I have been published in the Journal of Evidence Based Mental health this month. See previous post for further reading about this subject.
Evidence based mental health and Web 2.0
Introduction: Web 1.0 vs Web 2.0
Since its introduction in the early 1990s, the web has evolved significantly. Initially, most websites had a passive user role and either displayed static information or facilitated online transactions. However, recently the web has become more interactive and many of the most popular websites are now online applications which depend heavily on user participation.
This participatory model of web usage has come to be loosely known as ‘Web 2.0’ and the initial non-participatory web correspondingly as ‘Web 1.0’. The term has been popular since 2004 and it is as much ideological as technical. Applications associated with Web 2.0 commonly facilitate the creation and exchange of user generated content. Examples include blogs, social networking sites, wikis and media sharing sites. These sorts of sites have become some of the most visited and discussed about properties on the internet.
Web 2.0 applications are predominately easy to use and free of charge and respond much more rapidly to events than do traditional media. They offer new ways for clinicians to access, share and evaluate healthcare information. Due to their inter-active nature they are constantly evolving and enriching and anyone who uses them assists in their development. However, they also have limitations that need to be understood.
Healthcare professionals have yet to take full advantage of Web 2.0 technologies. In this article I will discuss and critique Web 2.0’s major applications and their potential for the practice of evidence based medicine and mental health.
Web 2.0 applications
Blogs, wikis and microblogs (together with Really Simple Syndication (RSS)) are reviewed ?rst as they have had the greatest impact and share some of the same advantages and disadvantages.
Blogs, RSS, wikis and microblogging
The blog was one of the earliest social software tools. Blogs are a very popular form of expression and account for 1.2% of UK internet traffic. They are very easy to start and allow anyone a voice. The term ‘blog’ is a contraction of ‘web log’.
Blogs are an extremely heterogeneous phenomenon. They range in size and seriousness and may be updated from almost constantly to only very infrequently. The majority are maintained by individuals but sometimes there are multiple contributors.
At their simplest blogs resemble an online diary. They can also offer commentary, descriptions of events, or other material such as pictures or video. Despite this diversity, all blogs share common features as follows:
- The front page of a blog consists of a list of the latest articles or ‘posts’, the most recent first.
- Old posts are archived by theme and/ or date.
- Readers can add comments to each blog post allowing an article to be discussed.
- Blogs are highly interlinked; active bloggers read each other’s blogs and reference other blogs in their own posts.
A blog is written by a blogger and the act of writing a blog is called blogging. Taken together the interconnected community of blogs are referred to as the ‘blogosphere’. Blogs allow groups of people with an interest in a common topic to reflect upon, share and debate their knowledge. Because of this, blogs can often attract a large and dedicated readership.
Many blogs are concerned with medical issues and are useful if one wishes to keep track of an emerging topic more closely than would be possible in a journal. Peer reviewed medical research is often examined by bloggers and this represents an additional further lay and peer review. Following the blogger’s critique this in turn, as well as the research paper, is further critiqued in subsequent reader comments and interlinked posts on other blogs. Posts from blogs discussing peer reviewed research are collated at sites like Researching Blogging.
Although all major journals have web presence, most have shied away from reader contributions to their sites. The British Medical Journal is an exception and has added blogs to its online featured content. It also allows readers to add ‘rapid responses’ to journal articles published online, a facility similar to blog comments.
Syndication – RSS
RSS is a web feed format used to publish frequently updated content such as blog entries, news headlines or podcasts. If a user subscribes to the RSS feeds of a number of sites of interest they then are able to read the collected ‘feed’ on a RSS reader. This avoids the need to check each site of interest individually for updates.
For the clinician, RSS allows a variety of information to be received via a single organised interface. This could include content from the best medical blogs, evidence based sites such as the Cochrane library and newly published content from medical journals
A wiki is a website that allows collaborative creation and editing of interlinked web pages. These web pages then form a repository of information and knowledge that can be used by large numbers of people. Contributions or modifications can be made by anyone who has been granted access. Wiki means ‘hurry’ in Hawaiian.
Anyone can set up a wiki, and the web hosting and software to allow this is easily available and in most cases requires no technical knowledge. The most well-known example of a wiki is Wikipedia. This site is an online encyclopaedia where the content has been contributed by volunteer users working in collaboration. The Wikipedia model offers many advantages over a traditional equivalent. With 15 million available articles, it has a scope which far exceeds even the most expansive printed encyclopaedia. It is free to access and available to anyone with an internet connection. As well as being an encyclopaedia Wikipedia is also a frequently updated news resource as updates appear very quickly. Each article has a discussion page where contributors debate a subject’s most suitable content. Wikipedia can be an excellent place to start researching a subject and one reason for this is that the best articles are referenced by external sources which are often web links themselves. Wikipedia’s accuracy has been found to be similar to that of the encyclopaedia Britannica.
There are several specialist medical wikis available such as Ganfyd and Wikidoc. Alongside Wikipedia they potentially offer up to date, easily accessible medical information.
