Google Medicine and open access (OA): team players in knowledge-based healthcare by Dean Giustini, UBC Biomedical Branch

Librarian http://weblogs.elearning.ubc.ca/googlescholar/) January 6th, 2006 (third revision) The more knowledge matters, the more open access to that knowledge matters - Peter Suber, Open Access Blog Many clinicians & researchers conduct Medline searches, but lack skills to do this well - Brian Haynes et al. Introduction Despite a number of advances in search in 2005, medical information continues to be inefficiently scattered across the Internet. Whats on the Web is poorly organized, repackaged for profit, locked away in commercial databases or hidden in the deep web. Some of medicines best evidence is inaccessible to most physicians except for the lucky few affiliated with universities or teaching hospitals. Such inequities demand our attention. Medical research buried in the deep web was identified as a problem in clinical trials and systematic reviews years ago. The deep web is said to be more than 500 times the size of the surface web. Is this literature critical to the practice of medicine in the information age? No one knows for sure. A growing body of evidence suggests that the invisible information in the deep web contributes, when found, to better overall clinical decision-making. The idea of bringing together the best medical knowledge and making it more accessible on the Web has been around since the mid-1990s. Centralized portals in medicine have been developed by a number of organizations in order to provide access to peer-reviewed research, government reports and conference proceedings. Examples include the National Library of Medicines Gateway, the National Health Service (U.K.), SumSearch (U.S.) and the Trip Database (three free searches a week). All-purpose tools combining research and genome search have been developed such as NLMs Entrez. Even Wikipedia has a jump page to its entries called Medicine Portal. However, taken in isolation, none of these portals really offers the kind of solution that librarians and physicians require. The evidence-based literature is located in too many sources. Consequently, medical searching is hard to do well, and easy to do poorly. Last week, after the BMJ published How Google is changing medicine, physicians e-mailed me to say that a central portal for medical searching on the open web was a good idea, and wanted more information. However, some questioned the logic of centralizing more power in Google to what amounted to a monopoly. Others suggested that a meeting should be planned to discuss the idea with the Google founders forthwith, and soon.

Easy access to information = better patient care From the outset, let me say I have no interest in Google Inc, financial or otherwise, and I dont know Larry and Sergey. I am only interested in access to information. If you believe (and I do) that access to information results in better science and better patient care, you might understand where my idea for a Google Medicine portal originates. For many physicians, conducting a literature search is fraught with difficulties. To start, there are too many sources and interfaces, and the evidence is fragmented across free and fee-based databases. Even librarians have a difficult time keeping track of all this information. In the summer of 2005, while attending the McMaster University How to Teach Evidence-Based Clinical Practice (EBCP), I saw firsthand how doctors around the world made clinical decisions upon appraising the evidence once the evidence had been located. Twelve librarians assigned to small groups were expert at searching; many doctors, however, struggled with basic searching. Not surprisingly, many participants were more engaged in critical appraisal than finding the evidence for themselves. Many asked me: Why is searching so difficult? Why cant search tools be more straightforward and easy to use? In some small group tutorials, search strategies were often discussed superficially or not at all. Was information retrieval an important part of evidence-based practice, or not? In private, physicians shared their feelings with me: searching has become too difficult. Interfaces need to be more intuitive (ie. like Google) and easier to use (ie. again, Google). Clearly, physicians wanted the searching part of evidence-based practice to be less onerous so that they could spend their time evaluating what they had found. Upon my return from McMaster, I vowed to do something about this conundrum. Physicians were expressing their concerns to me and wanted searching to be simpler, somehow. In my work, I teach and coach people how to search so I hear these comments more frequently. Were all my efforts at teaching more difficult tools like PubMed starting to wear me down? What would my colleagues think about the work I was doing in Google? Finding answers for every clinical question that came up in my work was impractical; my users have to be self-sufficient. And that was enough motivation for me. That - and helping doctors improve their delivery of patient care. In summary, physicians wanted to practice evidence-based medicine in the information age, but searching was taking them out of their natural domain of patient care. That meant that, as a librarian, I needed to devise alternatives for them. Search engines & open access Since their initial development, search engines have been used by all kinds of people to find all kinds of things of interest. Initially, the web was largely a recreational, social place. But now the web is a critical two-way communication tool for business, education and health indeed, society as a whole. Quite simply an important entry point to the world of information, the web has transcended early criticisms around its utility, especially in health. Especially for patients. Early in the Webs development, hospitals in Canada - such as Vancouver General Hospital made it necessary to install firewalls on Intranets to protect patient and human resources information. Why? Information stored behind hospital databanks throughout the world was made vulnerable with the introduction of the web due to spyware, hackers and viruses of various kinds.

