In part 1 of this intro post I addressed the trouble with information management in medicine. There are 3 main points:
- There is a lot of available information in medicine (increasing breadth and depth of medical knowledge, many specialists, scientific studies, review articles, summary services, etc.).
- There is a poor distribution of information in medicine (classic curbsides are ephemeral, isolated, not shared or searchable. Economic, social, geographic, and temporal limitations affect how well one clinician can obtain information from another clinician).
- There are poor mechanisms to promote good information in medicine (curbsides aren’t validated by multiple providers, daily questions and answers aren’t always backed by literature, review articles don’t allow for two way communication).
Part 1 was meant to highlight the above points. This post (part 2) aims to put those issues in the context of modern digital tools and how that led to the creation of MedCurbside.
The surplus of information in medicine is by no means a unique problem. The modern era is referred to as the information age for a reason. Never in history has any individual had access to so much information. However it is also called the digital age for a reason. Digital technologies have not only allowed for the proliferation of information, they have offered tools for managing that information. While medicine has experienced the information growth it has not fully experienced the digital growth. Digital growth is important to solve the problems outlined above. Technology works best when you build on what already works, so MedCurbSide tries to do this by borrowing from existing digital tools that work well and using them to solve these problems. These tools are highlighted throughout the rest of this article (literally…look for the bold text).
The vehicle by which most modern information is spread is the internet. Although it’s obvious, it is important to note the the first major feature of medcurbside.com: it is a website. This may seem like a simple point but it is not. In fact, it may be its most important feature because it comes with two primary benefits: searchability and scalability.
If you want to find recipes, research reviews on a new TV, or read about some current affair, you will probably search for it. Modern search engines are a unique indexing system. Nothing else like them exists for cataloging enormous amounts of information and quickly prioritizing the delivery of that information to users just based on a few keywords. This is one of the most important, effective, and pervasive modern digital tools for managing information.
So, if a repository of medical information is not accessible from a search engine, users are stripped of one of their most powerful and familiar tools. Antiquated, inaccessible repositories can exist in many forms: Hospitals and medical schools often provide their staff with medical information in the form of intranet sites, documents on network shares, EMR-embedded literature, etc. Many digital medical resources (like UpToDate articles) live behind login pages. Also, as described in the first post, physicians may verbally curbside colleagues. None of these information sources are accessible from a standard search engine. Hence, they aren’t indexed and they aren’t easily discoverable.
There are services that take advantage of this searchable model. If you perform a Google search for “management diabetic ketoacidosis”, the eMedicine article targeted towards healthcare professionals will likely be near the top of your results. This is how it should be; everyone knows how to search on Google so everyone can find this article. A search engine overcomes the segregation of information that occurs with the multitude of sources available today. MedCurbSide taps into this model by following modern design standards to allow search engines to quickly and effectively index the full content base of the site from user posts to articles to their relationships with each other (more details in another post).
The second benefit of being web-based is the ability to scale. Modern websites are built on advanced technologies that allow them to hold an incredible amount of data and be accessed by an enormous number of people by overcoming social, geographic, and economic barriers. Some of the medical repositories described above (ie, verbal curbsides, network shares, etc) aren’t designed with scale in mind. But modern medical knowledge continues to grow at an incredible rate so MedCurbSide is designed to scale in a way that can cope with both the size of a medical knowledge base and the pace at which it grows.
Just being web-based isn’t enough. The site’s organization is equally important. Over the years certain website subtypes have developed. These subtypes optimize access to different kinds of information. Most relevant to this discussion are the forum and the wiki. Forums allow for an exchange of information, which is critical for complex ideas. However, the lack of structure (just back and forth posts) allows for a rapid degeneration of content from on-topic, to off-topic, to non-sensical.
The other subtype, a wiki, is best exemplified by Wikipedia. By their own description the service is a “…web-based, free-content encyclopedia project based on an openly editable model”. We already discussed the advantages of being web-based. But wikipedia is also free and openly editable. The most important consequence of these two characteristics is that it helps create a large number of both content creators and content consumers. This in turn means the content base grows organically and quickly, making the site heavily utilized. This approach has allowed for the rapid growth of a complex knowledge base while still retaining a useful structure. However, the format is more conducive for topic reviews, not focused discussions.
