.0). Posted at: Gunther Eysenbach's random research rants (Blog). URL: http://gunther-eysenbach.blogspot.com/2008/03/ medicine-20-congress-website-launched.html. Accessed: 2008-03-07. (Archived by WebCite® at http://www.webcitation.org/5W9GcYyWN)
(Note: A more refined version of this blog entry will be published as editorial in JMIR - once published please cite as: Gunther Eysenbach. Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness. J Med Internet Res 2008 (in press) http://dx.doi.org/10.2196/jmir.1030 . DOI:10.2196/jmir.1030)

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Yesterday I officially launched the website (http://www.medicine20congress.com) of the forthcoming Medicine 2.0 congress in Toronto, Sept 4-5th, 2008, which has the by-line “How Social Networking and Web 2.0 changes Health, Health Care, Medicine and Biomedical Research”. Although (in collaboration with the people involved in the International Medical Informatics Association [IMIA] Web 2.0 Task Force) we discussed and collectively came up with a list of topics for the conference (listed here in the call for papers and panel proposals), some additional explanations on what I (as a conference chair) see as being in scope for the Medicine 2.0 conference are in order (these considerations are in part taken from my forthcoming JMIR Editorial – the full paper will appear (and should be cited) as: Gunther Eysenbach. Medicine 2.0. J Med Internet Res 2008 (in press) http://dx.doi.org/ 10.2196/jmir.1030. DOI:10.2196/jmir.1030).

Doing a conference related to Web 2.0 is perhaps always a bit of a risk, as the term Web 2.0 itself is controversial and ill-defined. My simplified view on Web 2.0 is based on Charlton Barreto’s concise description of Web 2.0, which I decided to adopt for the Medicine 2.0 congress:

Web 2.0 is a term which refers to a) improved communication and collaboration between people via social-networking technologies, b) improved communication between separate software applications ("mashups") via open Web standards for describing and accessing data, and c) improved Web interfaces that mimic the real-time responsiveness of desktop applications within a browser window.

There are obviously other definitions, and all of them have their merits, but I believe the description above is broad enough to cover most of the more narrow definitions.
Semantic web applications (sometimes called Web 3.0 – although I really hate this term because the semantic web idea actually precedes many Web 2.0 technologies) and 3D environments (Second Life) can also be seen as second generation Web technologies, and I made an executive decision that those are also within the scope of the Medicine 2.0 congress.

On the scope and definition of Medicine 2.0


I've created the figure above (updated 20/09/2008) to depict how the broader “Medicine 2.0” space can be mapped out. These are grounded in some extensive discussions with other academics and users, as well as a scan of what people submitted in response to the JMIR Medicine 2.0 call-for-papers, but again, this is not written in stone, but just happens to be how I view the field today and how I decided to scope the Medicine 2.0 congress.
The field is obviously highly dynamic and the landscape will change rapidly (in particular the Web 2.0 tools in the core of the graphic as well as the exemplary company/service names written in blue font may change rapidly – readers are invited to let me know if they propose additions or changes).
However, I believe that five major aspects (ideas, themes) emerge from Web 2.0 in health/health care/medicine/science, which will outlive specific tools and services offered. These emerging and recurring themes are (as displayed in the center of the graphic):
1) Social Networking,
2) Participation,
3) Apomediation,
4) Collaboration, and
5) Openness.

I believe that any academic discourse of the impact of Web 2.0 technologies should be framed around these themes. Each of the 5 themes will be considered in turn below.

