INABIS '98 - Orthogate - Discussion and Conclusion

The sites assembled to found Orthogate are truly an impressive group, with diversity of service but a surprisingly common philosophy and outlook. We discovered as we were discussing the concept of a gateway site that we all had the following beliefs and wishes.

The Internet is inevitably going to transform academic medicine and communication in medicine in general
The technology to make the computer a one-stop workstation for all our communication and education needs exists today and we want it today!
An authoritative unique gateway site would inevitably arise because only a site of that type would receive enough notifications of new postings to keep current.
We want the orthopaedic gateway to be managed by orthopaedists for orthopaedists
Support, in the form of colleagues, advice and funding was a necessity if the efforts made by individuals were to be sustained
If the vision of a gateway site was realized the traffic and thus the potential financial rewards would be phenomenal.
Because of the potential value of a gateway site we want it to be impossible for commercial interests to capture it, hence the foundation of ISOST

The foundation sites are successful as stand-alone webs managed by energetic and forward thinking individuals. With these people contributing a proportion of their attention to the group the energy and flow of ideas is vitalizing. Furthermore it seems as though orthopaedics on the Internet is small enough at the moment that virtually everyone who is interested is aware of Orthogate and supports it either in concept or with practical help. Cyberspace is so large that there may be another group working away without our being aware of it, but we beg leave to doubt. The fact that Orthogate and ISOST are international organizations of this complexity and with these aims is very encouraging for the future health of the subject.

In addition to posting the Orthogate site the project has aims to influence the orthopaedic internet in specific directions, cohesion, cooperation, high quality content and improving the availablility of all CME material. We have made progress in these other less tangible directions

1) Orthogate members are prominent in the "Internet Committees" of many of the big national orthopaedic organizations. These include the Australian, British, Belgian, Canadian and Indian Orthopaedic Association. We have been invited to meet with the AAOS to help establish their direction. Several of these organizations have endorsed the Orthogate Project.

2) Orthogate members are presenting papers and workshops on Orthopaedic on the Internet at 1998 AAOS meeting, 1998 COA, BOA, AOA, SOFCOT, Egyptian Orthopaedic Association, Indian Orthopaedic Association meetings, INABIS, Mednet98, 1999 AAOS, 1999 SICOT. We have also been invited to submit a presentation at the meeting of the Swedish Orthopaedic Association.

3) Several members have written articles and papers delineating our vision. (see Bibliography of publications)

4) Sponsorship discussions with all the major orthopaedic suppliers are in train.

5) A new academic society - ISOST - has been founded and its inaugural meeting scheduled.

6) We are being asked by many different groups to consult and our ideas are being taken seriously.

7) The mailing list Orthopod and the speciality lists which arose from it are tremendously successful. The sense of community which the mailing list fosters⁶⁹ and which Orthogate embodies is the core of the project.

8) Members of the project have been outstanding promoters of the orthopaedic internet. The number of orthopaedic surgeons using the internet for orthopaedic information is growing rapidly partly as a result of their efforts world wide.

The influence that project members are already having on the development of resources is out of proportion to our numbers

Yet, the central question, "is the time right to start this process?" remains unanswered. Our results show that readership of Orthogate itself, as opposed to its member sites, is very small. It is growing and the potential for exponential growth is seen in the trend so far. Yet the traffic does not warrant a claim to status as a gateway. The reasons are not difficult to find. The group's energy has gone into forming the cooperative associations and building the site, not into publicizing. Most of the links to Orthogate itself and a stunning 95% of links to ISOST are from inside the Orthogate project itself. We are in danger of talking to ourselves! By contrast, even though they are at most a fifth the size of Orthogate's, the library and commercial links pages' orthopaedic links collections (table 3) are referred to from hundreds of pages across the Internet. We need a massive effort to bring the Orthogate project and its status as a gateway to the attention of the Internet.

Other gateway sites in Medicine

Co-operative strategies.
In other fields of medicine there are, so far, rather few examples of co-operation between institutions or even individuals who post web pages. HealthWeb³⁵ is a co-operative venture between medical libraries in the USA. Each library is responsible for collections of links in one or more subjects. In the design specifications posted in 1995 they committed to "universal presentation" to make the pages look the same. However, layout, design and the subdivisions of the links collections are still different for each subject page. Details of how the member libraries communicate and pass each other updated links on different subject are not described. PEDINFO ³⁶ ⁷¹ is positioned to become a cooperative venture with input from a large paediatric mailing list. Being posted on a university site makes it less likely that it will be free to accept input from widely differing sources. The Baylor College Otolaryngology Site ⁴¹ offers a Grand Rounds Archive, Patient Information, a medical student syllabus, a CME course and a large links collection. Although also posted on a university site GASNET ³⁷ ⁷⁰ comes closest in design and concept to Orthogate and surpasses it in some areas. It is a cooperative venture with contributions from many members and many different institutions. There are many on site resources such as Global Textbook of Anesthesiology a German/English, Hebrew/English, Italian/English and Spanish/English electronic Phrase Book ³⁸ for communicating with patients, bibiographies, an On line journal ESIA ⁴⁰ and abstracts from major anaesthesiology journals. The site is backed by SATA ³⁹, the Society for Advanced Telecommunications in Anaesthesia, which performs much the same function as ISOST ⁸ . However, there is limited evidence of cooperation with other sites in anaesthesiology. Similarly OncoLink ^{72
73} is a huge resource for cancer patients and oncologists but does not show any intention of leading a movement towards cooperation and amalgamation. An informal survey of webmasters of major gateway sites offered the conclusion that Orthogate's aim to form a supersite by aggregation and cooperation of existing sites is unique. We believe the monolithic supersite or gateway is necessary to reduce the confusion for readers and provide authors with a place to publicize their productions. Others may have the same aim but are pursuing it solo. This is wasteful of the scarcest resource - the energy and enthusiasm of medical personnel with knowledge of the Internet. It may be necessary to construct one authoritative site so that everyone will know where to go; it is not necessary to exhaust, outlast or outcompete the others with the same idea.