It is a mistake to think that wikis are only suitable for projects on a grand scale. Any local facility, such as a hospital, could set up a wiki to be used as an easily assess-able and updatable repository of clinical information and local best practice. Many conferences now offer a wiki or blog to facilitate preconference networking.
Microblogging and Twitter
Typically a microblog consists of brief text updates, photos, audio/video clips or links. These are distributed to a group of subscribers via a website or hand held device. Content can be submitted via text messaging, instant messaging or email. Microblogs offer a new electronic communication medium, which can be used to complement those already established such as email.
Here I will concentrate on Twitter, the most popular microblogging plat-form. Twitter is one of the most high profile Web 2.0 applications and is enjoying exponential growth. On Twitter users post frequent short updates (up to 140 characters long) known as ‘tweets’. Tweets are public, but direct private messages can also be sent to other users. Taken together these updates form a chronological list (or feed) which can be viewed on a Twitter profile page or on a hand held device. A user can choose to subscribe or `follow’ another Twitter user’s tweets and this gives a real time picture of what the person they are following is up to or thinking important.
Twitter offers the possibility of a clinician communicating with a large number of knowledgeable peers about clinical questions while ‘on the go’ – there is no need to have desktop or laptop computer access. As such a group will have a wide cross section of knowledge it is possible for a clinician to send out a question to their Twitter net-work and to get the answer they seek very quickly. Because of this for some people Twitter has replaced Google, as they are more likely to ask their Twitter followers when they wish to know something than they are to use the search engine.
Twitter can also be used for mentoring, as a tool to gather data, and for brain-storming and feedback. It can also be used to allow delegates to give reactions to conferences in real time. Many online articles have a facility that allows readers to tweet the article if they find it of use. In this way the number of tweets that an article is awarded allow it to be rated.
Disadvantages of blogs, wikis and Twitter
Blogs, wikis and microblogs all suffer disadvantages for those wishing to undertake evidence based medicine or mental health. Principally, there is no guarantee of authoritative control over their content.
Blogs, as they are often written by individuals, are vulnerable to being superficial, to the expression of personal views masquerading as fact and to the echoing of pre-existing data or opinion. Wikis, due to their collaborative nature, are less prone to polarisation, but are particularly vulnerable to vandalism and misinformation – either malicious or due to commercially influence.
Some wikis have sought to minimise this problem by restricting the people who are able to edit their content. The restrictive editorial policy of medical encyclopaedia Ganfyd, as well as some sections of Wikipedia are examples of attempts at quality control. Changes to pages can be monitored and ‘rollback’ allows pages to be reverted to earlier, more correct versions. Others feel that ‘Darwikinism’ in which ‘unfit’ sentences or sections are speedily edited and replaced by other users is remedy enough. However, the time between notification of error and cleanup is still a window of possible harm.
Wiki entries are generally unsuitable for use as academic paper references. A wiki’s content is typically dynamic and wiki authors are often impossible to identify (along with their credentials). The content of blogs is generally more static as blog posts are not generally altered after they are posted. However, the content of a blog is still no more reliable than its administrator.
Tweets are no more verifiable than blog or wiki content. However their nature does make them less likely to be used as reference material over an extended period. Of note is that unlike wikis and blogs, which are often run privately on open source software, Twitter is a proprietary company with a profit motive. It is possible that in the future Twitter may choose to generate revenue from tweets or use account details in ways that run contrary to the preferences of an individual.
Overall, it would be very wise to double check any information gleaned from a blog, wiki or tweet should one wish to rely on it and/or have any doubt about its provenance.
Other web 2.0 sites
Online social networking services allow the building of social networks or relations among people. Users who sign up to a social networking site are represented on the site, usually by a profile. Other users who are registered for the service can then potentially access this profile. In this way social links can be made and individuals can share ideas, activities, events and interests either within their individual networks or more publically.
The most popular social networking site is Facebook. Myspace and Bebo are also examples. LinkedIn is a net-working site for professionals and is used for connecting people together in a professional work context. With services like Ning people can set up their own social networks.
In terms of the practice of medicine and healthcare, social networking has had its biggest impact in facilitating the communication of patient groups. Facebook allows individuals to easily set up group pages which allow the sharing of information to interested parties. More specialist patients focused sites allow people to share information about illness experiences and treatment. Revenue is generated by selling the data obtained from the users or by recruiting members for clinical trials conducted by pharmaceutical companies.
Social networking sites do exist for medical doctors, primarily in the USA. Such sites offer the possibility for members to extend their networks electronically to find resources and like-minded colleagues.
Social bookmarking is a method for web users to organise and share bookmarks of web resources. Unlike file sharing, the resources themselves are not shared, only their web addresses. As well as allowing an individual to bookmark web pages of special interest to them, users can also access bookmarks of other users. This collaborative categorisation of web content is known as folksonomy and has some advantages over categorisation automatically performed by search engines.