Before we delve into these five themes, I should briefly digress and discuss a frequently asked question, which is “what is the difference between Health 2.0 and Medicine 2.0”, or more specifically, why did we decide to call our conference (as well as the JMIR Theme Issue) “Medicine 2.0” rather than Health 2.0. The answer is simple: For purely practical reasons.
First, the term “Health 2.0” is trademarked by Matt Holt for his conference series – while we wish to brand our own (more academically and internationally oriented) conference series without risking confusion with the (successful) work of Matt. While there is clearly an overlap (and we hope that some of the Health 2.0 participants will attend our Medicine 2.0 conference!), we do see our conference as a complement rather than competition to the Health 2.0 conference series, as the latter attracts primarily a business audience, while Medicine 2.0 will primarily attract academics; moreover, Health 2.0 (both in terms of the current “definitions” offered at http://health20.org/wiki/Health_2.0_Definition and the conference) focuses very much on the US system, while Medicine 2.0 has an international focus.
Secondly, Health 2.0 has already been defined by various players, and as a conference chair I take the prerogative to start with a clean slate and to define what we mean with it ourselves.
Thirdly, some (e.g. Frank Dolan [WebCite]) view “Health 2.0” as the consumer-side of things, while we think that ultimately Web 2.0 applications should bring together (and foster collaboration between) different stakeholders and user communities. Fourthly, the dictionary definition of “medicine” is “something that affects well- being” and “the science and art dealing with the maintenance of health and the prevention, alleviation, and cure of disease” (Merriam Webster’s 11th Collegiate Dictionary). Thus, “Health” is a (possible) outcome, while “Medicine” is the means (the science and the art) to achieve the outcome. Much as we would call Web 2.0 business applications “Business 2.0” (business is the means) rather than “Money 2.0” or “Wealth 2.0” (the outcome), I prefer to call Web 2.0 applications in our field “Medicine 2.0” rather than “Health 2.0”. Moreover, as an academic I like the science aspect and I like to see proof (and do research myself) before I actually believe that Web 2.0 applications actually improve health. I also believe that creating successful Web 2.0 applications in our area is as much as an art as it is a science, so I like the “art” aspect in the definition of medicine as well. Lastly, I believe that “health” is one (but only one) of many possible outcomes of Medicine 2.0 applications; others could be cost-savings, improved communication and trust between different stakeholders, improved quality, convenience, user-experience etc. And I stress “possible”, because it remains yet to be proven that those applications actually improve health, venture capitalist rhetoric notwithstanding.
Thus, I view Medicine 2.0 as a wider concept and umbrella term, which includes consumer-directed “medicine” and encompasses Health 2.0 (as far as defined as the consumer-side of things), but which – for example – also includes applications that enables health professionals and biomedical scientists to stay abreast of the current literature and to improve the quality of the scientific output (Science 2.0, Peer-Review 2.0), as mapped out in the triangle in the figure in the lower right angle. While some (e.g. Frank Dolan [WebCite] ) view Health 2.0 “as being those that provide services geared towards the consumer, and Medicine 2.0 those geared towards services for the medical professional”, I should stress that I respectfully disagree with this notion - my perhaps more holistic view on Medicine 2.0 is that this distinction between consumer services and services for health professionals is of limited use, because the ultimate goal of Web 2.0 applications is to bring these user groups together, rather than to erect new walls and to continue the fragmentation and silo-thinking in health and health care. For example, peer-review processes and the quality of the scientific output can well be improved by involving consumers, and it is ultimately consumers who benefit from openness in the science field. While I couldn’t agree more that “medicine” must move out of the hospital and the silos of the current medical system (see my previous blogs and writings on consumer health informatics), I also think that “medicine” is a broad enough concept that also conveys that “medicine” must not necessarily be professionally led (i.e. it includes consumer-directed initiatives, self-help) and includes preventive as well as curative medicine.

Back to the definition of Medicine 2.0: In my framework (see graphic), the three main user groups of current Medicine 2.0 applications are represented as a triangle: consumers/patients, health professionals, and biomedical researchers. Each of this user group is at a different end of the spectrum of specialisation, and “formal” training, but I also like the notion that “the health professional is an expert in identifying disease, while the patient is an expert in experiencing it” (Davidson KP, Pennebaker JW. Virtual narratives: Illness representations in on-line support groups. In: Petrie KJ, Weinman JA, editors. Perceptions of Health and Illness. Amsterdam: Harwood Academic Publishers; 1997. p. 463-86 ). Thus, essentially all users can be seen as ”experts”. Current Medicine 2.0 applications can be situated somewhere in this space depending on what user group they are primarily targeting, however, as said above, the ideal Medicine 2.0 application would actually try to connect different user groups and foster collaboration between different user groups (for example, engaging the public in the biomedical research process).
Putting it all together, my (micro-level) definition of Medicine 2.0 is as follows:

Medicine 2.0 applications, services and tools are Web-based services for health care consumers, caregivers, patients, health professionals, and biomedical researchers, that use Web 2.0 technologies as well as semantic web and virtual reality tools, to enable and facilitate specifically social networking, participation, apomediation, collaboration, and openness within and between these user groups.