Another type of gateway is offered by major organizations such as the American Academy of Orthopaedic Surgeons ⁴² and equivalent organizations in other nations ^43-51. These sites offer information about the organisations, the meetings and publications they produce, policy statements, the web sites of subspecialty organizations and a wealth of other material. However, many restrict their aims strictly to the remit of the organization and do not provide a gateway. The Radiology Society of North America ⁵², American Heart Foundation ⁵³, American College of Cardiology ⁵⁴ and the American College of Rheumatology ⁵⁵ are other notable North American examples which do have wider aims. The American Academy of Family Physicians ⁵⁶ describes its website as "a resource for anyone interested in family practice, whether they are a patient, health care professional, government policymaker, family practice resident, or medical student".Because of their national orientation it is doubtful if these organisations would wish to construct a supranational gateway or supersite of the type Orthogate aspires to be. Part of the requirement is support from the international professional community as represented on the Internet.

The "Megasites" ⁵⁷review detailed 25 sites that provide entry to all fields of medicine, selected from 52 considered ⁵⁸ . These sites are legitimate gateways but because they try to cover the whole of medicine their coverage of individual specialist areas is not comprehensive. Because of their different aims and de facto competition between each other it would be difficult to get them to combine to form the sort of unified collection which Orthogate considers necessary for the future development of medicine on the Internet. Furthermore, their broad scope makes it unlikely that the other attributes of a supersite, textbooks, authoritative databases, electronic journals and the like, will attach themselves to the gateway. The paper is interesting in a number of ways, not the least of which is the criteria they select for quality in a gateway site ⁵⁹.

Strategies for quality control on the Internet

Considering that the quality of information on the medical Internet is such a concern to so many people it is surprising how few options have been proposed. The instinct to "control" the Internet and in some way to assure quality by denying access to "poor quality" runs up against the reality that there is no effective way to prevent people from posting or reading whatever they want. Closed webs with limited access to the Internet are perhaps the only way this can be accomplished for a limited group of users. The NHS in the UK has such a network and it remains to be seen whether good quality medical information will be available on that network or whether the best sites will be put off by the restrictions. Orthogate suggests that the best and only possible penalty for posting poor quality material is to be ignored. PLink ^{66
67}is a collection of plastic surgery links consciously assembled to assure patients and doctors that the information on the sites mentioned is reliable. However, it does not provide comprehensive access to pages on individual topics so readers still have to do their own searching on the approved sites.

Another formidable strategy for improving quality on the Internet is best exemplified by OMNI (Organized Medical Networked Information) ⁶³ . This network of UK medical librarians has a set of well worked-out criteria ⁶⁴ for inclusion of a site in their collection. Thus sites which are listed with OMNI have been positively vetted and a brief review is attached to each link. Unlike Orthogate the sites which do not meet the criteria are not listed. While this approach sounds highly appropriate the numbers reveal that no attempt has been made to make a comprehesive collection of all eligible sites. Indeed the process of review is so time intensive that the Internet probably grows faster than OMNI can. The total number of sites listed by OMNI for the whole of medicine is of the same order of magnitude as the OWL/Orthogate collection in orthopaedics alone. OMNI is clear that it is not attempting to offer comprehensive coverage. However, there is one concealed logical problem in this approach. If a site is not listed with OMNI is it because it doesn't meet with the quality criteria or because it hasn't been evaluated? There's no way to tell. This seriously weakens the value of the site, and the strategy. Only a combination of comprehensiveness and searching review will be effective in promoting good quality. We anticipate that the experience OMNI gains in reviewing will be of enormous value when the problem of how to provide comprehensive coverage has been solved and the two approaches can be combined. Until then we believe that searchers for information on the Internet will be attracted to the most comprehensive collections, not to those that provide the most information about quality. Whereas most professionals have been trained to evaluate information quite critically they are not familiar with searching for information; these people will go where the searching is made easiest. Patients, on the other hand, have little training in discrimination and are most in need of advice about the quality of the information they are exposed to. However, they are even less likely to visit a resource like OMNI because they wouldn't think to look for it and because they will not find what they are looking for in its index anyway. Laissez faire is the predominent attitude on the Internet along with a belief that censorship is simply a "glitch" to be circumvented. Traditional attitudes do not mesh well with that and have resulted in a number of efforts to measure quality of Internet postings. In a recent JAMA article Jadad and Gagliardi ⁶⁸ concluded "Many incompletely developed instruments⁷⁵ to evaluate health information exist on the Internet. It is unclear, however, whether they should exist in the first place, whether they measure what they claim to measure, or whether they lead to more good than harm."

Conclusion

In the free environment of the Internet readership will go where the service is most compellingly useful. Thus any site which aims to have influence must first capture the readership by being the most valuable resource in its field. Our analysis is that in the current state of the Internet readers value comprehensiveness more than they do comments of the quality of the resources. If both cannot be provided we will aim first for the fullest possible coverage and plan to progress towards comments on quality once Orthogate is established as an authority. Our on-site resources amount already to a gateway, if not already a supersite; our organization and philosophy is fitted to the task. It remains to be seen whether we can attract the readership, the personnel and the supporting resources to sustain our vision. The rationale for a gateway site in Orthopaedics is that there is no other practical way to lead the transformation and take advantage of the changes in academic and professional communication offered by the Internet.

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DISCUSSION & CONCLUSION

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