The combination of forum and wiki features are lacking from other common medical information management tools. Great services, like UpToDate and Dynamed, are useful but cost a lot of money, are not openly accessible, and content is edited by a small controlled group, not a larger community. And very few digital information tools allow for the two way exchange of information, as seen on a forum. All four of these characteristics (web-based, two-way information exchange, free, and openly editable) are necessary for any system that hopes to address the core problems highlighted at the beginning.
MedCurbSide incorporates these characteristics by blending a forum and a wiki: information exchange is two way and openly editable so it can grow organically. Information is free for non-commercial use as all content is copyrighted under a creative commons license (similar to Wikipedia’s copyright). But there is more control: there is a question and then answers; No room for endless conversations and tangents as in a standard forum. Content is question specific rather than being focused around topics like Wikipedia.
The website characteristics above help distribute and organize information but don’t fully address quality of information. Some of the existing medical tools listed above have systems to provide quality information: Sources like UpToDate are comprised of articles written by experts. Published journal articles may be peer reviewed (which arguably provides some validity). However, openly editable internet sources, like Wikipedia, have often garnered concern over content quality and aren’t geared towards the specific needs of the medical field (although they do use several mechanisms to ensure good information as described below). Also, forums usually don’t have any tools to promote citation of good evidence or organize community feedback. This brings us to one of the biggest concerns about, and benefits of, MedCurbSide…
Given the description of Medcurbside so far, it’s easy to wonder, what if someone decides to stray from the community goal of providing quality responses? Decides to post an irrelevant suggestion? Tries to advertise? Does not cite enough evidence for their claim, etc.? The solution lies in a system which is loosely analogous to a modern social network. Social networks like Facebook allow the community to interact with each other in “meta” ways. Rather than directly communicating with someone they can “like” a post , “share” a comment, or “tag” a photo. Similarly, MedCurbSide expects users to vote up/down answers, flag comments, vote on references, etc. The site keeps track of these “meta” actions to assign points to users, which acts as a system to measure community trust. Post a question that someone else up-votes? Provide an answer that is evidence based and that other community members have up-voted? Then you have proven yourself in a small way to the community and you get some points. Users with more points are allowed more rights, such as editing posts, providing their own votes, etc. There are also “power editors” who monitor/edit almost all posts, providing another layer of quality checks. This allows the website and the community to self-regulate. While that may seem like a scary proposition, it is in fact very much in line how we practice medicine today and in line with the tradition of professional medical practice.
There are numerous checks and balances so that quality content will always come to the top and irrelevant, erroneous, or misleading content is pushed to the bottom. The important part of this approach is that it is not experimental: Providing quality, reputable content online has evolved enormously since the birth of the internet and several tools prove it is possible. Wikipedia itself relies on a meritocracy as one measure to ensure quality edits. Additionally, the design of MedCurbSide isn’t a test: It’s modeled after StackOverflow.com, which fulfills the same niche with incredible success in the field of software engineering.
But MedCurbSide isn’t just a clone; it is adapted to healthcare’s specific needs. To do this it borrows from another principle of modern digital tools: different technologies can communicate with each other. You can sync your phone with your gmail contact list, an ipad app can pull friend statuses from facebook and twitter, your blog can embed other users’ youtube videos, etc. With medical questions we expect answers to be backed by evidence. When you post on MedCurbSide you can reference articles by simply linking to them. The site will automatically fetch the title and other relevant info, update the post, and put the abstract in the sidebar, so literature is put at the user’s fingertips. There are even more features focused on helping users discover good literature, just see part 3 of this post (coming soon)!
MedCurbSide will hopefully take the traditional medical curbside and digitize it by utilizing proven tools. This is just part of the model, though. Many more blog posts will focus on specific features and why they can help make medicine better. For your part, ask and answer questions, cite evidence, and make medicine better!