Editorial

Amol Deshpande, MD,MBACentre for Global eHealthInnovation, UniversityHealth Network andUniversity of Toronto,Canada

Alejandro R. Jadad,MD, DPhil, FRCPCCentre for Global eHealthInnovation, R. Fraser ElliottBuilding, 4th floor, TorontoGeneral Hospital,190 Elizabeth Street,Toronto, ON M5G 2C4,Canada

E-mail:ajadad@ehealthinnovation.org

Online 31 October 2006

332 Vol. 3, No. 4,

pp

Web 2.0: Could it helpmove the health systeminto the 21st century?

Amol Deshpande and Alejandro R. Jadad

How it is

One month had passed since Daniel noted the increas-

ingly painful wart on his penis. Too embarrassed to

discuss the issue with his 30-year old friends, he dealt

with his anxiety in solitude. He had been trying to get

a hold of his family physician for a week now by

telephone, but the lines were always busy. His after-

hours message still remained unanswered. His anxiety

level increasing, he turned to Google for an answer.

After getting millions of hits to his search query and

reading through numerous websites with varying

(and often conflicting) information, his panic heigh-

tened. Finally, the physician’s office called to offer the

earliest appointment in 2 weeks. Frustrated, Daniel

proceeded to the nearest walk-in clinic. After a pro-

longed wait and an awkward examination by an

unfamiliar female physician, Daniel was informed of

several possible diagnoses, including cancer, and

instructed to return to his family physician to obtain

a referral for an urologist, as soon as possible. Daniel

left the clinic, still filled with anxiety and his problem

unresolved. ‘There must be a better way.’ he thought.

Imagine. . .How it could be

Daniel had noted the increasingly painful wart on his

penis for a month. He was too embarrassed to discuss

the issue with his friends. His immediate reaction was

to turn to the Global Personal Health Information

Centre, a Web-based tool designed to support his

health needs. After logging in, he accessed his Personal

Health Record (PHR) from which he launched an

automatic search tailored to his profile and specific

query (penile lesions). After listening (Daniel had

difficulty absorbing text so his PHR defaulted to

audiovisual files) through the consistent quality infor-

mation specifically targeted at young men and review-

. 332–336, December 2006

ing multiple online images similar to his lesion, he

concluded that the most likely diagnosis was penile

cancer. Daniel was prompted by his PHR to answer a

questionnaire and upload images of his lesion for

review by his family physician. Following instructions

sent to him automatically by the Personal Health

Coaching System, Daniel used his hand-held digital

assistant to take samples of his lesion, uploaded them

to his record and sent an alert to his family physician’s

office for urgent processing (receipt was acknowledged

within a minute). A reply the next morning indicated

the digital samples had been forwarded to a derma-

tologist and an urologist for review. A provisional

diagnosis of squamous cell penile cancer was made

within 24 hours and Daniel was automatically pro-

vided with the names and locations of the two most

experienced and available urologists closest to him

who were most familiar with Daniel’s rare diagnosis.

After reviewing information about their profiles, com-

munication styles and satisfaction ratings provided

by other patients, Daniel chose the urologist most

suitable for him. After sending an electronic confirma-

tion, Daniel was scheduled for surgery within 3 days

in the emergency slot (his personal schedule was

checked in advance for availability by the intelligent

booking agent at the clinic). The procedure was

performed uneventfully as a day case, and he was

informed that the lesion was so localized that there

was no anticipated impact on his sexual life. Upon

discharge, the urologist who performed the surgery

had a conversation during which adjuvant treatment

options were addressed. As Daniel requested time to

think about them, he built an information prescrip-

tion in the recovery room with the urologist, that

included links to online support groups of men his

age with squamous cell penile cancer and to multi-

media resources on treatment options. Before Daniel

logged out of the PHR, he was automatically provided

with alerts for two recent studies published in the

� 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.

Editorial

last 48 hours that could impact his future treatment

decisions. The articles (already reviewed and highly

rated by 60% of the members in Daniel’s online

support group) had been posted by patients who

had also been diagnosed with penile cancer. Satisfied

with his overall experience, Daniel posted his encoun-

ter on his blog (the new content was automatically

distributed to all members of his online support

group), rated his various provider encounters and

out of curiosity reviewed the feedback from his urol-

ogist with information provided on the Wikipedia

page on ‘penile cancer’. Noting some errors, he

quickly corrected them online. Daniel, though

exhausted, felt some comfort from the fact that he

could access high quality relevant information, had

been supported quickly by the health system, the

lesion had been removed and that he had an open

channel for communication with the clinical team,

and access to a valuable support group for the journey

that lay ahead.

The first scenario is all too recognizable by

most individuals familiar with the health

system. The second scenario could appear

futuristic and even idealistic until we stop

to consider that the technology to achieve

this model of health service delivery exists

today. What would it take to bridge the gap

between what we do and what we could do?