Delicious is a popular general social bookmarking site. CiteULike and Connotea are similar but aimed at people wishing to share links to academic papers.
Podcasts, vodcasts and media sharing
Podcasts are audio files that are made available for download over the internet. A listener downloads the files and either plays them on a computer or on a listening device such as an iPod. The video equivalent of a podcast is the ‘vodcast’.
Many podcasts are updated regularly and users subscribe to them using a pro-gram such as iTunes or with an RSS feed. For example, the British Broadcasting Corporation makes podcasts available of many of its radio shows, with listeners downloading the latest instalment every week.
A major advantage of podcasts is that, thanks to small and powerful media playing devices, they can be listened to any-where leading to ‘mobile learning’ and a maximisation of the time available for education. Many well-established publishers of clinical evidence provide pod-casts to complement their journals. It is also possible for individuals to produce and distribute podcasts at low cost.
Video sharing sites allow users to upload, view and share video clips. YouTube is by far the most popular. These video clips can also easily be embedded in other websites. Unlike vodcasts, video clips hosted on YouTube are generally streamed rather than being downloaded. Users can search the website for particular topics or can subscribe to YouTube ‘channels’. There are many YouTube video clips on the subject of mental health and some journals have their own YouTube channels.
Other media sharing
Other media sharing websites allow the sharing of users’ digital photographs, documents and presentations.
Disadvantages of podcasts and media sharing websites
Established content providers such as journals have been active in establishing podcasts and YouTube channels to compliment their written output. These have the advantages of peer reviewed content. Video and audio files shared by individuals have no authoritative control and may or may not be reliable.
Many of these media sharing sites are commercial concerns and this affects the intellectual property rights of media uploaded to them.
Other Web 2.0 sites
Second life is a ‘massive multiplayer online role-playing game’ where users create online representations of themselves (or avatars) and navigate a virtual world much like in a video game. A virtual medical school exists, and online tutorials and conferences are possible.
Health and medicine 2.0
The possibilities suggested by Web 2.0 applications for the practice of medicine and healthcare have lead to the related concepts of Health 2.0 and Medicine 2.0. ‘Health 2.0’ is usually taken to refer to the use of Web 2.0 technologies to promote collaboration between, but not restricted to, patients, medical professionals and caregivers. ‘Medicine 2.0’ is similar in meaning but with an additional focus on science and research. The Health 2.0 movement is entrepreneurial rather than academic.
Web 2.0 and the future of paid content
The advent of World Wide Web and particularly Web 2.0 has lead to a remodelling of how individuals source information. Many people have come to expect their online information to be free of charge. This has particularly affected the newspaper industry, whose publications have generally not yet successfully transitioned to a universally successful postweb model. Most news-papers feel obliged to provide their con-tent to be read online for free as they are concerned that subscription content, to which other sites cannot easily link, will be ignored.
Medical Journals are unlikely to be unaffected by this debate. Most journals require readers to have a subscription although this is not universal. Of the major journals the Canadian Medical Association Journal is free to view and the BMJ and The Lancet have adopted a model where some articles are available with-out charge. The British Journal of Psychiatry makes all its papers free to access after 12 months.
The Web 2.0 paradigm encourages participation and collaboration and has a culture of openness which may lead to the increasing expectation of an equally generous attitude from medical publishing. This demand may gain momentum if further journals encourage reader participation and more empowered patients wish to access the evidence on which their treatment is based. Demand may also come from authors, as the impact of papers may yet become determined by the blog links and Twitter traffic they generate. Contributors may find them-selves frustrated that less important, but more accessible papers, steal the limelight.
Like newspapers, academic journals will need to reach a compromise between the influence and good will that free access brings, versus the revenue that subscriptions generate.
Web 2.0 allows healthcare professions the ability to access, share and debate medical evidence more easily than ever before. The main web applications with relevance to the practice of evidence based healthcare that have emerged from Web 2.0 are blogs, wikis, and Twitter. Podcasts, social bookmarking and media sharing are also of relevance.
The collaborative nature of these applications, together with rapidly developing software and hardware technology, means that their use is still evolving and their impact on the way on the way medicine is practiced is yet to be fully realised.
In comparison with academic printed media, it is more difficult to ensure that information accessed on collaborative media is authoritative. Therefore, although the author would encourage healthcare professionals to use Web 2.0 applications in their practice, users are advised to exercise caution.
Web 2.0 Resources
Start your own blog with WordPress (http://wordpress.org/)or Blogger (https://www.blogger.com) software
http://www.frontierpsychiatrist.co.uk (author’s site)
The Carlat Psychiatry Blog:
Web based RSS reader:
Desktop RSS reader:
How to start a wiki guide:
It is also possible to start a wiki on Google Sites:
Author’s Twitter feed:
Author’s Delicious bookmarks:
Podcasts can be subscribed to using iTunes:
British Journal of Psychiatry podcasts:
Institute of Psychiatry Podcasts:
American Journal of Psychiatry podcasts:
JAMA YouTube channels:
BMJ YouTube channel: