He@lth Information on the Internet
Orthopaedic Web Links (OWL) – catalogue of the orthopaedic Internet Mr Christopher W Oliver DM FRCP FRCS (Tr & Orth) Consultant Orthopaedic Surgeon, Royal Infirmary of Edinburgh
[email protected]
Dr Christian Veillette BSc MD Orthopaedic Surgery Resident, University of Toronto, Canada Dr JF Myles Clough BM BCh DPhil FRCSC Clinical Instructor, Department of Orthopaedic Surgery, University of British Columbia, Canada
OWL aims to identify and categorise information on the Internet that is relevant to the orthopaedic community. The article describes OWL, and raises important issues for all such indexes/gateways irrespective of subject content.
Introduction Orthopaedic Web Links (OWL) has been in existence since 1996. In 2002, with the addition of two editors, OWL underwent a major reorganisation from a static HTMLbased format into a dynamic database. OWL now consists of a categorised, searchable links directory to over 7000 Web pages. OWL is unique in three aspects: (i)
it is the largest collection of peerreviewed orthopaedic hyperlinks by several orders of magnitude ± OWL editors are responsible for identifying and validating the sites;
(ii) the links go directly to the subjects of interest, instead of requiring further navigation from the top level URL of a large site; and (iii) the interactive community format of OWL makes it possible for all orthopaedists to become members and then to submit and maintain links to their Web sites or presentations
Technical aspects OWL has been developed from a customised version of the versatile Links SQL directory management engine from Gossamer Threads Inc. OWL is, therefore, extremely modular and contains a wealth of features for directory, user, and administration management ideally suited for the efficient maintenance of a large database of resources.
OWL is currently powered by a MySQL database running on an Apache Web server under the FreeBSD Unix environment . All these resources are open-source. The OWL directory has the ability to organise information into an unlimited depth of categories and sub-categories making it easy for a visitor to navigate through the database and find relevant information quickly. In addition, members of OWL can add resources to the database, which are then marked for validation by OWL editors prior to being made accessible to the public. Importantly, OWL has a sophisticated indexed search engine, which can be used on the entire database, within categories, as well as on specific fields. A feature of OWL that has yet to be fully realised is the powerful review system, which has the potential to allow members of the OWL community to provide reviews of a resource and thus create a true peer-reviewed paradigm. The administrative features of OWL allow for the efficient maintenance of the directory through a completely Web-based control panel. A powerful multiprocess link checker allows OWL to make sure links are still valid automatically. Editors can be assigned to any category or subcategory of OWL, based on their expertise, and provided with a defined set of administrative permissions. Currently under development is an Orthopaedic
Internet spider that would search the Internet and automatically index relevant pages.
Educational resources The largest section of the collection concerns information of direct educational interest to orthopaedic surgeons, including `orthopaedic topics’ (organised by subspecialty, region and condition), `teaching resources’, `case presentations’ and `multimedia presentations’. A major resource is the abstracts of papers presented annually at the American Academy of Orthopedic Surgeons (AAOS) Meeting. Although these abstracts have been posted on the AAOS site , OWL allows a filtered search of these abstracts in the wider context of the Orthopaedic Internet. It would also be desirable to include the abstracts of orthopaedic journal articles and thus hasten the integration of journals with the Internet.
Lists of organisations Another major part of the collection concerns academic, professional and commercial organisations, including national and international orthopaedic organisations, university and teaching institutions, clinics and hospitals, journals and orthopaedic supply corporations. Inclusion in OWL has been based solely on whether an orthopaedic surgeon might want to find the site. Unlike OCTOBER 2002
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He@lth Information on the Internet other `Yellow Pages’ collections, the organisations listed are not required to pay a fee. As a result, the OWL list is much larger than any other similar list.
