Friday, September 19, 2014

Highlighting clinical uncertainties

I've been involved in clinical uncertainties for many years.  I had the pleasure of helping create the DUETs database (UK Database of Uncertainties about the Effects of Treatments).  Around the same time Trip released the Tag Cloud of Clinical Uncertainty which was a great experiment. In all aspects of my professional life I like to highlight the importance of clinical uncertainty.  Although the term often unnerves people, I think they feel threatened by the notion.  But, it could be worse, the likes of Iain Chalmers and Muir Gray have often used the phrase clinical ignorance - which is far harsher.

My interest in uncertainties stems from my desire to improve the research procurement process.  The main drive with Trip is to help clinicians answer their clinical questions.  Without knowing the gaps in their knowledge and the evidence base how can you procure suitable primary research or even secondary, evidence synthesis?  Myself and my teams have answered over 10,000 clinical questions so we know how frequently the research base is lacking or not focused on clinical care.  So things need to improve and I think recording uncertainties is a great way to help.

I raise all this as, in my business planning, I've spoken to one of the UK's largest research 'agency' and they are keen to work with Trip to better understand users questions and gaps in the evidence base.  So, for me, the answer is to try and capture the clinical questions our users have and when Trip has let them down.  I have a few ideas around this, including creating a PICO+ tool; a step-by-step tool to allow users to easily answer their clinical questions.  The user would start by adding the full question and then we would guide them through the PICO steps (e.g. what is the population, what is the intervention).  At the end they can tell us if their question has been answered.  If not, it's got a good chance of being a clinical uncertainty. 

Seems like a plan!

Tuesday, September 02, 2014

The Answer Engine and The Journal of Clinical Q&A

Trip prides itself as a great tool for answering clinical questions. Over 80% of users find the information they need, all or most of the time.  But that's still not perfect and one idea I keep coming back to is the 'answer engine'.  The wonderful Muir Gray said, in relation to finding evidence, that three clicks was two clicks too many.  So, the challenge is, is there a way of getting answers based on a single mouse click?

The answer (or perhaps 'My answer') is the answer engine.

This would involve a system to try and understand the search and display a suitable answer.  So, if a user searches for minocycline and acne we can be fairly confident that they're interested to know if minocycline is effective in treating acne.  Therefore, we could drop in the following answer:

Minocycline is an effective treatment for moderate to moderately-severe inflammatory acne vulgaris, but there is still no evidence that it is superior to other commonly-used therapies. This review found no reliable evidence to justify the reinstatement of its first-line use, even though the price-differential is less than it was 10 years ago. Concerns remain about its safety compared to other tetracyclines.

This has been taken from a recent Cochrane Systematic Review.  The normal search results would appear beneath the 'answer'.  The user gets a great answer in one click.

There are a few issues with the above and one is scalability.  Parts of this can be automated but much of it will be manual.  Also, relying of sources - such as Cochrane - means it's led by the evidence producers not the user.  So, the challenge is to have users supply answers.  Which leads to the Journal of Clinical Q&A.

The idea is to set up a brand new journal dedicated to answering real clinical questions.  Based, roughly on the BestBETs site it will follow a similar structure (e.g. Steroids in lateral epicondylitis).  The clinical bottom line will be pulled through into Trip to act as the 'answer' and then users can click to see the full article.

Peer-review is problematic on many levels and Richard Smith (former editor of the BMJ) has frequently criticises the current peer-review process (e.g. A woeful tale of the uselessness of peer review and Scrap peer review and beware of “top journals”).  But how can we improve on it?  I'm not sure we can but I'm open to help!  My current proposal is as follows:
  • Each answer will be reviewed by an in-house team, a sanity check.  Those that seem reasonable will be released into the answer engine as an 'answer pending approval'
  • We would then ask the wider Trip community to read and rate the answer.  This would borrow from the F1000 approach which uses three classes: Approved, Approved with Reservations and Not Approved.  An article will be considered published when it reaches a certain approval threshold. Note, the F1000 approach is not without criticism (e.g. PubMed and F1000 Research — Unclear Standards Applied Unevenly), hence writing this article with the hope of obtaining help.
Trip would have a good answer and the person who uploaded it will obtain a citation.  The plan is to start slowly, see how it develops but the longer-term view would be to see the answers appear in Medline/PubMed - as currently happens with a large number of the articles in BestBETs.

The above is an idea, a work in progress.  I think there is every chance this can become a reality but a little help in refining the concept would be really good.