However, as organizations moved their services to the web, and digitized more information, hospital IT departments views changed. Health care workers started to use the web in increasing numbers to locate high-quality content and to search free Medline (PubMed.gov). Access inequities creating a digital divide (for instance, those without access or poor search skills) seemed to improve markedly in the period after 1997. In 1998, Googles appearance was universally welcomed. In head-to-head comparisons with AltaVista, Lycos and other search engines, Google scored the highest in terms of usability and results relevancy. Proving to be extremely helpful for health professionals with few search skills, Google started to be used in greater numbers to access all kinds of medical information. For those working in hospitals, information retrieval skills were increasingly important as patients were using the Internet and locating more evidence themselves. Consumer information was plentiful. Meanwhile, Googles popularity hit its peak in mid-2004 by the time of its initial public offering. By the end of 2004, Google announced Google Print (now Book Search) and Google Scholar. The latter gave physicians a second option when accessing the literature. Some started to consult PubMed less often or only when a current literature review was needed. PubMed records were appearing in Google and Google Scholar anyway, so why use PubMed? Requests from my library users to teach Google Scholar started to pour in. Users asked why PubMed was needed I noticed a discernible paradigm shift in mid-2005, even though numerous critiques of Google Scholar were being published. While doctors needed to know how to search PubMed, it was difficult for them to search it well. However, I continued to teach it alongside search engines like Google. However, open access and search engines are now creating an undeniable synergy. In 2006, Google and Scirus now seem central to searching the medical literature. Accessing free content and learning how to use all kinds of search engines (not just Google) - is essential to the practice of health around the world. In writing the BMJ editorial in December 2005, the idea of a central portal continued to impress itself into my thoughts. What main issues would a central portal in medicine address? How would it help physicians access the literature efficiently? What would it contain? What new information technologies will mean Over the past year, we have seen a number of trends and counter-trends. Two of these are the rise of search and digitization. In addition to these predictable trends is user-generated content, which is on the rise in medicine. To see how much medical information and discussion is generated daily in the blogosphere, have a look around at technorati.com or blogsearch.google.com. Wikis and blogs are rising in popularity; for one thing, they remove some of the traditional hierarchies and boundaries in publishing. As social technologies they stand to change how physicians communicate and share their clinical research with each other. In open, more transparent online environments new means of communication are created. How does collaborative writing and editing change medical publishing? Will open peer-review processes create barriers to integrity in research? With less strict reviewing, will misleading or dangerous information be published? With ever-increasing numbers of documents produced, will information overload be a constant?

