Trends in Medical Publishing:
Impact of Electronic Content on Biomedical Publishing

In 2002, the medical publishing market grew 6.2% to $2.53 billion dollars. This growth was fueled by add-on acquisitions, global sales and electronic content. The six top publishers of medical content (based on gross revenues) each increased earnings, despite a general slow-down in STM publishing. In fact, medical publishing overtook business publishing, which had total sales of $2.41 billion and growth of just 0.4%. This analysis includes medical content published and utilized in the following media formats: academic, trade, and reference books; journals; and electronic content.¹ Although book and journal publishing continue to contribute to overall sales for medical publishers, their joint contribution to revenue growth is declining relative to electronic content. This trend is driven by a combination of factors, including demand for electronic content, sophisticated technological interfaces such as personal digital assistants (PDAs) that facilitate greater reliance on electronic delivery, consolidation of the medical publishing sector (figure 1), internationalization of medical publishing and noncompetitive partnerships between publishers that exploit Internet technology to increase overall sales of content. This trend is underscored by the overall trend in STM publishing; in 2002, STM book publishing increased by 2.6%, compared with 4.7% for journals and 10.1% for online content. ² In short, the entire culture of STM publishing, and medical publishing in particular, is changing.

Activity within the last 12 months illustrates how these trends are shaping the industry. Reed Elsevier with $790 million in sales of medical content in 2002, compared with $394 million in 2001, can attribute much of that gross profit to its acquisition of Harcourt in 2002. The value of their portfolio was bolstered by an additional 1500 journals from the Harcourt acquisition, including 335 electronic journals that were added to ScienceDirect, the Reed Elsevier online content division, bringing the total number of online journals to 1500. Besides adding journals to its portfolio, Reed Elsevier introduced PDxMD, an electronic point-of-care clinical guide and continues to invest in its online reference product, MD Consult. With respect to print products, Reed Elsevier is enhancing its offerings with interactive educational materials. Reed Elesevier is leading the pack, but other medical publishers are also acquiring electronic content and deploying resources towards electronic content platforms. Wolters Kluwer, with $711 million in 2002 revenues from medical publishing, compared with $593 million in 2001, is increasing content available in its online library, OVID, and offerings for its PDA platform, @OVID. Meanwhile, Thomson Scientific, which had $514 million in medical publishing revenues in 2002 versus $480 million in 2001, is bringing out the MobilePDR, an online version of the Physician’s Desk Reference, and Ingenix Publishing Group is working to bring its core businesses, which focus on books, clinical reimbursement software and HIPAA print products, into the electronic realm. Also, McGraw Hill, which is strong in medical textbook publishing, grew its online delivery by 120% in 2002; and John Wiley, which did $29.4 million in medical publishing business in the fiscal year ending April 29, 2002, increased the number of journals available on Wiley’s InterScience from 8 to 15 between year-end 2001 and year-end 2002.^3,4

The trend towards the electronic delivery of medical content will continue as publishers seek to integrate their products electronically while retaining some print journal and newsletter offerings. ⁵ Currently, 90% of Thomson’s revenue comes from electronic content oriented towards a clinical audience, and by 2005, John Wiley and Sons anticipates that 50% of its revenues will be derived from electronic content. Also, the trend towards consolidation will continue as consumers seek to simplify the process of procuring content by using aggregated sites. Production of both direct-to-professional (DTP) and direct-to-consumer (DTC) content will be driven by quality concerns as availability, and therefore competition, increases. Furthermore, improved delivery platforms, pay-per-view access, and improved archiving and linking features will increase quality and convenience for end-users.⁶

In addition to delivering electronic content to existing print customers, including healthcare professionals, academics and marketing professionals, publishers are continuing to expand abroad. According to Rick Noble, CEO of Thomson, “The nice thing about medical information is that it travels well.” Towards that end, Thomson’s international division publishes drug reference products comparable to the Physician’s Desk Reference for eight Latin American countries ³

These factors combined represent a change in the medical publishing model from one driven by print media formats to one in which print and electronic content are available to end-users through different output devices. Nonetheless, despite the consolidation of the medical publishing industry and the fact that the industry as a whole is moving towards electronic delivery, there is still fragmentation. Smaller electronic-only publishers of medical content, such as NewsRx, host-service organizations such as HighWire Press and “non-publishers”---including organizations that aggregate, distribute and archive electronic medical information, such as Infotrieve, E-pocrates.com and PubMed Central have roles to play in this realm. Also, companies committed to open access of ideas, such as BioMed Central (www.biomedcentral.com) provide a community for authors looking for alternative publishing conduits and users looking for access to medical content free or at lower prices than larger publishers charge. Plus, the leading medical publishers are still committed to maintaining print publishing as part of the overall mix. Brian Nairn, CEO of Health Sciences at Elsevier Science confirms this commitment saying, “We certainly do not subscribe to the belief that print is going away in the next year.” ^7,8

The purpose of the following paper is to analyze the impact of the electronic revolution on medical publishing. Specifically, how it can impact profitability and opportunity in the long-term by looking at the top medical publishers: Reed Elsevier, Thomson Medical and Wolters Kluwer. However, because smaller publishers, aggregators, distributors and hardware manufacturers are active in the medical publishing marketplace, their role will also be considered. Most recently, the largest medical publishers have increased profits by adding electronic content to their respective product lines. In response to this trend, the following questions will be addressed: whether electronic content will continue to drive profits, whether the industry will consolidate further, and whether there will be room for competition from companies and organizations with goals that differ from large publishers. Moreover, this analysis will highlight how the definition of medical publishing is changing. A related issue that will be addressed is how increased publication of electronic medical information will affect the quality of content (especially important for the reporting of clinical data) and its utility and value for end-users. By understanding that medical information is a body of knowledge that grows daily, is always relevant to a broad population of end-users and is subject to strict quality-control processes, this paper will also address the challenge posed by the threat of commodification . Additional topics to be explored include the shifting balance between profits derived from electronic versus print content in medical publishing enterprises and the growth of each sector; the challenges that will confront medical publishers attempting to deliver electronic content; and opportunities to thrive using such models. Additionally, this paper will specifically explore how Wolters Kluwer created digital assets by taking core print products and transforming them into digital media and leveraging investment capital to create a unique digital portfolio.

Ancillary issues that will be addressed include pricing of digital versus print content, intellectual property, the role of the consumer and a discussion about the impact of larger macroeconomic and business forces, e.g., pressure on library budgets. Figures and charts will be included.

The Evolution of Medical Publishing

Consolidation (see figure 1) in the medical publishing industry has created a more uniform infrastructure, which in turn has allowed larger firms to take the risks associated with implementing electronic content (e-content) platforms. For example, Reed Elseivier spent $1.17 billion on e-publishing initiatives between 2000 and 2003⁷, and Thomson Scientific budgeted $1.8 billion for Internet-based products between 2001 and 2004.⁸ Because the STM market is driven by information, the demand for efficient delivery of medical information has provided publishers with an opportunity to add value. Therefore, as medical research proliferates and the volume of information increases, users want expedient access to well-structured information as inexpensively as possible.⁹ The ongoing challenge for medical publishers is to continuously create quality content and re-purpose it to a variety of outputs, thereby increasing utility for users and profit for themselves.⁷

MEDICAL PUBLISHING: CONSOLIDATION AND GROWING REVENUES

Figure 1. TOTAL MEDICAL PUBLISHING MARKET 2002: $2.53 BILLION ³

Understanding The Value of Electronic Medical Content

In 1995, Esther Dyson, an intellectual property rights specialist, put forth a theory about how publishers would be remunerated for the intellectual content they distributed on the Internet. The Dyson model assumed that end-users would not want to pay for content, especially when sources of free content existed. Rather, her model was based on the notion of attracting as many viewers as possible who would then be targeted for advertising and marketing purposes.¹⁰ This theory captured the imagination of publishers and became part of the standard business model for Internet publishers, who anticipated a deluge of profits---at some point in the future. However, this did not happen and the failure of non-subscription Web sites without funding from larger brick-and-mortar companies is a well-known chapter in recent business history.^§

Like any other type of publishing, the goal of electronic publishing is profit. In general, medical publishers, such as Wolters Kluwer, do not rely on advertising revenues in return for publishing peer-reviewed articles and distributing them through Ovid (www.ovid.com), their online library. Rather, the standard revenue model for Wolters Kluwer and the other large publishers is offering institutional access to libraries or hospitals for a customized fee or allowing individual viewers to order articles on a pay-per-view basis. Ovid will be discussed at greater detail in another section of this paper.