Enter Web 2.0

Web 2.0 is a term used to herald the second wave

of the World Wide Web, one that allows indi-

viduals to publish, collaborate and share experi-

ences with other like-minded individuals or

groups. Web 2.0 may simply represent new

jargon for what the Web was meant to achieve

all along [1], a marked contrast with what

happened during the first wave of Web devel-

opment, which was characterized by a hier-

archical structure (ruled by Webmasters)

offering static web sites broadcasted and dis-

tributed mostly through hypertext links.

Web 2.0 is already part of our mainstream

culture. A Google search in August 2006 of

‘Web 2.0’ yielded over 103 million hits. By

contrast, a search of Medline with the term

‘web 2.0.mp’ failed to provide even one docu-

ment. This dearth of information within the

biomedical literature motivated us to write

this article, as an attempt to introduce the

reader to Web 2.0 and its features, highlight-

ing its potential impact on health and the

health system, with an emphasis on men’s

health issues. Although not exhaustive, we

discuss some of the more practical features

of Web 2.0 that could, in the near term, sig-

nificantly impact the experience of patients

and providers.

Some of these features [2], which are all

about connecting people to people, could be

found in Web 1.0, but appear to be essential for

Web 2.0 applications that are already having a

major impact in most sectors of society.

Decentralization: moving healthinformation closer to the user

The power of Web 2.0 does not reside in any

one server, individual or organization. Instead

of relying on command-and-control mono-

lithic systems to generate value or efficiency,

Web 2.0 operates by allowing individual users

to interact with a site and affect its behaviour

based on a common set of low level rules. This

bottom-up rather than top-down approach is

notable in web sites such as Slashdot, a technol-

ogy news service that allows its members to

write, publish and rate technology stories

online. Using a few simple rules, members

decide which stories are the most interesting

and deserve high traffic, while they push

‘weaker’ stories to the bottom.

The power of decentralization in the health

system could enable providers and patients to

manage the information overload. As high-

lighted in the scenario above, patients could

automatically obtain current and potentially

relevant documents that could influence their

decision-making. More importantly, these

documents could be ‘filtered’ by peers, thus

providing greater significance and applicabil-

ity to specific contexts. Information rated and

‘approved’ by like-minded individuals could

prove to be more beneficial than the tradi-

tional top-down approach. It is not difficult

to envision a parallel system for health provi-

ders that could allow results of clinical

research, in fact, to be filtered by other provi-

ders (rather than by editorial boards) and

served up to members based on relevance

and suitability to practice settings and patient

profiles. This filtering system becomes even

more efficient and valuable as the amount of

available health information continues to pro-

liferate.

Vol. 3, No. 4, pp. 332–336, December 2006 333

Editorial

334 Vol. 3, No. 4,

User contribution: people sharing theirhealth experience and knowledge

The ability for users to provide new knowledge

that could enhance an existing service is not

exclusive to Web 2.0 applications. This feature,

best exemplified by Amazon’s book review and

other ratings services, has been very successful

in assisting consumers in the purchase of goods

and services. Several other commercial sites

have now embedded user feedback in an

attempt to engage users and improve their

services.

User-contributions in the health system,

which are now not only sparse but often dis-

couraged, could be used to transform consu-

mers and providers of health services into

‘virtual agents’. By promoting feedback at

the grass roots level we could obtain richer

and more accurate information quickly

regarding the quality, location and types of

services available for specific conditions. A

simple example could be a health provider

directory, with ratings of patient satisfaction

and guidance as to the most suitable provider

in a specific location. Providers could also

adopt similar systems to offer guidance to

other colleagues in choosing consultants or

peers with experience in uncommon or diffi-

cult cases, irrespective of distance or personal

relationship. As a result, anyone in touch with

the health system could carry a ‘virtual map’

drawn by others who have experienced the

battles and lived to tell the tales.

Another simple format to allow patients to

contribute and share their experiences and

help others is through the use of Web logs

(blogs). Early attempts to apply these con-

cepts to health are already being seen with

cancer patients through very successful

efforts such as The Cancer Blog, which is now

ranked amongst the top 500 blogs in the

world.

Network effects: finding andsupporting one another

Web 2.0 enables large numbers of individuals to

unite and collaborate around a common

resource. The most recent and notable example

of individuals congregating at a virtual site to

benefit from the network effect is MySpace. This

site enables individuals to create, post and share

personal information with like-minded indivi-

duals irrespective of gender, race, socioeco-

pp. 332–336, December 2006

nomic status or location. From its date of

inception 2 years ago, until August of 2006,

the site had logged 47.3 million members and

attracted an estimated 160,000 new users daily,

becoming the 5th most visited site on the Web

[3]. Flickr, YouTube and del.icio.us are also based on

the ability to share personal content and pre-

ferences with other individuals. In the case of

Flickr photographs taken by individuals can be

stored, shared and organized for others to view.

YouTube is similar, but involves videos, while

del.icio.us allows users to access, share and search

web browser bookmarks from anywhere on the

Web.