Patient information resources The third major subject area is patient information. This may be the most important contribution of OWL. These pages have been collected from reputable sources, e.g. the AAOS, university and hospital affiliated sites and professional sites. This is in stark contrast to the collection that is assembled by any of the standard Internet search engines. The latter collections are weighted in the direction of commercial sites. `Pro bono’ sites often come far down the list. This has contributed to the poor reputation of the Internet as a source of information for orthopaedic patients. However, there is excellent information out there. Orthopaedic surgeons must accept that patients are active seekers of information on the Internet and are in danger of finding a high proportion of specious and suspect pages if left to search on their own. Clinicians should value the pre-selected OWL collection, contribute to it and advise their patients to use it.
Widespread access to ‘specialised’ knowledge Why is this whole subject important? The growth of the Internet has been so fast that the profession has not kept pace with it and has not really considered the implications of this radical change. Compare the development of the Internet to the invention of printing. Before printing, an individual had to travel to a library to read one of the very few manuscript documents on a subject of interest. Knowledge and scholarship was confined to a select group. Printing allowed the wholesale dissemination of knowledge. Prior to the Internet, `general’ knowledge was widely available in the industrialised world. What the Internet changes is the availability of `specialised’ knowledge.
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Resources such as Wheeless’ Textbook of Orthopaedics make detailed orthopaedic information available to everyone. Patients, journalists, lawyers and politicians no longer require interpretation of orthopaedic information by a professional. With a little effort, they can educate themselves about a small area of orthopaedics to a level higher than the average GP (and perhaps some specialists). This demystifying of information is unstoppable and the consequences are only beginning to be considered.
Information overload Another important change is information overload. Medline lists over 100 journals solely concerned with orthopaedics and sports medicine. It is no longer possible to `keep up’ with the growth of orthopaedic knowledge. However, electronic information databases allow us to search for knowledge when we need it, so we can concentrate instead on developing skills and experience. We foresee an important shift in the way orthopaedic surgeons form the interface between patients with problems and the knowledge needed to treat those problems. Currently, we would tend to conceal the fact that we are not absolutely up-to-date in a particular area. We would also tend to be hostile to any patient who points out that fact, inevitable and undeniable though it may be. Yet the interested patient may well be more persistent in finding out about their problem. For unusual problems, the patient may become the valued research assistant for the surgeon. Once we accept this, a new partnership between patient and physician can develop.
The orthopaedic Internet – issues The profession has not taken these consequences seriously and the institutions to make the Internet work well for orthopaedics have not yet developed. These institutions include: (i) an agreed set of orthopaedic subject headings to aid efficient searching;
(ii) quality criteria so that a site can be reviewed against a standard; (iii) an authoritative index to orthopaedic information on the Internet; and (iv) a body of expert orthopaedic surgeons who are able and qualified to undertake the tasks of orthopaedic informatics. What these experts build must be aligned with the needs of orthopaedic surgeons and patients. Multiple competing portals are not likely to serve those needs. One of the problems we have found as editors of OWL is that very few authors of orthopaedic resources notify us when they post or upgrade their site. The mind-set of traditional publication is still operating and currently it is the business of the publisher to notify the indexing tools such as Medline. Since every institution that posts information on the Internet becomes its own `publisher’, this mind-set must change, but it will be much easier if there is only one index site to notify. A purely commercial enterprise may not be the best choice for such an index. There are plenty of commercial sites that would be delighted to become the portal to the Orthopaedic Internet. However, this would probably require a prolonged process of competitive attrition, which would not serve orthopaedic surgeons well. One of the purposes of OWL was to try to pre-empt the position of an authoritative index. The editors of OWL are orthopaedic surgeons, trainees and allied professionals who have a sense of service to the orthopaedic community. For the last 6 years, the enterprise has remained viable without external funding and has managed to maintain and consolidate its leading position and improve the technical aspects. This steadfastness attests to our staying power and our confidence in the process we are participating in. But the final outcome is by no means determined. We estimated in 2001 that there were more than 100,000 pages on the Internet with orthopaedic content. Although OWL, with 7000 pages, may be the `most complete’ index, it is by no means comprehensive. Some of the `missing’ pages may be duplicates, translations,