Before there was Ovid, ScienceDirect or BioMedNet, there was the online bibliographic MEDLINE Database. The MEDLINE database is a copyrighted, electronic catalog that is produced and owned by the National Library of Medicine. Access to the MEDLINE database, which goes back to 1957, is free, but this was not always the case.¹¹ When the National Library of Medicine developed the PubMed portal and made the database available online in 1995, users paid a small licensing fee to access the database and download abstracts. Several medical communications companies funded by pharmaceutical companies decided to license MEDLINE and make it available as a gateway to the literature for physicians—their target audience---free of charge. The end of result was that physicians were no longer willing to pay for access to MEDLINE. Eventually, the National Library of Medicine decided to make MEDLINE access through the PubMed portal free. However, while access to bibliographic information and medical abstracts from peer-reviewed articles is free, most full-text articles from peer-reviewed journals are not. Nonetheless, this is changing because of the open-access movement. Open-access advocates believe that biomedical research and literature should be available to the medical community free-of-charge. They also support the notion that publishers should be able to publish in electronic communities and gain academic respect and credibility for their work. The genesis of the centralized open-access movement was the online publication of the Public Library of Science Open Letter ( www.plos.org/openletter.shtml), which has almost 33,000 signatories in 183 countries. The letter is a statement supporting the establishment of an online public library that publishes and archives the entire contents of the medical literature and makes new research available within six months of publication. According to the authors of this letter, the material should be available electronically and have full search and linking functionality, as well as permanent archiving. As of September 2001, signatories of this letter are committed to exclusively publishing in, subscribing to and participating in the peer-review process for open-access journals. This movement has catalyzed controversy in the medical publishing community, as some publishers reject this position. This topic will be explored in further detail later.

The open-access movement has an economic construct different from larger medical publishing enterprises, but the organizations that support and participate in open-access publishing are gaining credibility. As an alternative to publishing and accessing content published by large publishers and distributed both in print and electronically through their online libraries, the online publisher BioMed Central publishes open-access journals and also provides access to other publishers’ journals. Another important alternative source for open-access journals is HighWire Press, which hosts journals electronically, including journals that publishers offer free of charge or at reduced prices, and many society titles. Moreover, the Scholarly Publishing and Academic Resources Coalition (SPARC), a worldwide alliance of research institutions and libraries, http://www.arl.org/sparc/) was founded in 1997 by the United States Association of Research Libraries. SPARC’s mission is to underwrite journals that can compete head-on with the expensive titles. Their goal is simple: “To return science to scientists.” Finally, another important player in the open-access movement is PubMed Central. PubMed Central (PMC) (www.pubmedcentral.com) is a digital archive of life sciences journal literature. PMC does not publish material, rather it archives peer-reviewed original research articles, essays, editorials and review articles from participating journals, and allows publishers to retain copyright. The real value offered to users accessing content from PMC is the availability of diverse archived materials in a single repository that can be searched and cross-referenced using the standard value-added features of most online journal article collections: searching, retrieving and cross-referencing. PMC, does not, however, accept non---peer-reviewed content. So while the possibility to publish, archive and utilize electronic content has driven profits and most likely improved what many consider already high margins for large publishers (40% in 2000, according to Michael Nathanson, an analyst at Sanford Bernstein in New York City¹²), the same forces have lowered the barriers to entry for publishers who choose to compete and are attempting to shift the medical publishing paradigm towards a new model based exclusively on electronic delivery. The economics of this model are based on charging the author fees to publish, while making the content available free or at modest prices to endusers. However, while the revenue models are different between large publishers and organizations that support a more open-access, electronic-only publishing environment, the stated goals are the same: to publish quality content to serve the medical community.^{13 #}

One primary reason used to justify the cost of medical content is the peer-review process. In 1998, the average annual costs associated with administration, editing, lay-out and the peer-review process of a scientific journal (costs are comparable for medical journals) was approximately $400,000. However, the production and distribution costs were minimal, costing roughly $40 per customer.¹⁴ According to an article by B.J. Markovitz, M.D. writing in the Journal of Intensive Care in 1998, “The peer-reviewed medical journal is the ‘gold standard’ of medical research publication”¹⁵ In fact, the notion of peer-review as a form of quality control is as old as medical publishing. When Henry Oldenberg published the first medical journal in England in 1655, he laid out the “Philosophical Transactions” that still define medical publishing. The four qualifications were as follows: 1) registration of an author’s work to establish authorship; 2) validation of claims---essentially peer-review; 3) communication of results to an interested community and 4) archiving, or creating a permanent place in the scientific literature.¹⁶ This legacy influences biomedical publishing and is the reason that the imprimatur of a society title, like the Journal of the American Medical Association or a “high-impact” title from Reed Elsevier, Wolters Kluwer or any other large publisher carries so much weight.

This peer-review driven approach to medical publishing affects the professional well-being of healthcare researchers and practitioners. This is because, medical publishing serves professionals in the field in two major ways: 1) It provides practitioners and researchers with practical and theoretical peer-reviewed, quality-controlled data; and 2) It functions as a key driver of career upward mobility and professional placement in a hierarchical field.¹¹ Therefore, in the marketplace, content published by established biomedical publishers has innate value, because of its peer-reviewed status. However, without the imprimatur of a review committee, published content loses value amongst members of the medical community. Members of the open-access community maintain that the content they publish and support undergoes an online peer-review process. However, in the minds of many, modified processes cannot replace peer-review, the publisher’s core service, although technology might potentially facilitate the peer-review process. According to Richard Smith, an editor at the British Medical Journal, the medical community is nervous about what William Shulenberger, provost of the University of Kansas, refers to as the “minimal refereeing provided by PubMed Central and BioMed Central.¹⁷ That being said, biomedical content from large publishers, particularly the online equivalent of print journals will continue to cost money for the foreseeable future and to drive increases in revenue. However, publishing in the open-access environment will gain momentum because of various factors, including the budgetary restraints of research libraries, which will be addressed shortly.

Established medical publishers have the advantage of an established brand and established publishing processes, including an established peer-review process. With respect to the electronic publishing arena, there are advantages for publishers who have a history of strong publishing in the area of print biomedical journals. According to Richard Smith, “Strong publication is associated with prestige, credibility, reliability, wide availability and permanence.”¹⁷And while these qualities can exist outside of large publishing enterprises, there is the problem of creating and maintaining a consistent publishing process that produces uniform products. The fact that large publishers charge for content is directly related to the cost of the processes they rely on to create value. Copy-editing, editing and peer-review greatly enhance publications and result in a uniformity that makes it easier to bring products online and maintain the integrity of the medical literature. Moreover, uniformity supports the creation of an index structure and search functionality across common parameters, which makes it easier to convert into electronic data.¹³ One of the defining features of the refereed medical literature is the assumption of quality and credibility, and while the ability to publish and access electronic biomedical information could be a boon to researchers and users, it could also compromise the integrity of the literature.

Regardless of the size of the publisher, biomedical content available in an electronic format can potentially benefit the user and enhance the research process. There are numerous advantages associated with electronically accessing biomedical content from sites that function as publishers or as digital archives or hosts. The most important being expedience. Immediate access to content has revolutionized the way research findings are disseminated and the way people use medical data. Prior to 1995, there was no medical journal information available on the Internet. If a healthcare professional or someone in a profession who relied on medical data wanted an article from a biomedical journal, getting the article was a paper-intensive endeavor. As an example of the procurement process: One could call a representative of a document delivery service who had physical access to the National Library of Medicine. That person would then go the library, photocopy the requested article and charge the customer a fee for service, as well as the fee for sending or faxing the article and the copyright fees. Depending on the length of the article and how quickly it was needed, costs ranged from $7.50 to $50. Even under ideal circumstances, there was always a lag time of at least several hours between the time the article was requested and the time it was received. There were other document delivery companies that made STM materials available to users by entering into agreements with publishers, while other companies, such as Adonis, adapted and put biomedical content on CD-ROMs. Again, this business model was no longer viable with the advent of the Internet, as immediate availability is a much better business proposition than a CD-ROM with biomedical content that is already outdated.¹⁹