More traditional search tools in medicine are not immune to information overload. In early 2006, PubMed indexed its sixteen millionth article. Though widely regarded as the gold standard in medical searching, PubMed is getting unwieldy and difficult to search. Some doctors, for example, view NLMs journal selection as elitist and American-biased. Some librarians have started to question its indexing practices which seem idiosyncratic and slow to respond to the fast pace of new research. To add to this, NLM is considering machine-driven indexing, which librarians will need to watch in terms of upholding standards and quality control. Scirus, one of a few specialized science and medical search engines, indexes 200 million items but it has been criticized for being too European and Elsevier-focused (no wonder, Scirus was created by Elsevier). As for Google Scholar, it will eventually index more content than anyone, due to its crawling of all disciplines research, journal sites, bibliographies, library catalogues and open access repositories. However, no one knows for certain what is indexed because Google isnt saying. If that were not enough, the information age seems to be introducing new political and logistical problems. For instance, many librarians fear search engines monopolization of information. For better or worse, librarians are custodians of the human record. Once Googles digitization project is complete, it stands to hold the record of human history. Is this what we want for our society? Do we want private interests to control culture? Doesnt it make sense for librarians to be the stewards of this information? Little wonder that the National Librarian of France vowed not to let Google dominate their print culture. Googles monetization of search is its bread and butter. Well-placed ads and click-through rates increase profits exponentially. But free web content is easy to index. In medicine, a lot of information is inaccessible. Evidence-based synthesized content is locked down by publishers and vendors. ACP Pier, Best Evidence, DynaMed and UpToDate are but a few examples. Access is available only to those who can afford to pay, like rich physicians and universities. This closed access is detrimental to human health, and true evidence based practice. Conclusion Medical associations should closely monitor web trends affecting search in medicine, especially open access and user-generated content (ie. physician-created). Wikipedia and blogs are creating more reliable scientific content all the time to see, read and download freely. Novel models of broad information distribution may be a way to gain back control of medicines knowledge-base. Physician-created content utilizing open-source software has great potential in disseminating new research findings. At a minimum, physicians should continue to submit their research to open access journals and self-archive so that web-bots can find and index these articles easily. This would be one way around paying for evidence-based studies and systematic reviews. Perhaps Google being the do-no-evil, philanthropic search engine it is could work with open access publishers and database vendors to liberate the evidence in medicine, even if only to ensure that abstracts are searchable. Pay-as-you-go models could be devised to obtain full-text. In an ideal world, rich countries would pay; developing countries would get free access. Only time will tell if Google (or some other search giant for that matter) can be the team-player we need. Freeing the evidence for all to see presents the best future for medicine in a more open evidence-based world.

REFERENCES Beavers C. Understanding Google's algorithm. Search Engine Review. July 2005. http://www.apollohosting.com/apollohosting/articles/search/07-05-Search-A06.php Dimov V. How Doctors Use Google. http://casesblog.blogspot.com/2005/06/how-doctors-usegoogle.html Giles J. Internet encyclopaedias go head to head. Special Report. Nature. 14 December

2005. http://www.nature.com/news/2005/051212/full/438900a.html
Giustini D. How Google is changing Medicine: a medical portal is the logical next step. http://bmj.bmjjournals.com/cgi/content/full/331/7531/1487 (To read some background around the debate of Google Scholar's usefulness in medicine (or lack thereof), see: UBC Google Scholar blog http://weblogs.elearning.ubc.ca/googlescholar) Google Books Library Project. http://books.google.com/googlebooks/library.html The Google Foundation. http://www.google.org Guyatt et al. Evidence based medicine has come a long way. BMJ. 2004 Oct 30;329(7473):990-1. Hawkes N. More people consult Google over health. The Times. June 6th, 2005. http://www.timesonline.co.uk/article/0,,2-1642381,00.html Haynes RB, McKibbon KA et al. Optimal search strategies for retrieving scientifically strong studies of treatment from Medline: analytical survey. BMJ. 2005 May 21;330(7501):1179. Health Information for Developing and Transitional Countries. MLANET. 2005. http://ics.mlanet.org/general.htm How to teach Evidence-Based Practice. McMaster University Library. http://wwwhsl.mcmaster.ca/ebcp/ Hooper-Lane C, Combs AM, Feldstein D. Finding the best available evidence: what's new? WMJ. 2005 Apr;104(3):18-21. McAuley L. Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? Lancet. 2000 Oct 7;356(9237):1228-31. Suber, P. Open Access (OA) Blog. http://www.earlham.edu/~peters/fos/fosblog.html. This principle appears on Peters blog: "the more knowledge matters, the more open access to that knowledge matters." Tomlin S. Science in the web age: The expanding electronic universe. Nature December 2005 438. Wikipedia. Semantic Web. http://en.wikipedia.org/wiki/Semantic_web Wikipedia. Web 2.0. http://en.wikipedia.org/wiki/Web_2.0