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EDITORIALS: Sasha Shepperd and Deborah Charnock Against internet exceptionalism BMJ 2002; 324: 556-557 [Full text]

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Hard print medical publishing vs the Internet – a modern day Cinderella story

Lindy C van den Berghe   (13 March 2002)

Integrity in Internet Information

Michael J Rigby   (30 March 2002)

Hard print medical publishing vs the Internet – a modern day Cinderella story 13 March 2002
Lindy C van den Berghe, Freelance editor, writer, page layout artist, designer and illustrator 12 Woodland Close, Marlow, Bucks, SL7 3LE Send response to journal: Re: Hard print medical publishing vs the Internet – a modern day Cinderella story	Sasha Shepperd and Deborah Charnock are right to highlight that Internet expertise is still too basic for presenting packaged information in a truly useful, accurate and accessible way. Meanwhile, I’d like to add that the overenthusiastic and carelessly thought out development of Internet products has diverted investment away from the exciting developments now possible for hard print medical publishing. Print and publishing technology have come a long way since I first started in medical publishing in 1986 after working for five years as a hospital doctor. At that time the publishing process was cumbersome and its potential severely limited. Now in 2002, publishing software and hardware are sophisticated enough to support an exciting high-tech revolution in hard print. We can edit quickly to a level we could only dream about one year ago using annotated PDF files for communications between editors and authors. Accuracy and consistency can be maximised and information easily updated using computerised checking against databases and within documents. Now, hard print design can always be attractive, effective and useful, and all illustrations can inform and yet be inspirational and mood-elevating works of art. A major innovation is cost-effective printing of high-quality full-colour books within days of being ready for press from PDF files sent electronically to printers in the UK. Three-month delays between book production and publication should now be history. If the whole ‘new’ publishing process is carried out effectively, book prices should fall and book quality improve. Over the past 12 years as a freelance medical and general reference editor, writer, layout artist, and occasional illustrator and designer, I’ve worked for almost 30 different publishing companies, including great innovators such as Gower Medical Publishing (which has since been taken over by about eight different companies) and Dorling Kindersley. Sadly, much of the investment in innovation of the late 1980s and early 1990s has not progressed. Instead time and money have been spent in management shake-ups after takeovers, maximising profits from backlist titles and investment on Internet products. Medical publishing professionals like me have been unable to develop the high-quality medical books that most people haven’t even thought of and that, for the moment, we can only dream about. Internet development has, without doubt, had a damaging, but hopefully not irretrievable, impact on the development of innovative hard print medical publishing. Competing interest: Managing Director of new medical publishing company First Line Medical Communications Ltd
Integrity in Internet Information 30 March 2002
Michael J Rigby, Senior Lecturer Centre for Health Planning and Management, Keele University, Keele, Staffordshire, ST5 5BG, U.K. Send response to journal: Re: Integrity in Internet Information	The focus on Internet health information in the edition of 9 March was timely, yet showed the usual diversity of views, and issue avoidance. The consensus of most papers was that regulation is inappropriate, and that the answer lies with consumer education and voluntary codes (1,2). However, this position fails to understand the complexity of public behaviour and provider variation, or the power of search-engine delivery to the home in homogenous format. It continues to leave the vulnerable at risk. Worryingly, the issue of trust, considered pivotal elsewhere in health care, was missing. It is akin to arguing for the citizen to have unconstrained choice of pharmaceuticals, or to select health professions without authenticated credentials. The general public is very different from the concerned person; the expert lay student of a chronic condition different from the anxious person in a new acute situation. Internet health information may be sought when the citizen is confronted with a sudden health crisis. In these circumstances they are unlikely to apply the principles of an undefined diffuse consumer education philosophy. Behavioural studies of consumer attitudes on health topics such as funding priorities show that prior rationality is forgotten when confronted by the immediacy of personal health need. Information providers have different motives, including the commercial, campaigning, and mischievous. Evidence and sources may be opaque or misleading. An empirical study found wide concern at potential harm from the Internet, compromising the overall benefits (3). The epidemic of good practice initiatives would not be happening if there were not concern. At the same time, their proliferation confirms that they are ineffective, with poor compliance, little monitoring, and no available sanctions (4). What is needed is introduction of measures of trust, within an open system. Unfortunately, most commentators confuse site regulation, which is near impossible, with a regulatory framework. Formal standards in labelling, underpinned by legislation, would achieve this, enabling the citizen to select sites with more confidence. This approach has safeguarded consumer purchasing of food for many years, co-sponsored by the World Health Organisation and underpinned by international treaty enacted by national legislation (3); why not a similar international approach to information on the Internet? There would be freedom of site display – it would be false labels that would be illegal. Secondly, by providing a legislative framework, an optional trusted seal system could be introduced. This could enable special groups including ethnic, affinity, and patient groups to define criteria for their recognition of sites. Third party agencies would verify compliance, on an optional basis for a fee but backed by law, as happens with CE marking (5). There is a justifiable belief that information is powerful; Information Society initiatives promote this. Therefore it is unethical to sidestep associated risks, while a purely voluntary approach is futile. Those advocating no regulation appear either to be claiming either that Internet information has no power, or that the citizen has the right to be misled. Michael Rigby Senior Lecturer Health Planning and Management 1. Shepperd S, Charnock D: Against Internet Exceptionalism; British Medical Journal, 324, 556-557, 2002. 2. Purcell GP, Wilson P, Delamothe T: The Quality of Health Information on the Internet; British Medical Journal, 324, 557-558, 2002. 3. Forsström J, Rigby M, Roberts R, Nilssen S-I, Wyatt J, Beier B, Delfosse I: Towards Evaluation and Certification of Telematics Services for Health (TEAC-Health) - Key Recommendations (Final Report of the EU Health Telematics Application Programme project HC 4101, Towards European Accreditation and Certification in Health (TEAC-Health)); University of Turku, Turku, 1999. (available on www.multimedica.com/TEAC) 4. Meric F, et al: Breast Cancer on the World Wide Web: Cross Sectional Survey of Quality of Information and Popularity of Websites; British Medical Journal, 324, 577-581, 2002. 5. Rigby M, Forsström J, Roberts R, Wyatt J: Verifying Quality and Safety in Health Informatics Services; British Medical Journal, 323, 7312, 552-556, 2001.