Saturday, August 23, 2014

A Trip evidence service?

Trip is a wonderfully useful search engine, widely used and it has a great reputation and brand. We're thinking we could build on this to create a formalised evidence service. 

An evidence service could undertake a number of roles to support users (probably organisations) for instance:
  • Literature searches
  • Critical appraisals
  • Evidence reviews/synthesis
  • Clinical Q&A
  • Horizon scanning
  • Etc
We have a network of highly skilled information experts who would undertake the work.  Due to our low overheads we could provide a very cost-effective service.

I have experience in the UK where there are a large number of organisations (e.g. CCGs) that do not have timely access to timely, robust evidence to support their decisions.  This is really problematic when introducing changes to the system; how can they be evidence-based with no evidence input?  I doubt UK is atypical in this respect.  Therefore, there is a real opportunity to improve care and improve our business!

If you're interested in the service and want to help us develop our service then let me know.

Thursday, August 21, 2014

Beauty is in the eye of the beholder

Clickstream data is not widely known about.  In short it's the analysis of users clicking on websites.  We've started exploring this and the clickstream we're using is based on users clicking on particular search results. In short, if you do a search on Trip and click on documents number 2, 4 and 9 you're effectively telling us that, for your intention, they're connected.  In isolation it's arguably meaningless, but over thousands of searches you start to see structure.  I've blogged about this previously (here, here and here) but now we've got more results.

Below is the largest continuous graph/map of connected documents - over 10,000 long (click on image to expand). 

Tuesday, August 19, 2014

Recruiting for clinical trials: a role for Trip?

Clinical trials are vital if we wish to improve healthcare, as such they are an important component of EBM.  However, trials are not straightforward and one major problem can be the recruitment of enough patients to ensure the trials have enough power.  There are numerous papers on the topic (well hundreds) and below are a sample:

I raise this as Trip has had two conversations in a week with organisations involved with trial recruitment and both are very interested in working with Trip and our network of users.  Trip has around 100,000 registered health professionals, the vast majority will appreciate the need for clinical trials and therefore be sympathetic to the need to recruit patients.

So, the idea seems to be that if we are made aware of a trial, of say heart failure, we alert health professionals who have indicated an interest in heart failure (either through their registration or their search history) and are based geographically close.

Early days but it seems like a great idea.  As well as hopefully improving patient recruitment it could also help Trip's finances - win:win.

Friday, July 25, 2014

Freemium: the next stage

Earlier this week I had the first planning meeting around turning Trip into a freemium service.  Much of the current site will remain free. The premium (paid for) service will have no restrictions and will have some enhancements. 

So, here's what we're thinking:

Free service
  • no advanced search
  • limited export options
  • no images, videos etc.
Premium service
  • better exprot facilities
  • improved meta-data
  • advanced search available
  • all content types available
  • no adverts
  • various discounts from evidence-style products
  • ability to add (and share) reflective notes against each article
  • introduce the answer engine
Costings is still fluid.  I intend to have an individual subscription and an institutional one.

Individual - My aim is to suggest a monthly charge of around a cup of Starbucks coffee but people will be at liberty to reduce (or increase) the amount they pay, although there would be a lower limit.

Institutional - Various levels based on the number of individual accounts available.  In addition we intend to introduce some analytics so the institution can see how the service is being used.

It's still early days and if you have any opinions please let me know.

Thursday, July 10, 2014


We have recently been in discussion with an organisation about potentially partnering with us.  This would have brought some financial security to the site as well as allowing me to further develop some of the products we're currently working on.  These technologies being shared with the organisation. While nothing has officially been said I get the impression that it's not a priority for them - so I need to move on.

I have come to the conclusion that I cannot rely on others to support Trip and therefore we need to strike out on a 'Plan B'; which is a freemium version of Trip.  In a nutshell most of the current Trip remains free and certain enhancements are made to create a 'paid for' premium version.

The insecurity around funding is getting more than tiring - so something has to change.  We've got to work out the details (features etc) but my plan is to keep the price low - I quite like the idea of linking it to the local price of a Starbucks cappuccino (or similar).  The point being that if you value Trip you'll surly pay a monthly fee that is the same as a Starbucks (I'd welcome feedback on this point).

If we can get a regular, secure income we can properly plan for Trip.  We can enhance and roll-out some truly great products.  The vision I have for Trip is really exciting and as such I could have gone and secured venture capital funding.  But that would have changed the nature of Trip, something I'm not particularly keen on - for obvious reasons.