The broader idea (the macro level) of Medicine 2.0 or “second generation medicine” is the notion that healthcare systems need to move away from hospital-based medicine, focus on promoting health, provide healthcare in people's own homes, empowering consumers to take responsibility for their health etc. – much in line with what I and others have been writing previously about the broader field of consumer health informatics (of which Medicine 2.0 applications, particularly those in the upper angle of the triangle and PHR 2.0 [WebCite], are one example). Thus, in a way, Medicine 2.0 also stands for a new, better health system, which emphasizes collaboration, participation, apomediation, and openness, as opposed to the traditional, hierarchical, closed structures within health care and medicine (In that sense it is perhaps similar to the broader definition of Health 2.0 proposed by Scott Shreeve [WebCite] – although that definition has been criticized as “perhaps overly ambitious” [WebCite], and I have personally difficulties to see how that notion of Health 2.0 is fundamentally different from what we have been writing for decades on the more general notion of consumer health informatics). Another word of caution: I do think that information and communication technologies can be a catalyst for change, but I think the step from pre-Web era to Web 1.0 was probably a much more significant step to change our thinking in terms of the role of the consumer than the step from Web 1.0 to Web 2.0 (and Tim Berners-Lee, who also dismisses the term Web 2.0 saying that this was what the web was all about in the first place, would agree). Also, while Medicine 2.0 tools clearly have a role to play in accelerating change in health care and biomedical research towards these ideals of participation, collaboration and openess (as does the Internet itself and first generation Web tools), one should not be naïve enough to believe that Web 2.0 approaches alone will be sufficient to suddenly revolutionize the way medicine is currently done – wider policy interventions and change management processes are necessary to achieve this goal. This is analogous to the concept of empowerment and why Internet or Web interventions alone are not sufficient to change the entire health system: “Information” is one necessary aspect in “empowering” a specific group (e.g. consumers), but alone and in itself not sufficient – other dimensions need to be addressed on a political / policy level to truly “empower” a user group, including access (e.g. to resources), choice (e.g. of resources), representation (in decisions about structure and deployment of resources), redress of grievances (mechanisms to address concerns how ressources are used) [Brennan & Safran. Chapter 2 Empowered Consumers. In: Lewis, Eysenbach, Kukafka, Stavri, Jimison. Consumer Health Informatics. Springer, 2005].

Now finally back to the 5 major themes mapped out in the diagram.

Social networking is central to many Web 2.0 and Medicine 2.0 applications and involves the explicit modelling of relationships between people, forming a complex (and scale-free) network of relations, which in turn enables and facilitates collaboration and collaborative filtering processes. This enables users to see what their peers or others with a predefined relationship (“friends”, “colleagues” etc.) are doing, enables automated filtering and selection of “relevant” information (based on what peers are doing), enables reputation and trust management, accountability and quality control, and fosters a viral dissemination of information and applications (it is this “viral marketing” aspect that makes venture capitalists salivating over Web 2.0 applications). I do believe that the social networking aspect (i.e. modelling relationships between players) is a relatively important and new aspect in health informatics. Electronic health records traditionally do not contain any form of modelling of relationships between people (it’s difficult enough to model the doctors’ thinking!), and when we combine social networking approaches with emerging technologies such as Personal Health Records a new class of applications emerges [see my previous entry with my conceptualization of what I call PHR 2.0 [WebCite]]. However, for quality management and collaborative filtering, the application of social networking (and the attempt to model relationships) has been tried before. In fact, almost a decade ago, in the framework of the MedCertain and MedCircle projects, we started thinking about this and viewed the explicit modelling of social relationships and the “who said what about a specific website” as one promising way to guide consumers to high-quality information. We developed a vocabulary to describe relationships between those involved in quality initiatives on the Web, with the eventual goal to build intelligent tools that can harness this information [Eysenbach G. An Ontology of Quality Initiatives and a Model for Decentralized, Collaborative Quality Management on the (Semantic) World Wide Web. J Med Internet Res 2001;3(4):e34.]. Today, this approach might be called a Web 3.0 application, but as I said above, I hate this term, as the relevant technologies such as semantic web, RDF, FOAF etc. pre-date most Web 2.0 technologies. Based on my experiences with MedCertain and MedCircle I also remain sceptical that “Web 3.0” will really take off – my scepticism is grounded mainly in a lack of a business model and huge privacy implications which most people seem to ignore. Can anybody imagine that Facebook would release its vast database content (i.e. social network data) as a machine-readable (RDF-FOAF) data dump?