Harnessing these network effects in the

health system could be used to address concerns

of patients that are considered to be a low

priority by most health providers. Virtual com-

munities are a good example of this phenom-

enon. Patients can connect, communicate and

commiserate with like-minded individuals

across the street or across the world. Although

the benefits of virtual communities and electro-

nic support groups remains unclear [4,5], the

sheer number and longevity of on-line support

groups suggests that the majority of members

are obtaining benefit from this intervention [6].

Now sites such as My Cancer Place are using the

same tools to assist patients and expand their

social networks [7]. These social networks, in

turn, could encourage self-management and

help support newly diagnosed patients in crises

who have unanswered questions and face a

sometimes unsupportive and indifferent health

system.

Co-creation: collaborating to manageinformation overload

Web 2.0 allows users to contribute knowledge

in a collaborative fashion. A successful online

example of this phenomenon is Wikipedia, a

free online encyclopedia that enables anyone

with Web access to post articles on any topic,

edit them or challenge their relevance. In less

than 5 years, Wikipedia has grown to include

3.7 million articles in 229 language editions,

becoming by August of 2006 the 17th most

visited Web site on the Internet [8]. More

compellingly, though, is the fact that Wiki-

pedia, which relies on anonymous, unpaid

volunteers, seems to be as accurate in

covering scientific topics as Encyclopedia

Britannica [9].

Editorial

For health information, Wikipedia already

provides a valuable tool. The site contains over

27 subcategories in the disease section alone

with over 500 pages of user-generated informa-

tion. For example a query of ‘penile cancer’ on

Wikipedia yields page results informing the

reader on aspects including risk factors, sta-

ging and treatment.

The accuracy of websites involving numer-

ous individuals is not limited to Wikipedia. In

an unmoderated Breast Cancer Mailing List it

was noted that of 4600 postings, only 10 were

found to be misleading or false. Of these 10,

seven were corrected within 5 hours of the

original posting [10]. This ability to derive

accurate information from numerous mem-

bers and diverse data sets has been well docu-

mented and is not unique to Web 2.0 [11].

Leveraging the long tail of health:meeting the diverse demands ofpatients and providers

From an economic standpoint, the long tail

represents the numerous fringe individuals

and groups that are poorly served by compa-

nies because they do not fit the model of the

‘average’ customer. With Web 2.0 technolo-

gies, these groups are not only easily accessed,

but as a collective their numbers are signifi-

cant, and in some cases are even greater than

the mainstream [12].

The long tail has many potential applica-

tions within the health system. In our sce-

nario, Daniel quickly reached a tentative

diagnosis of penile cancer (rare condition),

obtained relevant quality information in his

medium of choice (multimedia rather than

traditional text based documents), identified

health providers familiar with his rare disor-

der and connected to a virtual support group

to help guide him through his time of crisis.

For patients located in a geographically

remote or isolated community, the benefits

of leveraging the long tail would only be mag-

nified while the shortcomings of the tradi-

tional health system become accentuated.

Some closing remarks

Since the mid-1990s, we have witnessed the

dramatic transformation of major industries

by information and communication technolo-

gies (ICTs). The introduction of online consu-

mer services has led to irreversible and

invigorating changes in very traditional sec-

tors, such as banking, entertainment, and

tourism. The health sector, however, somehow

remains trapped in the pre-Internet era.

At the dawn of the 21st century, most dis-

cussions about the role of ICTs to improve

health and the health system still revolve

around centralized electronic health records

under the control of managers, IT specialists or

health professionals, and designed to reinforce

inefficient processes that are clearly unsustain-

able. Most processes continue to consider the

public as the passive (and incompetent) reci-

pient of services, excluding it from priority

setting efforts, discussion on the relevance of

existing workflows and roles, or the allocation

of limited resources. In the outside world, and

particularly in the business sector, the patron-

ization of the public at the level that occurs

within the health system is not only passe but

tantamount to commercial suicide. Why

should the health system be regarded as

immune to the changes that are taking place

everywhere else in society? The answer

‘because it can’ is no longer valid. As consu-

mers (most of whom will eventually become

patients) continue to self-organize using Web

2.0 technologies, they will expect similar inter-

actions with the health system.

With Web 2.0, we now have an opportunity

to make amends. Although not presently con-

ceivable by most people, the day when health

care providers find themselves playing a bro-

kering or coaching role rather than simply a

supplier of medical services may be very near

[13,14]. The main message provided by efforts

such as Wikipedia, MySpace, YouTube and health-

related virtual communities like the Breast

Cancer Mailing List is that the public now have

the tools to manage knowledge, answer ques-

tions and find services in a way that is bypass-

ing and even exceeding the capacity of the

traditional establishment and its gatekeepers.

Some are even stressing the fact that those

belonging to the M (Millennial or Multitasking

or Multimedia) Generation (born between

1982 and 2000) are already tuning out their

predecessors, thanks to tools such as instant

messaging services, blogs and podcasts [15].

The power of these tools, however, pales in

comparison with what is emerging thanks to

Web 2.0 applications. Rather than becoming

Vol. 3, No. 4, pp. 332–336, December 2006 335

Editorial

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