As early as 1987, there was one document delivery company destined to survive into the Internet era. Infotrieve (www.infotrieve.com), a Los Angeles-based company that specializes in STM document delivery currently offers more than 30 million articles and 20 million abstracts through its database. It delivers content to customers, who pay a service fee and the necessary royalties and copyright fees and integrate the content into proprietary Intranet-housed digital libraries. Infotrieve even provides a virtual library platform to facilitate this. However, prior to 1996, Infotrieve maintained relationships with publishers and acted as a one-stop document delivery source for institutional and corporate users looking for STM material, which they delivered in print format or on CD-ROM. However, they were one of the first companies to provide online access to MEDLINE in 1996, initially offering partial access for free and increasing the price to $50 a month for access to the entire database. By integrating the MEDLINE database with an order interface, Infotrieve took the first step that would help it maintain relevance as publishers began to offer their content electronically.²⁰ Conversely, companies set up based on the model discussed earlier, in which margins were generated by procuring the content physically, quickly became anachronistic and went out of business. Infotrieve continues to aggressively pursue contractual agreements with STM publishers and societies to distribute their content. Document delivery is an additional sales channel for publishers and provides users with an additional option for article procurement and management without making an institutional commitment to an aggregator. Infotrieve dominates the document delivery market in a manner that mirrors the consolidation of the medical publishing industry in the last eight years. According to Information Today (March 2003)²¹, the only viable competitor is Ingenta, Ltd., which provides online publishing services, document delivery and Web site building. Another development that reflects how quickly the landscape is changing for distributors of STM content is the closing of the government-sponsored PubSCIENCE, which closed its site down on November 4, 2002. PubSCIENCE was a database launched in 1999 and produced by the U.S. Department of Energy’s Scientific and Technical Information division in partnership with the Government Printing Office. Its mission was to provide free Web search capabilities for journal article abstracts and citations in the physical sciences. The collection boasted over 1200 journal titles from 35 publishers, including Kluwer Academic Publishers, Springer Verlag, the American Society for Microbiology and others. In the final analysis, when the founders of the project were testing it against commercially available options, notably Infotrieve, they found that it was impossible to justify its cost, especially considering that Infotrieve offers free search capabilities on its site.²² The story of Infotrieve and the history of document delivery exemplify the fact that the advent of electronic publishing has redefined the entire medical publishing landscape for publishers and for those companies that formally were involved with printing, production and distribution of medical content.

Early efforts in the mid-1990’s went beyond licensing MEDLINE and hosting it on a Web site. The earliest effort at electronic biomedical publishing resembling contemporary online libraries was BioMedNet (www.bmn.com), which was founded by Current Science, Inc. in 1996. BioMedNet offered an online library, a virtual community for biomedical researchers and a job search portal. Initially 6000 individuals signed up for the service.²³ In 1996, BioMedNet targeted individual users who were encouraged to download content on a pay-per-view basis. Pay-per-view access was deemed critical to the success of this site, because the target audience generally had the authority to make discrete purchases, but not to take on serialized subscriptions.²⁴ In 1998 Reed Elsevier purchased BioMedNet from Current Science, and used this site as a way to gain visibility---and ultimately instructive experience--- in the online biomedical community. After the acquisition, subscription access to journals on BioMedNet became an option as Elsevier sought institutional clients. BioMedNet has never been profitable, yet it remains as an Elsevier offering. Today, the site has 1.13 million registered members and is a gateway for access to over 100 Elsevier Reed journals.^13,24

Besides the allure of instant availability, online medical content has greater utility than the same content in print format. Web site functionality provides another dimension for researchers, which informs and enhances their experience. Beyond the individual user experience, researchers can react to material through an electronic community and participate in an exchange that further increases the value of the information. Users can download the article needed as well as additional pertinent information through hyperlinks. Despite the costs associated with high-impact journal titles, the option of downloading discrete articles on a per-article basis or participating institutionally provides financial flexibility and allows for more targeted spending than subscribing to numerous journals just to obtain individual articles from each of them. This point epitomizes the impact of electronic delivery on healthcare professionals who need to read the medical literature to stay abreast of changes in rapidly changing fields, such as HIV/AIDS. Keeping up with necessary reading has always been a challenge, and the time and money needed to procure various biomedical print journals whether through subscription or research libraries has been a large part of the problem.¹⁵

Medical Publishing: Overview of the Corporate Landscape

Within the past five years, each of the three largest medical publishers has moved to consolidate its presence in the area of providing electronic biomedical content and developing or acquiring the ancillary delivery platforms and packaging that support electronic content distribution. These medical publishers can choose to market their information into two main marketplaces: the research market or the clinical “practitioner” market. According to Cheryl Chisnell, e-publishing consultant, the publishers’ goal is to create the knowledge once and re-purpose it as many ways as possible for different audiences and outputs.¹³

Below is a brief overview of the medical publishing activities of Reed Elsevier, Thomson Science and Healthcare and Wolters Kluwer (For additional data, see table 1):

Reed Elsevier Science & Medical: Overview

Properties/Offerings

• ScienceDirect (vertical online library)
• MD Consult
• PDxMD
• Elsevier Science
• Embase
• BioMedNet
• ChemWeb
• Compendex (Engineering)
• Excerpta Medica Communications (healthcare communications)
• MDL (informatics)
• Academic Press
• Harcourt Health Sciences
• Journal of Emergency Medical Services
• The Lancet

The flagship electronic offerings from Reed Elsevier are MD Consult and PDxMD for the clinical practitioner community, and ScienceDirect, a database of the biomedical literature aimed at researchers that boasts more than 1700 individual titles, including The Lancet. Reed Elsevier has created a well-powered electronic database with multimedia capability, robust search functionality and rapid access to content. ScienceDirect, which was launched in 1999, has evolved from a database housing Elsevier Reed’s journal offerings to a database that includes over three million articles and 59 million abstracts from all fields of science. (http://www.info.sciencedirect.com).

Elsevier also has an electronic drug guide product, GenerEx, which competes with Thomson’s Physicians’ Desk Reference (PDR); however, according to Chisnell, the product is poorly branded and is not competitive with PDR.

The pricing model for ScienceDirect is primarily aimed at institutions. Customers are offered some combination of print journals, access to electronic journals, access to individual titles or access to a subject area. In addition, customers can opt for varying levels of access to the back catalog, reference books and special print options. Transactional access costs $30.00 per article. In 2001, revenues for ScienceDirect topped $1 billion and accounted for two-thirds of Elesevier’s medical division’s subscription revenue.⁴

MD Consult integrates medical content online, including reference books and journal articles, for clinicians. Reed Elsevier’s newest product is PDxMD, which is an evidence-based primary care clinical information system that is continuously updated. Areas that are covered include patient/disease evaluation and diagnosis, therapeutics, patient management and outcomes (http://www.mdconsult.com). MD consult and PDxMD are synergistic. While MD Consult focuses on a comprehensive set of clinical references, PDxMD provides concise decision-oriented information for physicians.

Thomson Science and Healthcare: Overview

Properties/Offerings:

• PDR, PDR.net, mobile PDR
• Medstat.com
• Gardiner Caldwell
• Center Watch
• MICROMEDEX (focuses on point-of-care electronic offerings)
• BioWorld
• American Health (CME)
• Dialog
• Physician's World (medical education)
• ISI Web of Science
• Derwent World Patent Index
• Medical Economics Magazine

According to information provided by Thomson Science and Healthcare (www.thomson.com), in 2002, a full 10% of Thomson’s $7.8 billion in revenues were generated in the science and healthcare division, with $514 million generated from sales of healthcare content. And while the corporation at large grew 7% between 2001 and 2002, the science and healthcare division grew by 13%.

Micromedex in Denver, Colorado handles Thomson’s medical e-products. A full 92% of the top hospitals in the United States rely on Micromedex (www.micromedex.com) for electronic access to evidence-based health care information. Through their Integrated Index Systems, data from multiple databases are deployed across a variety of platforms to various audiences. Jackie Smith, Corporate Communications Manager at Micromedex, characterizes the growth of the electronic offerings of Thomson as “phenomenal.” Based on an explanation provided by Smith, Micromedex can deliver content via several different platforms, including: Intranets, the Internet and intermediate proprietary systems. Enterprise-wide distribution allows systemic access to Micromedex content that functions as a clinical guide, but also incorporates selected information from the medical literature. Plus, Thomson’s delivery platform allows hospitals to integrate their proprietary electronic medical system (EMS) with Thomson’s database. This facilitates interdepartmental access (labs, the emergency room, treating practitioners) to the same information.