Participation is another central theme in Medicine 2.0, and is particularly important for the user group of consumers/patients. The Internet has always been a tool for users and citizens to get more involved, but Web 2.0 tools take this to a new level. Personal Health Records and in particular PHR 2.0 [WebCite] are a part of this development. We have come a long way – when I first wrote about consumer health informatics tools opening up the possibility for consumers to view their electronic health record (Eysenbach G. Consumer Health informatics. BMJ 2000) some people thought I was crazy... Personally, I have always seen the Web and related technologies as the perfect tool for user empowerment and engagement, but again, Web 2.0 approaches take this to a new level, as the philosophy of end-user participation and engagement is deeply ingrained in the Web 2.0 thinking (“trust your users”), exemplified by tools like Wikis.
Wikis, rating tools etc are also the perfect example to illustrate that the "participation" theme is also relevant for other user groups such as scientists or health professionals.

Apomediation is a new scholarly socio-technological term that characterizes the process of disintermediation (intermediaries are middlemen or “gatekeeper”, e.g. health professionals giving “relevant” information to a patient, and disintermediation means to bypass them), whereby the former intermediaries are functionally replaced by apomediaries, i.e. network/group/collaborative filtering processes [Eysenbach, 2008 [WebCite] and 2007b]. The difference between an intermediary and an apomediary is that an intermediary stands “in between” (latin: inter- means “in between”) the consumer and information/service, i.e. is absolutely necessary to get a specific information/service. In contrast, apomediation means that there are agents (people, tools) which “stand by” (latin: apo- means separate, detached, away from) to guide a consumer to high quality information/services/experiences, without being a prerequisite to obtain that information/service in the first place. The switch from an intermediation model to an apomediation model has wide implications for example for the way people judge credibility, as hypothesized and elaborated in more detail elsewhere [Eysenbach 2008] [WebCite].



In the health context, disintermediation (cutting out the middleman) means a more direct access of consumer to their personal data (e.g. in web accessible EHRs – left circle of the diagram) and general medical information (on the web – right circle of the diagram) with all its advantages and hazards. The main problem of cutting out the gatekeeper is that the traditional role of the middleman is to guide consumers to relevant and credible information (the intersection of both circles in the center of the diagram) and that by bypassing the middleman consumers/users may “get lost” in the vast amount of information. Apomediation theory conceptualizes that “apomediaries” (which includes Web 2.0 approaches) can partly take over the role of the intermediary and “push” or “guide” users to relevant and accurate information.
The Web 2.0 environment is essentially an “apomediated environment”, with all the issues affecting related to apomediation phenomeon, raised by [Eysenbach 2008] [WebCite].
and summarized in Table 1.

Table: Apomediation vs Intermediation Environment.
(Citation: Eysenbach, Gunther. Credibility of Health Information and Digital Media: New Perspectives and Implications for Youth." Digital Media, Youth, and Credibility. Edited by Miriam J. Metzger and Andrew J. Flanagin. The John D. and Catherine T. MacArthur Foundation Series on Digital Media and Learning. Cambridge, MA: The MIT Press, 2008. 123–154. doi: 10.1162/dmal.9780262562324.123 Copyright: 2008 Massachusetts Institute of Technology. Published under Creative Commons Attribution-Noncommercial-No Derivative Works Unported 3.0 license). http://www.mitpressjournals.org/doi/pdf/10.1162/dmal.9780262562324.123


Apomediation theory further argues that apomediaries, such as users and friends in the case of Digg, can help users navigate through the onslaught of information afforded by networked digital media, giving additional credibility cues and supplying further metainformation. Other examples of apomediaries and apomediation tools include consumer ratings on amazon.com or epinions.com; technologies like PICS or MedPICS labels and its RDF successors that enable machine-processable dissemination and interpretation of user ratings (Eysenbach, Yihune, Lampe, Cross, & Brickley, 2000; Eysenbach & Diepgen, 1999a); collaborative filtering and recommender systems as exemplified by StumbleUpon.com; and other second generation Internet-based services and tools that let people collaborate on a massive scale and share information online in new ways, including social networking sites, social bookmarking, blogs, wikis, communication tools, and folksonomies (Wikipedia, 2007b; Wikipedia, 2007c).
The Dynamic Intermediation-Disintermiation-Apomediation model (DIDA) (illustrated in the Figure below) argues that whether or not consumers prefer an apomediation or intermediation environment is highly situation-specific, and key variables in determining consumer preference are autonomy, self-efficacy, and knowledge in a specific area for which information or support is sought. For example, a cancer patient may initially prefer an intermediary, but with growing autonomy, self-efficacy, and knowledge prefer Web 2.0 approaches to guide him/her to information deemed trustworthy.