He@lth Information on the Internet or of marginal interest and quality, but it is not safe to make that assumption. So a huge task still remains. The OWL editors are also members of the Internet Society of Orthopaedic Surgery and Trauma (ISOST) , which is an international group of orthopaedic surgeons with an interest in IT. ISOST has three roles: (i) educating orthopaedic surgeons about IT; (ii) creating and maintaining the OWL index; and (iii) fostering communication between orthopaedic surgeons on the Internet. In the recent past, university professors and journal editors have played the major role in determining the development of our speciality. The cost and convenience benefits of the Internet should result in it playing an increasingly important role in academic communication. In that case, those who are managing the Orthopaedic Internet will have an active role too. Everyone is concerned about the poor quality of orthopaedic information on the Internet. However, it is impossible to impose standards, and the mechanisms that work for `papers’ cannot be transferred unchanged to the Internet. We believe that no mechanism will work without an index, which occupies a position of authority. Once there is such an index, its opinion about the quality of a specific site may have some effect in a similar manner to the HON code . Until that authoritative
index has been established, concerns about quality will continue, but will have no productive outlet. Orthopaedic surgeons should understand enough about orthopaedic informatics and think hard enough about the issues to have a valid opinion on how the Orthopaedic Internet is organised. We would hope that orthopaedic organisations would also formulate an official position. They could support the efforts of ISOST or set up their own competing Internet portal. We hope they will put their muscle behind the efforts of OWL and ISOST. The fundamental changes required are important
enough that they should not occur by default. It is important that the orthopaedic portal exists for the benefit of our speciality; designed and controlled by orthopaedic surgeons for orthopaedic surgeons.
The future of OWL For the future, OWL needs to be placed on a secure business footing. Possible business models would include: (i) a non-profit organisation, charging a fee to ISOST for providing OWL; (iii) a for-profit business; or (iii) an academic model with grants covering OWL’s running costs. The first option would still require ISOST to have funds, so the problem is moved not solved. However, we believe that funding a specialist society is an easier concept than supporting a `for-profit’ business. The balance between making OWL a sustainable institution and maintaining the concept of a service to the orthopaedic community will be difficult to achieve. There is intense suspicion about the Internet, its unsound business history and its dubious ethics. We are advocating that an authoritative Orthopaedic Index is desirable and should be supported by national and international organisations. Secondly, we are suggesting that the position of such an index is one of power and commercial value. Thirdly, we are speculating about possible business models to allow the OWL index to continue. Lastly, we are dressing it up with language about service to the orthopaedic community. It would be easy to be cynical about our motives. However, we have very real concerns. OWL cannot continue indefinitely as a self-funded `hobby’. Yet any commercial model risks losing the trust of the orthopaedic community without which OWL cannot fulfil its aims. We invite the widest possible discussion of this subject and suggestions for ways to provide ongoing support. The issue cannot be left to non-professionals. Reference Clough JFM, Oliver CW. Orthopaedics, networks and computers. J Bone Joint Surg Br 2002; 84: 481±485
News item Web links The King’s Fund Information and Library Service has a large set of links to other Web sites in health and social care
Editorial Board l Betsy Anagnostelis, Librarian, Royal Free Hospital School of Medicine, London l Harry Brown, General Practitioner, Leeds l Tim David, Professor of Child Health and Paediatrics, University of Manchester l Julie Glanville, Information Services Manager, NHS Centre for Reviews & Dissemination, York l Alastair Hutchison, Consultant in Nephrology and General Medicine, Manchester l Robert Kiley, Head of Systems Strategy (Library), Wellcome Trust, London l Carol Lefebvre, Information Specialist, Oxford l Nick Loman, Medical Student, St Bartholomew’s and The Royal London SMD, London l JA Muir Gray, Director of R&D, NHS Executive, Anglia & Oxford l Chris Oliver, Consultant Trauma & Orthopaedic Surgeon, Edinburgh l Ahmad Risk, GP and Chairman of British Healthcare Internet Association l Jill Russell, Lecturer in Postgraduate Education, Open Learning Unit, University College London l Richard Wootton, Professor of Online Health, University of Queensland, Australia l Jeremy Wyatt, School of Public Policy, University College London
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