As a publisher Thomson excels in providing electronic information for the clinical setting. According to Lois Smith, an Account Manager at Thomson’s Montvale, NJ office, “Mobile and .net are simply an extension of our print products with the endgame being e-prescribing.” Their products revolve around structured content comprised of data from various sources. In fact, employees author 85% of Thomson’s products. With respect to profitability, pricing for access to the Micromedex suite of products is competitive. The PDR, which is sponsored by pharmaceutical companies, is not a high revenue product for Thomson, but it gives the company a well-branded presence in the medical information marketplace. Thomson is firmly ensconced in the clinical information marketplace and does not compete head-on with either Elsevier Reed or Wolters Kluwer for the research market.

Wolters Kluwer: Overview of Medical Publishing

Properties/Offerings

• Lippincott Williams & Wilkins (LWW)
• Facts and Comparisons
• Ovid Technologies
• Medi-Span
• Adis International.(healthcare communications)
• Clineguide (point-of-care solution)
• Skolar MD (clinical information for institutions)

In a Wolters Kluwer (http://www.wolterskluwer.com) press release issued on November 5, 2002, Hugh Yarrington, an executive board member, made a statement that in many ways characterizes the current state of medical publishing. He said, “We are extending our proprietary content and brands to software solutions that help health professionals be more productive. Thanks to steady product introductions and acquisitions of smart tool companies, Internet and electronic products already represent almost one-third of the Health cluster’s annualized sales.”

In November 2002, Wolters Kluwer’s announcement of its sale of Kluwer Academic Publishing (KAP) to the KAP management team for $531.5 million reaffirmed its focus away from its science/technical division to its healthcare division.²⁵ Wolters Kluwer’s commitment to growing its medical publishing property, and its attendant focus on electronic offerings in particular, is underscored by a recent history of acquisitions. When Wolters Kluwer acquired Ovid in 1998, it became the leading aggregator of licensed biomedical journal articles for researchers. However, when it acquired Silver Platter in 2001 and folded the new offerings into Ovid, it became the undisputed market leader in terms of content, functionality and clients. The SilverPlatter acquisition effectively doubled Ovid’s institutional client base bringing global clients in Europe and Asia, as well as academic and non-medical customers.¹³ Ovid was attractive to Wolters Kluwer for its client base, but also Ovid’s developed software platform came with tremendous potential. As of April 2001, Ovid had over 16,000 institutional clients, and links to over 6500 journal titles and11 million bibliographic entries in full text.

In the case of Wolters Kluwer, as with the other publishers discussed, acquisitions are fueling growth, but according to the press release issued on November 5^th, 2002, the company’s aim is to grow “organic” growth above the industry’s 2% to 5%.

Publisher	2002 Revenues	Growth From 2001	Area of Focus
Elsevier Reed	$790 million	100%	Expand e-offerings; integrate Harcourt content into electronic database
Wolters Kluwer	$711 million	20%	Add databases to Ovid; increase clinical offerings with current databases
Thomson (medical)	$514 million	7%	Increase database offerings through acquisition. Expand PDA point-of-care offerings
Ingenix	$90 million	12.5%	Bring core print products online and dominate HIPAA information market
McGraw Hill	$70.9 million	5%	Preserve medical textbook business aimed at a traditionally stable market; move core products online
John Wiley & Sons	29.4 million	6%	Maintain small e-database and provide PDA offerings

Table 1: 2002 Overview of Medical Publishing: Investment in Electronic Publishing Drives Growth³

Historical Perspective: The Story of Ovid Technologies, Inc.

The story of Ovid Technologies is a representative history of electronic medical publishing: the perfect admixture of passion, technical knowledge, risk-taking, conservative restraint, client relations and well-chosen personnel. In 1984, Mark Nelson was a graduate from Columbia University with a degree in Classics. While working for a medical writer doing research, he was frustrated by his inability to quickly find articles. Unfortunately, he was hindered by his lack of familiarity with clinical medicine and terminology. Instead of quitting, he decided to build a simple search tool and collaborate with librarians to figure out how to make it functional and useful. It was during this time that he developed the original interface for the software product that would become Ovid Technologies’ flagship search-and-retrieve solution for searching Medline and other medical databases. ^13,26

After undertaking his research, Mark Nelson released a CD-ROM product in 1988 that allowed individual users to search Medline. Early on Nelson worked with Marty Cahn to get private equity, but chose not to work with venture capitalists. The same year he incorporated and named his company CD Plus. The early years were similar to those of most start-ups (with the exception of extravagant dot-com era examples). The CD Plus offices were located in several upper West side apartments in New York City, where employees ran cables outside of the windows between the apartments. Although Nelson was not a programmer he learned to program in the computer language C and hired Mike Grewskin, a programmer who worked on designing what would become the Ovid infrastructure. Within a year, he upgraded his product so that twenty-four networked users could search Medline simultaneously. The new product was aptly called the Plus Networking Product. Less than five years later in 1993, the interface was developed. In 1994, CD Plus was renamed and became CDP Technologies, which was the name the company went public under in the same year. As it turned out 1994 was a fortuitous year for the company as CD Plus acquired the BRS Online database, which would become central to its activities. Within a year of acquiring the database, CD Plus became Ovid and released the Core Biomedical Collection in 1995. ^13,26

Nelson and his colleagues at Ovid made a decision early on to opt for quality high-impact biomedical journals over quantity. From the beginning, the goal was to license content from publishers based on contracts that allowed them to choose certain journals and leave others on the table. The Core Biomedical Collection was created to appeal to primary care physicians, to represent a broad cross-section of specialties and to reflect the best society titles. Included amongst the 15 titles that comprised the core collection were The Journal of the American Medical Association (JAMA), The New England Journal of Medicine (NEJM), Science, the British Medical Journal, the Lancet, the Canadian Medical Journal, the American Journal of Obstetrics and Gynecology, Annals of Internal Medicine, Archives of Internal Medicine, Circulation, the Journal of Bone and Joint Surgery, Annals of Surgery, the Journal of Clinical Endocrinology and Metabolism, Archives of General Psychiatry and the Journal of Family Practice. The pricing model was aggressive: In exchange for giving publishers access to markets via the Internet, Ovid took 50% of the revenues on average. Although the general pricing structure remains today, publishers generally attempt to give Ovid a lower cut when they have leverage. Ovid was a singular solution for the medical community. The Ovid Gateway system was Web- and Windows-based and had a 100% SGML full-text search system with linking and indexing functionality and 150 journal titles. ¹³

By the time that Ovid Technologies released their premiere product to the medical community, the World Wide Web and the Internet were becoming widely used in the STM publishing community. In 1996, the same year that Elsevier Reed acquired BioMedNet, Ovid released Ovid Web Gateway to facilitate user Web access. Subsequently, Ovid formed a clinical information division in 1997, and a year later, in 1998, the company launched journals@Ovid. ²⁶ Mark Nelson could have sold his company to any number of e-publishers, but he chose to sell to a large publisher with the resources to properly utilize and leverage the product that his team had developed over a 15-year period. Wolters Kluwer was the publisher who fit the bill and in 1998, Mark Nelson sold Ovid Technologies to the publishing concern for $240 million.^13,26

Since Ovid became a part of Wolters Kluwer it has continued to add titles and databases, while providing an interface with the value-added features of linking to both full-text articles and bibliographic databases. According to a press release on Ovid.com, as of September 19, 2002, Ovid had more than 33 million links available through its portal. Currently, Ovid connects to the following databases: Agricola, AMED, Cambridge Aquatic Science and Fisheries Abstracts, Biological Abstracts, British Nursing Index, CAB Abstracts, EI Compendex, Cambridge Life Sciences Collection, Derwent Drug File, EMBASE, Cambridge Environmental Science and Pollution Management Abstracts, FSTA, INSPEC, Periodical Abstracts, PreMEDLINE and Sociological Abstracts.