Dynamic Intermediation-Disintermiation-Apomediation model (DIDA).
(Citation: Eysenbach, Gunther. Credibility of Health Information and Digital Media: New Perspectives and Implications for Youth." Digital Media, Youth, and Credibility. Edited by Miriam J. Metzger and Andrew J. Flanagin. The John D. and Catherine T. MacArthur Foundation Series on Digital Media and Learning. Cambridge, MA: The MIT Press, 2008. 123–154. doi: 10.1162/dmal.9780262562324.123 Copyright: 2008 Massachusetts Institute of Technology. Published under Creative Commons Attribution-Noncommercial-No Derivative Works Unported 3.0 license).
http://www.mitpressjournals.org/doi/pdf/10.1162/dmal.9780262562324.123


Apomediation is not only important with the consumer as end-user and the health professional as intermediary in mind. As mentioned in a previous blog post, we also witness an apomediation process in science, with the former intermediaries such as journals becoming partly (and increasingly) obsolete, with much of the communication between scientists taking place on the Web before an article is actually published, necessitating scientists to use "apomediaries" to guide them to the relevant information on the Web (in fact, the only reason why we appear to still need journals is to make online information "citable", which in itself is absurd - as mentioned in a previous post - and could be overcome by archiving tools such as WebCite). Also, health professionals now partly bypass traditional intermediaries such as information brokers or librarians. I remember that when I was in medical school I had a summer job as information broker, where health professionals or scientists would call or see me and I would do an online Medline search for them. Today, people obviously use PubMed and other Internet tools directly, and search the web and/or the library for relevant information. But what is "relevant", and how can we deal with the onslaught of information? The "apomediaries" here are shared bookmarking tools such as CiteULike or Connotea, where people receive pointers to recently published relevant literature based on what others with a similar citation/bookmarking behavior have cited/bookmarked.

Collaboration specifically refers to bringing groups of people closer together who have not or insufficiently interacted with each other (including for example public participation in research, user engagement in health care decisions etc.). From a Web 2.0 perspective, email is old technology – the youth of today is using RSS feeds to keep informed about what others’ in their social network are up to. Collaborative filtering processes (harnessing the “wisdom of the crowd”) provide a powerful incentive for users to collaborate in the first place and to feed information into the system rather than to just “lurk”. For patients this means for example that – once they enter or make available additional information about their health status in a “PHR 2.0” (see my previous blog and figure below)– they can receive resource recommendations based on what other people with a similar profile recommend or do. For health professionals and researchers, collaborative filtering means that they can get relevant recommendations for literature resources once they use social bookmarks, citation tools such as CiteULike or Connotea, or web citation/archiving tools such as WebCite. Collaboration between researchers on one hand and the public and health professionals on the other hand also means improved possibilities for knowledge translation – getting research findings into practice.



Finally, I would argue that openness is another important and emerging theme partly fuelled by the Web 2.0 way of thinking. On one level – the technical level -, Web 2.0 stands for transparency and open interfaces on a coding and interoperability - “don’t lock me in”, “my data belong to me”, “web as operating system”, and “open up your API” are popular philosophies associated with Web 2.0. HealthVault and Google Health both have (or are promised to have) APIs for other people to connect to. The “openness” philosophy of Web 2.0 tools will raise the expectations of the Facebook generation in terms of dealing with their health data. Web 2.0 savvy consumers (especially todays’ generation) will push the envelope and demand more than just a institutions-specific “portal” (also called tethered PHR). Patients 2.0 will demand full control over their data (as a minimum, XML export!) – many Medicine 2.0 applications fall short in that regard, in that people can feed information into the system, but can’t get it out again.
On another – societal - level, Medicine 2.0 also implies openness and transparency which enables for example users (including the public) to access information and data they previously did not have access to (open access journals, open data etc.) or even to engage in the research process (open peer-review).

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Medicine 2.0, PHR 2.0 are trademarks registered by the author