Folding Ovid into the publishing behemoth, Wolters Kluwer, was not without its challenges. One challenge was the issue of streamlining platforms. In electronic publishing, the fewer platforms, the better, meaning that a publisher should offer its content through as few highly functional user-friendly channels as possible. When Ovid came to Wolters Kluwer, LWW was already offering its journals electronically through title-branded Web sites. When Ovid started to offer the same titles, this was direct competition between two entities owned by the same publisher. That problem was addressed in 2002 when the Ovid and LWW databases were merged. Also, when Ovid was a publisher-neutral licensing company with a technical interface that could increase circulation for publishers, those who signed on were not giving revenue to a direct competitor. Publishers were using an aggregator as a sales channel and paying for the service. However, after the acquisition, negotiating contracts became more difficult, because individual publishers wanted to retain as much profit from each title as possible. In 2001, Reed Elsevier decided to not make The Lancet, one of the largest circulating medical journals, available through Ovid. Ovid kept the tiles available through EMBASE, a database compiled pre-acquisition, but lost several Elsevier titles. ¹³

The state of publishing is constantly in flux, but the state of e-publishing changes by the minute. The real challenge for Ovid is not the lack of willingness of the other large publishers and the society titles, such as the Journal of the American Medical Association, to negotiate contracts favorable for Ovid. The challenge is the competition posed by small companies such as HighWire, a content aggregator and host that provides a distribution source for a publisher along with branding and loading for a fee. In direct contrast, Ovid brands licensed content with its own corporate affiliation. In fact, part of Mark Nelson’s reasoning when he sold Ovid to Wolters Kluwer was the issue of having guaranteed access to content. ¹³ Of course, there is competition from other content aggregators and smaller companies that are finding ways to distribute medical information. Nonetheless, the largest medical publishers have the advantage of a portfolio of print offerings and established products that can be migrated online, as well as the advantage of brand recognition. Still, as history has shown, small companies with superior technologies that can improve delivery or utility in the e-publishing environment may not seem like a threat, but in fact as will be discussed later, they are. Any company that can be acquired and folded into a larger enterprise can shift the balance of power.

The Way Online: Content is Still King

Electronic content distribution is forcing the definition of publishing to change. But, it still takes more than strong technical capabilities and good functionality for an e-publisher to survive. Even with the best search and retrieval system or hyperlinking technology, publishing is still a content-driven business and a publisher must either create content or license it. Without exception, each of the six large publishers is looking at its print offerings as the way online. This represents an opportunity for publishers who can use the content from their print offerings either as whole reference products or as a starting point for creating databases that can be re-purposed and delivered in discrete formats. For example, Reed Elsevier publishes approximately 1700 individual STM titles. Although it has the largest collection of medical journals amongst the medical publishers, many of those titles are considered low-impact (in contrast to high impact titles like Cell or the New England Journal of Medicine, which are available through Ovid). The strategy is to maximize the utility of their titles. Elesevier can license titles to Ovid to increase circulation, and it can also use the information in those low-impact journals to inform and enhance its clinical guide products, such as MD Consult. This strategy works, because even though the many Elsevier titles are deemed low-impact, they are still peer-reviewed. Moreover, ownership of intellectual property allows a publisher to disseminate content in various forms.

Wolters Kluwer’s dominance in the marketplace for e-content aimed at researchers is enhanced by its PDA offerings through Ovid@Hand. In June 2002, Ovid launched A to Z Drug Facts, Lippincott’s Nursing Drug Guide, the Drug Interaction Facts Module and MedWeaver Disease Profiles in handheld formats. Much of the content in these offerings is derived from print products and the databases that support Ovid. In the case of Thomson, creating a handheld delivery system for the PDR, the MobilePDR, was a logical segue into the electronic marketplace. Even the smaller publishers are finding their way online with existing products. Ingenix Publishing Group has an initiative to combine some of its print pieces into online products. However, it should be noted that one of the most successful revenue-generating products in 2002 for Ingenix was a print product line, specifically two loose-leaf binders and two newsletters that address issues associated with Health Insurance Portability and Accountability Act (HIPAA) which was enacted in April 2001 and is being gradually phased in.³ There is a twist though: HIPAA regulations address numerous issues related to patient records and confidentiality, and the impact of digitalization on medical records and access to confidential information is a pressing concern in the healthcare community. So, in an indirect way, Ingenix is using a print product to address the concerns of its clients, who have a problem that is a byproduct of the electronic revolution. McGraw Hill grew its online business by 120% in 2002, mainly by migrating content from its well-known reference text, Harrison’s, to a PDA format, Harrison’s OnHand. Moreover, their new Web offering, Access Lange is from their print Lange series. Finally, Wiley, which has a database of 15 journals on Wiley InterScience, added seven of those titles in 2002.³

The main arena for competition in the electronic realm for medical publishers has been becoming the main gateway to the medical literature. But outright ownership of the literature also drives revenues. The infrastructure that girds this system is a series of databases. Just as providing access to databases, which is the gateway model, was the first step in the movement online for medical publishers, the capacity to offer customers linking from databases to abstracts and full-text articles is a proposition that drives revenues.²⁷

The Road Ahead: Consolidation or Fragmentation?

At the end of 2002, several editors and market research specialists at the British Medical Journal ²⁸ speculated about the future of medical publishing. Their conjectures were based on professional observations and their experience running a refereed medical journal that has been online since 1998. BMJ is an example of a respected peer-reviewed journal distributes its print journal for a fee while offering free access to the online equivalent enhanced by search-and-retrieve, hyperlinking and cross-referencing functionality. Before they presented their four versions of the future of medical publishing, the authors provided several ideas that reflect the most common notions about the direction of medical publishing. One of those ideas is that in the future authors will communicate directly with readers, which will diminish the role of STM publishers. Additionally, even as publishers maintain that the peer-review process fosters the integrity of the medical literature, many in the healthcare community are skeptical about whether that information has built-in biases depending on how research is funded. The response to this skepticism has been an increased focus on systematic evidence-based medicine. That information comes in various forms from different sources, but it must be clinically based and verifiable. In addition, the writers considered the impact of increasing reliance on PDA technology and the focus on continual CME (continuing medical information) for healthcare providers. They also cited the information paradox---namely the idea that doctors are deluged with information, but when they need to find something, they often aren’t able to. And finally, they considered the fact that patients are better informed because of the Internet and expect access to the same information as their treatment providers.

Using these ideas as premises, the authors spun four potential scenarios about what medical publishing may look like in the future. Following is an explanation of the four scenarios accompanied by an analysis of whether these respective versions of medical publishing reality currently exist to any extent, and how they are affecting the overall medical publishing industry.

The first scenario was based on the idea that individual academic communities would archive research data on their Web sites and eliminate publishers from the process. This is the way the industry would look if SPARC and advocates of the open-access movement became the dominant forces. According to the BMJ version of this reality, much of the content available to the medical community would simply be the text or e-mail version of conversations between researchers, but based on this analysis, that content would be intrinsically valuable. These conversations would not be formalized in the way that peer-reviewed biomedical articles are, but would constitute an important part of the body of knowledge. If researchers in this community-based model needed information, they could go to outside search engines where they might encounter publishers with fee-based content, but these would be marginal sources. In this model, the moneymakers would be hardware providers and not publishers, however researchers supported by academic institutions would thrive.

Already, these types of virtual communities exist, although they co-exist in a world where the large publishers dominate (See figure 1). For example, BioMed Central (www.biomedcentral.com) is an independent publishing house committed to providing open access to peer-reviewed biomedical research. All journals published by BioMed Central must go through their peer-review process. The publishers of BioMed Central are well aware of the impediments that authors face when attempting to publish and gain credibility for their work. Therefore, they state their commitment to establishing impact factors on their Web site, however, the publishers at BioMed Central feel that additional factors should come into play to assess an individual article’s importance, including: editorial and peer judgments, as the well as the commonly used parameters, citation rates and usage statistics. BioMed Central also offers authors an expedited peer-review process of 4 to 10 weeks and the right to retain copyright. As a corollary to their commitment to quality, in 2002, BioMed Central started charging a $500 processing fee to authors publishing on the site. The fee is intended to cover the costs of peer-review and publishing and retain free access for users. This is a hard case to make to authors, especially those who are already publishing in the high-impact journals published by larger publishers who pass the costs on to users---and make a profit for themselves. However, if a researcher is looking for additional publishing opportunities, $500 is not a formidable barrier to entry.

The second scenario is the institutional model, which is the version closest to contemporary medical publishing. Large publishers dominate in this model, and institutions pay for medical information that is distilled into usable content for healthcare practitioners and researchers.²⁸Currently, the institutional model is the prevailing paradigm for making money in online medical publishing. Both Ovid and ScienceDirect focus on providing content to academic, hospital-based and corporate endusers through institutions. This allows Elsevier, Wolters Kluwer and Thomson to operate profitably, maintain margins and provide content to more people than they would promoting strict pay-per-view access. As mentioned earlier, BioMedNet failed to make money relying on a pay-per-view model. In fact, this early effort has informed the revenue model for online libraries.²⁴ The current revenue model for online libraries owned by large publishers is based on institutions buying varying levels of access to either all available databases, discrete journal titles or a package that includes access to journal titles, reference materials and clinical guide materials customized to a client’s needs. (www.sciencedirect.com; www.ovid.com ) Access can range from procuring comprehensive full-text articles to the ability to procure bibliographic data and abstracts to an interface that allows transactional pay-per-view access. Detractors to this model claim that publishers should decrease the price of medical content, and that they should not make a profit on researchers’ work. Moreover, this perspective is partially based on the notion that the cost of production for online medical content is effectively zero, which pushes profit margins into a realm indicative of an unfair monopoly. According to Chisnell, this is not true. “You don’t save money by stopping print,” she says. The real costs are associated with first-run production and all that entails, including peer-review. Therefore, most publishers only provide a discount on electronic content if the institutional client buys the print offerings that it was subscribing to before it decided to license the right to access content online. In that case, the customer continues to receive its traditional print offerings, as well as the electronic offerings it chooses.

Ovid and Science Direct use a construct for institutional pricing based on full-time equivalents or FTEs. An FTE is defined as a full- or part-time student. Access to each electronic journal title or reference work is priced based on the reduced price of the print journal and the number of institutional FTEs. For example, ScienceDirect offers electronic access to the reference book The International Encyclopedia of the Social and Behavioral Sciences for an annual fee of $1500 for an institution with less than 10,000 FTEs. The same access is offered for $3000 for 10,001 to 25,000 FTEs and $4500 for over 25,001 FTEs. When an institution buys access to various journal and reference titles, as well as a publisher’s clinical guides, the prices are customized based not only on FTEs, but the amount of content purchased. In addition to subscription fees, institutions can also purchase licensing rights, which affects the level of access to the subscription material paid for. (sciencedirect.com ) Undoubtedly, electronic access has addressed the archiving problem to some extent, but there is concern amongst research librarians that if they have to discontinue online library service, they effectively lose access to archives and material that they paid for. ¹⁴ Yet, despite this concern, the value-added features provided by electronic libraries, are enticing to endusers. Not only do you get material when you license content form ScienceDirect, you also get functionality across a uniformly structured set of databases.

In the third scenario²⁸ envisioned by the BMJ researchers, original medical research would be free on Web sites like PubMed Central. However, physicians would receive print publications with information about what’s happening in the medical industry with respect to appointments and publishing endeavors. So instead of printing peer-reviewed medical journals, publishers serving the medical community would produce something akin to glossies with gossip and tips for career advancement. The substantive content would all be found online, and available free-of-charge or for a nominal fee. In this particular reality, much of the available medical content would be commodified and publishers would focus on creating clinical guide offerings for PDAs and creating a systemic evidence base. Like the two previously mentioned scenarios, this vision reflects a sliver of the reality of the real world of medical publishing, and PubMed Central (www.pubmedcentral.com) epitomizes this model. PubMed Central is a digital archive of life sciences journal literature, which is managed by the National Center for Biotechnology Information (NCBI) and the National Library of Medicine. PubMed Central is not a publisher; it functions as a large library that promotes open access to digital medical literature. For the most part, BioMed Central functions as the publishing arm of PubMed Central. Participating journals provide full-text access to peer-reviewed original research and review articles, and must meet the editorial standards set forth by PubMed Central. Although PubMed Central does not provide a publishing venue per se, it does allow a publisher to place its content on a site where it can be synergistically cross-referenced with other content in an open-access environment. Currently, Wolters Kluwer provides a product similar to that envisioned by the BMJ authors---except it’s aimed at generating profits. Using Ovid’s evidence-based systems, customers can buy packages comprised of evidence-based information that can be used to justify procedure and drugs in the clinical setting. Given, the focus of insurance companies on health outcomes, these products have become valuable.^{29 *}

This version of potential medical publishing reality highlights an ongoing trend, which has changed the nature of publishing. From the clinical perspective, access to drilled-down knowledge in a point-of-care context has advantages for clinicians, who rely on accurate information to make life-and-death decisions. Before there were electronic guides, there were reference books, pocket guides from pharmaceutical sales representatives and notes jotted down on postcards. Now there are electronic clinical guides across a range of therapeutic areas. Using these electronic guides, physicians can readily access historical, prescribing, diagnostic and dosing information saving time and improving the practice of medicine. Owing to the rise in electronic clinical guides, the medical publishing realm includes other business entities besides publishers and aggregators. Inside and outside of the large medical publishers, delivering clinical content on an as-needed basis to endusers is a big business. Thomson with its suite of MicroMedex products, including Mobile PDR, is the most active in this arena out of all the large medical publishers, but the other large publishers recognize that demand for distilled clinical content delivered to a PDA or a desktop is growing. In the mid-1990’s the trend line was becoming apparent; electronic products that supported clinical activity, training and education, and practice management, all areas that now are serviced using PDA access, were proliferating. On the other hand, the introduction of new electronic products for research was declining. (see figure 2) ^3,13,30 These divergent trends underscore the nature of electronic publishing and highlight opportunities in electronic medical publishing: PDA offerings must be constantly updated and the demand is consistently high, while electronic research offerings, which are mainly controlled by large publishers, are distributed on established platforms.

Figure 2: Electronic Products Available By Healthcare-related Market

As discussed earlier, Elsevier Reed’s MD Consult, which provides point-of-care information and Wolters Kluwer’s Ovid@Hand products also function as clinical guides; however, independent companies that focus only in the area of clinical guides are, in some cases, outperforming larger companies. Although Thomson excels in point-of-care information, it is not the leader in the market for delivering point-of-care information via PDA. Its competitor is a four-year-old company, ePocrates.¹³ ePocrates (www.epocrates.com), the largest handheld network of health care professionals, was founded in 1999 to provide clinical point-of-care information to people who require healthcare-related data. The company, which is privately owned and based in San Carlos, CA, is used by over 25% of the physicians in the U.S. All told, 500,000 individuals use ePocrates, including physicians, professionals in pharmaceutical, biotechnology, medical device, managed care and market research companies. The content, which is delivered on Palm OS-compatible PDAs, available to users includes a variety of drug information, such as dosing guidelines and information about drug interactions and contraindications. In addition, ePocrates provides formulary information that correlates with different insurance plans. ePocrates may seem like an improbable competitor for Thomson, however, their business model was based on giving away their product for two years and letting the market discover its utility.^13,31,32,33Another example of a small company taking on a role in delivering clinical content is Franklin Electronic Publishers (www.franklin.com), which defines itself as the world leader in hand medical reference products. This company provides a platform for numerous electronic products, including medical reference products. With respect to medical publishing, Franklin provides the hardware and digital conduit for distributing other publishers’ reference titles. Their medical software titles include numerous reference titles adopted from print, including Stedman’s from LWW, Oxford University Press’s Clinical Medicine and Thomson’s 2003 PDR. There are also clinical-consult software offerings, such as the BMJ Publishing Group’s Evidence-Based Cardiology, a clinical tool authored by a set of clinicians. Whereas prior to the widespread availability of electronic content, publishers relied on printers and distributors for support, they now rely on companies like Franklin and face formidable competition from up-starts like Epocrates, which will most likely become an acquisition target.

The last of the future scenarios described by the BMJ researchers is perhaps the most far-fetched at the moment. In this scenario, large organizations like Microsoft, Disney, United Healthcare, the World Health Organization and Merck would provide medical and scientific information as a subsidiary function to their main service or product, or as one division of a diversified corporate enterprise. In this scheme, there would be no traditional STM publishers, and academics, and editors would work for these firms towards corporate goals. There would be no independent research, as all research would be commissioned by a corporate entity. In my opinion, this scenario is unlikely, because the value of medical content and the proliferation of medical information necessitate dedicated study on the part of researchers. Subjugating medical research and dissemination of findings to a subsidiary function in a company driven by profits more than scientific study would diminish progress. Publishers committed to quality-control are better able to create, aggregate and distribute credible medical information.

Shifting Relationships: Publishers, Users and Authors

Medical publishing is driven by quality-control as much as it’s driven by an urgent need for expedient publishing of new data. In 1995, a recent medical school graduate could expect her knowledge base in her specialty area to be outdated within seven years. Now, for a 2003 graduate, within four years that information is no longer current or comprehensive.²⁹ Several factors impact the proliferation of medical information. First, progress begets progress: genomics, the DNA-oriented approach to medicine, is changing pharmaceutical development, laboratory testing and disease diagnosis. Also, genomics has shifted the treatment paradigm, so that healthcare practitioners can become more focused on DNA-based prevention and early diagnosis. Of course, the easiest way to distribute medical content quickly is electronically, which is also the easiest way to distill new research and the most up-to-date medical information into utilizable and reliable content.²⁹

As mentioned earlier, medical publishing serves professionals in the field in two major ways: 1) It provides practitioners and researchers with practical and theoretical peer-reviewed, quality-controlled data; and 2) It functions as a key driver of career upward mobility and professional placement in a hierarchical field.¹¹ Each of these functions is influenced by the peer-review process. This is true for users because they need to trust the quality of the research they rely on to make clinical decisions or to inform their own research processes. Original research is numbers based, documenting clinical trials that involve human subjects, statistical outcomes and drug dosages. Statistical measures should be accompanied by an explanation of significance or non-significance and results should be thoroughly explained. Before being published in a peer-review journal, this analysis undergoes a thorough examination by an editorial board qualified to judge the value and accuracy of the data being presented. If there are inconsistencies or irregularities, the paper will not be accepted. This process defines the culture of medical publishing and maintains the integrity of the medical literature. Therefore, publishers who publish and distribute high-impact journals with a high-usage profile and a large number of citations have access to desirable content that meet certain criteria, and people who operate under the same cultural assumptions are willing to pay for it.

Users stand to gain as much from accessing electronic medical information as the publishers who provide it. Academic libraries and medical consortia are the largest buyers of medical information. In addition, governments, marketing companies and individual healthcare consumers also purchase medical content. In the 1990’s library budgets were overwhelmed by the cost of buying and archiving large numbers of print publications.³⁴ Between 1990 and 1997, United States-based research libraries (members of the U.S. Association of Libraries) spent 142% more on medical journals than between 1980 and 1987, however they ordered 6% fewer titles. In fact, in 1997, Harvard University alone, which has the biggest academic library budget, spent $70 million on STM publications.¹⁴ In the same year, Reed Elsevier had 40% profit margins in their medical publishing division. Research libraries were faced with high prices for low-circulation journals and the attendant cost of archiving. So, they started looking for ways to cut costs. One of the first targets were low-circulation journals, however because of the balkanized nature of medical publishing, researchers in specialized fields relied on those journals and suffered in their absence. Although, the U.S. Association of Libraries, which has 122 member libraries and spends $900 million a year on medical content, still balks at the cost of medical literature, the advent of electronic publishing has helped address the issue of balkanized research.¹² In fact, this balkanized landscape has influenced the way electronic products are packaged and licensed to institutions by Ovid. For example, the Ovid Psych 1 Package, which is aimed at hospitals and medical schools includes 10 journals from seven publishers and the reference book, The New Oxford Textbook of Psychiatry. The journals in the package are high-impact journals, but in some specialties, such as gastroenterology, a specialist needs to access more than 50 journals to keep up with this therapeutic area. True, some of those journals may be low-impact and low-circulation, but necessary reading nonetheless. Content aggregators and publishers who provide that service can package content for specific therapeutic areas and meet customers’ needs.¹⁷ As a corollary, small publishers stand to benefit from allying themselves with a large content aggregator like Ovid, because it provides them with access to markets and increases their visibility in the research community. A historical example is the placement of the Canadian Medical Association Journal in Ovid’s first core offering in 1995. Placement in Ovid’s core offering was viewed as both positive for the journal’s reputation and good for circulation by the Canadian Medical Association.¹³

Before aggregated packages were available for specific specialties, users faced exorbitant prices, particularly for titles published by large publishers. In 1992, Brain (now Brain Research) cost $7500 a year, and by 1996 that price had doubled to $15,000 annually. As of April 2003, Brain Research, which is available through ScienceDirect, can be purchased as part of a package that includes Brain Research, Brain Research Protocols, Brain Research Reviews, Cognitive Brain Research, Developmental Brain Research and Gene Expression Patterns and Molecular Brain Research. This package, which is $19, 971, is priced lower than the combined price of the journals together and each journal is discounted from its print price. Moreover, search functionality allows a reader to browse content, cross reference and search individual parameters.¹⁷

The interests of authors must be considered separately. Because publishing in the field of medical research functions as a key driver of career upward mobility and professional placement in a hierarchical field¹¹, authors have an incentive to publish their work in a venue in which it is most likely to be frequently cited and used. Electronic publishing provides authors with venues beyond the traditional conduit of print publishing. The goal of many researchers is to return control of scholarly publishing to not-for-profit societies. As was discussed earlier, this has spawned a movement for open-access in publishing by academics and those who support the goal of providing biomedical content to the public either free or for a low fee. This open-access movement is taking place on the Internet as various online services attempt to legitimize medical publishing beyond the confines of the large publishers. HighWire Press (www.highwire.stanford.edu), a not-for-profit electronic hosting service founded in 1995 by Stanford University research librarians and academics, helps publishers have an online presence at low cost. HighWire brands the sites for the publishers and distributes the content free of charge or for the fee requested by the publisher. Some well-known titles hosted by HighWire include Science, The Proceedings of the National Academy of Medicine and The Journal of Biological Chemistry. In November 2002, the American Medical Association announced that it would be moving its journal site for JAMA from Ingenta to HighWire. Its stated goal is to create a more unified offering for customers that allows increased linking with other HighWire-hosted journals, including the New England Journal of Medicine, the society title of the Massachusetts Medical Association. Currently, both JAMA and NEJM are widely distributed electronically by Ovid and ScienceDirect; however, they are interested in having a presence in the research community populated by individuals committed to open access not only because it’s a good distribution channel, but also, because HighWire has become a legitimate---and necessary--- part of the publishing community.³⁵

Generally, when the content on HighWire is not free, the fees are lower than they would be if the same content was distributed through an aggregator like Ovid. For paid content, the cost-per-article is $7.00 and site access is $20. With 717, 509 free full-text articles, HighWire is the largest online hosting service providing free full-text downloads of biomedical content. HighWire also boasts links to 4500 Medline journals entries and 12,493,985 articles. HighWire is making significant strides in bringing society titles and titles from smaller medical publishers. In 1999, HighWire hosted 100 journal sites, and as of April 2003 that number had grown to 361. In addition to offering access to the titles they sponsor, HighWire also provides varying levels of access to other publishers’ titles that are not sponsored by HighWire. The pricing construct is priced around time and access parameters. There are some pay-per-view articles available on HighWire, however, a customer buys access for a period of time and for some journals a user can even purchase a “pass” allowing access for a period ranging from 24 hours to 30 days. Passes cost between $5 and $25. Examples of free titles available through the site not published by HighWire include the Archives of Family Medicine, Clinical Diabetes and The Oncologist.

As much as HighWire, PubMed Central, BioMed Central and SPARC may be marginalized financially by the culture of medical publishing, the orchestrated efforts of these players and the Public Library of Science open-access advocates is challenging the oligolopic nature of an industry in which approximately 98% of revenues are controlled by six publishers. A notable defection occurred in 1999, when Michael Rosenzweig, the editor-in-chief of Evolutionary Ecology Research (www.evolutionary-ecology.com) defected from Wolters Kluwer and with the help of SPARC started publishing the journal under his own auspices in Tucson, Arizona. The turning point for Rosenzweig was when the price of the journal, which he had founded in 1987, hit $777 a year.³⁴ Four years later, the journal costs $406 for institutions (including print copies and electronic access), $350 for electronic-only access, $115 for individuals and $56 for individuals affiliated with subscribing institutions in the U.S. Highwire is indexed in Biological Abstracts, CAB Abstracts, Current Contents, Ecology Abstracts and Environment Abstracts & Zoological Record. On his Web site, Rosenzweig promotes the SPARC alternative explaining that SPARC is devoted to “reducing the exploding costs of knowledge to the academic community that creates it in the first place.” He goes on to state, “EER is showing that a commercial journal can succeed without profiteering.” The case of EER illustrates how an individual academic can publish a journal. In general, the problem is creating an audience and maintaining circulation. One of the goals of the SPARC movement is to draw papers away from top competitors and make it easier for authors to publish quality papers and retain copyright, while simultaneously making it easier for the scholarly research community to access the work at reasonable prices.³⁴ EER openly states its commitment to commercial activity meaning it’s not publishing in order to lose money, and while it is a good example of success, the fact that the title was published by Wolters Kluwer provided the EER with name recognition, which could only help when Rosenzweig sought independence.

While publishing without the support of large publishers is difficult, some publishers choose not to participate in the open-access movement, because they feel it may undermine their goals. For example, Science published by the American Association for the Advancement of Science (AAAS) and Nature, published by the MacMillan Group, refused to sign the Public Library of Science Open Letter. In the case of Science, the society is invested in maintaining print circulation. Between 1996 and 2000, their BPA-audited circulation dropped from 160,000 paid subscribers to 148,863, and the average subscription price fell by 7%. Unlike the majority of scientific research journals, Science earns revenues from advertising to the tune of $7500 for a 4-color page. In fact, the AAAS had total revenues of $54 million in 1999 and $34 million came from advertising. One problem for journals like Science is the perception that an electronic presence that undermines the demand for print could compromise the rate base. In fact, Science was forced to remove its rate base guarantee in 1999. Nonetheless,Science has agreed to make its content available for free after 12 months. However, because the newsworthiness of medical content becomes out-of-date very rapidly, open-access advocates feel that the AAAS is not cooperating and is putting profits above science. ³⁶

Beyond the Dichotomy: Common Benefits Accrued From Electronic Publishing

It is understood that commercial publishers control the most prestigious journals that provide contributing authors with credibility amongst their peers. And there are legitimate arguments about why medical publishing should stay the way it is now, just as there are arguments that there should be open access to the medical literature. But, in many ways, publishers, researchers and users of medical information have commonalities that unite them and make the possibilities associated with electronic publishing desirable.¹⁷ Arguably, any publishing activity or content distribution that improves the overall integrity of the literature or expands the knowledge base is a good thing.

According to Robert Smith of BMJ, “The value of information increases as more people have access, because they can use the information in their own environments and add new insights, increasing the value for everybody.”¹⁷A good example of Smith’s statement is the electronic Cohcrane Database of Systematic Reviews. Since 1995, protocols for systematic reviews have been published in the Cochrane Database resulting in an open peer-review process in which a reader can function in the capacity of a peer-reviewer. In this role, the reader submits comments via e-mail, fax or regular mail to the San Francisco, CA-based Cohcrane Center. The U.S. government supports the goals of the Cochrane Center. In fact, in 1997, the U.S. Food and Drug Administration Modernization Act was promulgated calling for the establishment of a federally funded database containing information on all government-funded and privately funded clinical trials. This online database has the potential to help publishers publishing on sites like BioMed Central gain credibility in the larger publishing and research communities. Electronic publication of research protocols could improve the journal submission process and discourage unacknowledged and inappropriate revisions. It could also reduce duplicate publishing and provide protocol background for reviewers.³⁷ Currently, the Cohcrane Database of Systematic Reviews (www.cochrane.org) functions as an electronic evidence-base that covers all important areas of health care and includes systematic reviews of randomized controlled trials. Because of its broad mission, the Cochrane database has multifunctional applicability from maintaining the integrity of the research and publication process to educating healthcare practitioners and consumers.

The value of electronic publishing is substantial enough to foster unlikely alliances. In fact, the entire medical publishing community is united about the value of CrossRef. The goal of CrossRef is to integrate the biomedical literature and facilitate efficient linking using digital object identifiers (DOIs). With the fully realized implementation of CrossRef, each article will have a DOI, which can be linked to a full-text article or a bibliographic entry, through a common repository. All participating publishers, aggregators, hosts and archives stand to benefit when a user is linked to their channel. The implications for this are the ability to integrate medical literature going back to the 1800’s into a common online format and profoundly integrate the literature with links. This initiative has united authors, researchers, publishers and users towards the goal of enhancing the dynamic quality of the literature. ³⁸

Also, the idealism of the biomedical research community has driven the goal of distributing content to researchers, medical students and healthcare practitioners in low-income countries. In January 2001, publishers made the top 1,000 biomedical journals available electronically to low-income and middle-income countries, with funding provided by the World Health Organization, the BMJ Publishing Group and the Soros Open Foundation. The journals are provided free for the lowest income countries and at low fees for low- and middle-income countries. In this case, electronic-only access is a functional model, especially considering the cost of print distribution abroad and the low marginal cost for publishers to bring these users online, giving them access to the biomedical research, which defines the community of which they are an important part.³⁹

I've Seen the Future, and ...

While it’s likely that the alternative open-access movement will continue to gain momentum, it is highly unlikely that open-access publishing and distribution will usurp the standard medical publishing process. If the biomedical literature were going to be widely disseminated completely free, by now there would be an active pre-print service comparable to the service in Los Alamos National Laboratory in New Mexico, through which physicists have had access to electronic preprint articles for 12 years. This process has worked well for physicists. It’s democratic and at less than $100 per year, affordable. The reason this model works in the arena of physics is because the articles are written by scientists for scientists. In contrast, medical literature is written by researchers and clinical specialists, however it is read by a broad cross-section of people, including general practitioners, specialists, allied healthcare practitioners, professionals using the content for marketing purposes and consumers. Therefore, the literature must be reviewed. The stakes are too high to allow completely unrefereed literature to function as a point of reference for medical decisions. This is not to say that HighWire Press, PubMed Central and BioMed Central are not well positioned to maintain high quality standards. Rather, it is most likely that several prominent players, such as those mentioned in this paper will control the open-access movement. ^13,40

While publishing biomedical research will remain in the hands of relatively few publishers, the market for electronic clinical guide material will remain open and competitive; however, the large publishers will most likely acquire the most competitive companies or align with them for strategic purposes. Nonetheless, the material will be judged on its credibility, as the focus will continue to move towards evidence-based medicine.²⁹ With respect to the continued consolidation of the medical publishing industry, it seems unlikely that it will become more concentrated than it is now. There are two reasons for this: 1) Intolerance against what is perceived as a monopoly in medical publishing is increasing. In fact, the Reed Elsevier acquisition of Harcourt was referred to the Monopolies and Mergers Commission in the United Kingdom, and 2) Electronic distribution has lowered barriers to entry so that new publishers will compete, especially in the market for clinical guides.

Philip Scibilia, president of Lumina Publishing, a NJ-based medical publisher, envisions a future in which the electronic-distribution model is firmly ensconced. Twenty years from now, Scibilia predicts that medical information will be housed in three-dimensional relational databases. Within the realm of the clinical setting and in medical schools, textbooks will no longer exist. The matrix of information will be based on various constellations of delivery devices, digital content and evidence-based structuring formats. In this world, content will be judged based on usage. For example, marketing managers will be able to look at how many articles are being downloaded by users, and those authors will become de facto experts and opinion leaders in their respective fields. Moreover, Scibilia asserts that a paradigm shift is in order for how authors are treated by publishers. Instead of receiving book royalties, they will most likely be paid on a per-use basis. This model incorporates the assumption that some content will be medical information will be commodified. This is true, but there will still be high-end products that can drive revenues. Those products will be published and delivered electronically in response to urgent demand. In fact, using this pricing structure the publisher stands to make as much money with one chapter of a reference text, such as Harrison’s, as with the entire print textbook. Again, meeting a customer’s urgent need with expedient delivery results in premium pricing. Moreover, much of the demand for medical content will come from pharmaceutical companies that rely on an electronic distribution system, as this facilitates better tracking of user metrics and can help them plan continuing medical education activities. In this system, the role of print will be greatly diminished and will only exist for the purpose of creating enduring materials to accompany electronic content.²⁹

The point is that the future is here. Electronic publishing is the dominant paradigm in biomedical publishing, although print publishing will not disappear entirely. There will continue to be new markets for electronic content in the STM publishing industry.¹³ Despite the intense competition for market share amongst publishers, medical publishing will benefit from advances in the technology that supports the production, distribution and accessing of content. Still, certain remnants of the peer-review driven medical culture will remain to guard the integrity of the biomedical literature.

The advent of electronic publishing has been compared many times with the introduction of Gutenberg’s printing press in the 15^th century. As cliché as this comparison is, it is instructive. After all, it was impossible to see how the introduction of the printing press would lead to a publishing industry that has affected every facet of social, economic, political, scientific and cultural history and development. While it’s obvious that electronic publishing in general will affect comparable changes, biomedical electronic publishing stands to alter the course of human history, because it is revolutionizing that part of our world that deals with life and death.

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