Web 2.0 and Social Technologies: What Might They Offer for the Future of Health Informatics?

Health Care and Informatics Review Online, 2008, 12(2), pg 5-16, Published online at www.hinz.org.nz ISSN 1174-3379

Web 2.0 and social technologies: what might they offer for the future of health informatics?

Peter J Murray PhD, RN, FBCS CITP

Director and Founding Fellow, Centre for Health Informatics Research and Development (CHIRAD) Vice President for Working Groups and Special Interest Groups, International Medical Informatics Association (IMIA) United Kingdom

Abstract While the term "Web 2.0" has been in existence since 2003, [1, 2] an understanding of its meaning, implications and potential for application within the health sector and health informatics is still being developed. The purpose of this paper is not, therefore, to provide any definitive answers, but to raise awareness, issues and questions for further discussion and exploration within the global and local health and informatics communities. There are two ways to examine the issues; we can either explore the more generic Web 2.0 tools and technologies that exist and how they might be applied to health informatics, or we can identify health informatics issues, especially ones that might seem intransigent, and explore whether and how Web 2.0 applications and approaches might help us deal with them. This paper concentrates mainly on the former approach as, while Web 2.0 applications have been used by health informaticians, there are, as yet, few Web 2.0 applications specifically designed for use within health and informatics.

1. Introduction The term "Web 2.0" [1] has been in existence for about five years (since 2003) [2] and there are differing views on its precise meaning and long term implications [3, 4]. This is due, in part, to the debate as to whether Web 2.0 genuinely represents anything new or is simply a natural progression in the development of Web technologies or, even, little more more than US-lead marketing hype or business model development.

This paper introduces some of the common Web 2.0 technologies that are being used by health informaticians and explores possibilities, issues and challenges that Web 2.0 might present for the global health and biomedical informatics communities. It will also briefly touch on what is termed "Health 2.0", due to the similarity of issues raised. It will not provide a detailed overview of current definitions of Web 2.0 (for definitions refer to Iain Doherty’s paper "Web 2.0: A Movement Within The Health Community" in this edition), although will use a recent definition for situating the discussion, and briefly show how it differs from what has been retrospectively termed "Web 1.0".

The main focus will be on some of the main categories of Web 2.0 applications, with examples drawn from everyday use, and from education and health-related uses. From these, we can see how they are currently being explored for use within health and health informatics, especially for communication, collaboration and manipulation of data, and how they might be used more widely in the future as "enablers in health and health care, for organizations, clinicians, patients" and others [5].

Discussions on the potential application of Web 2.0 to health informatics are also being undertaken by the Web 2.0 Exploratory Task Force of the International Medical Informatics Association (IMIA). A paper examining

some of the issues in more detail, in particular as they relate to a global health informatics organisation such as IMIA, is available in the 2008 IMIA Yearbook [6].

2. Web 2.0, or "social technologies": a description In order to situate the discussion, it is useful to start with a description of Web 2.0. While many exist, one of the most promising for uses within health, health care and medicine is that used by Eysenbach [7], based in Barreto [8]: Web 2.0 is a term which refers to a) improved communication and collaboration between people via social-networking technologies, b) improved communication between separate software applications ("mashups") via open Web standards for describing and accessing data, and c) improved Web interfaces that mimic the real-time responsiveness of desktop applications within a browser window. More recent discussions of the nature of Web 2.0 are focussing on the social interaction aspects, and on how Web 2.0 technologies and approaches might complement existing methods of interaction, or facilitate new ones in many areas of education, clinical practice, or the development of professionally-based "knowledge communities". The important aspects relate to its facilitating "a knowledge-oriented environment where human interactions generate content that is published, managed and used through network applications in a service- oriented architecture" [9]; also termed the "participatory web" [10], or the "read-write web" [11]. Terms such as "social technologies" [12] are being used almost synonymously with Web 2.0. Descriptions and definitions of Web 2.0 are also no longer confined to text and documents; a concise description is provided by the YouTube video, "The machine is us/ing us" [13].

The focus of Web 2.0 applications is on interactivity between websites and users, with dynamic, user-generated content, as opposed to users’ simple consumption of static content. Whereas in "Web 1.0" applications, users follow links to content, Web 2.0 allows them to also rate, annotate, mix, edit, create and share content, facilitating social networking, collaboration, communication, education, and active participation [14]. This is increasingly seen by many as not simply a set of technologies, but a philosophy; as the actor and author Stephen Fry says, it is "all about people" [15]. In the health and informatics domains, Web 2.0 technologies as seen as representing a revolutionary way of managing and repurposing or remixing online information and knowledge repositories, which could include use of clinical and research information [5].

The current relative lack of overtly health-specific Web 2.0 applications (a few examples of which are introduced later) means that much of the discussion must be somewhat speculative; the aim is to provide stimulus for discussion and identification of areas where possible future application development might prove fruitful. Through engaging the international health informatics community, to explore their perception of real user needs, and simultaneously exploring the potential of the technologies, from their use within non-health domains, we can determine the real implications for the future of health care, and the ways in which we must take account of, and interact with, the phenomena.

3. Some common Web 2.0 tools Common Web 2.0 tools such as blogs, podcasts, and wikis [16, 17] are being actively explored for use in health care and health/biomedical informatics contexts, in particular to enhance learning experiences in digital learning environments through engagement and collaboration [5, 17]. Other newer applications offer the potential development of online social networks that may complement or overlap with existing face-to-face networks, or allow the creation of new networks among people separated by space and time zone.

While many people will be more interested in what Web 2.0 technologies can offer, it is useful to briefly note the underlying range of technologies [1]; most web 2.0 applications work through combinations of: • AJAX (Asynchronous JavaScript and XML) programming (as only small amounts of data are exchanged with the server, the site’s interactivity, speed, and functionality are increased); • Cascading Style Sheets (CSS) (separation of presentation and content);

• folksonomies (collaborative creation and management of tagging, classification and indexing to annotate and categorize content; metadata is generated by creators and consumers of the content, not just by experts, contrasting with traditional subject indexing); • syndication, aggregation and notification of frequently updated content though RSS (RDF Site Summary, or "Really Simple Syndication") or other feeds; • user-generated content; • mashups (web applications that merge content from different sources into a single integrated tool) [6].

Blogs facilitate information dissemination through "a hierarchy of text, images, media objects and data, arranged chronologically, that can be viewed in an HTML browser".[18] They are usually edited and published using a Content Management System (CMS), many of which are built with Linux/Apache/MySQL/PHP (LAMP) open source architecture.[19] They are seen as facilitating knowledge sharing, reflection, and debate, and supporting "the drawing together of small virtual groupings of individuals interested in co-constructing knowledge around a common topic within a community of practice" [17].

Information delivery and personal expression is not limited to written text, but increasingly via personal audio broadcasting in forms such as podcasting, a portmanteau of "broadcasting" and "iPod" (Apple Computer’s MP3 player). Podcasts can be distributed via RSS feed and listened to on almost any device, providing creative opportunities for truly "any time, any place" distance education. Enhanced podcasting, a relatively new addition to personal broadcasting, includes text, images and video [16, 20].

Wikis are dynamic web pages, usually developed by group collaboration, although the "group" may be of individuals who have never met, but who have a common interest. The most well-known is Wikipedia (www.wikipedia.org), the online editable encyclopaedia. The content of a wiki can essentially be updated or changed by anyone visiting the site, although many are having to implement user registration to minimise vandalism. They allow for asynchronous group socialisation, communication and collaboration, and are a tool for archiving documents, brainstorming, and collaborative writing.

There has been considerable exploration of the potential of Web 2.0 tools in education, where social applications that facilitate student-centred collaborative learning are increasingly challenging teacher-centred pedagogies [21]. Podcasting can be used for archiving and distributing lectures in video or audio format, while video and slide sharing websites (eg, Slideshare - www.slideshare.net) can be used to publish lectures and conference presentations more widely. Teachers and learners are also turning to video-sharing sites such as YouTube (www.youtube.com) to find and distribute educational materials [22].

Tools such as blogs, wikis and online discussion forums allow large numbers of users to interact on open access websites, and this may be the area where they have more benefit for health informatics. The use on these tools on closed intranets or with small groups may limit their usefulness, due to "critical mass" issues, although this is one of many areas where further empirical research would be beneficial. Web 2.0 tools are useful for individuals who access computers from different locations; thus, social bookmarking services such as Del.icio.us - http://del.icio.us) facilitate "update once, access from anywhere" saving and sharing of hyperlinks, while mobile professionals can use collaborative document sharing, authoring, and editing (eg, Google Docs - http://docs.google.com), interact with online communities (eg, social networking sites such as MySpace - http://myspace.com), or access other resources (eg, podcasts, YouTube videos, photographs) [14].

An important, but under-appreciated, aspect of Web 2.0 is that minimal IT skills are needed to create simple blogs or wikis, or to create a community site and develop an idea; this changes the power structure and social dynamic between service/site providers and users. However, while many end-users access content, it is created by relatively few. Despite the ease with which almost anyone now can create content, the "1% rule" is an emerging rule of thumb which suggests that, for each 100 people online, one will create content, 10 will "interact" with it (comment or offer improvements), and the other 89 will just view it [23].

4. The use of blogs in informal professional development as an example of Web 2.0 tools Blogs have been used in nurse education, and small-scale evaluations from their use for teaching and research purposes, and within other educational contexts, shows that they can "enhance health professionals" writing, communication, collaboration, reading, and information-gathering skills’ [24]. Other practical examples support the use of blogs within education [25, 26] for professional development, sharing information, interacting as part of a learning community and building an open knowledge base.

Farrell [27] offers five major uses of blogs in education: • To replace the standard class web page; • To link Internet web links and other commentary to courses; • To organise class discussions; • To organise class seminars and provide summaries of readings; and • Using blogs written by students as part of a portfolio-based assessment process.

4.1. Blogs for virtual conference participation Conferences provide an opportunity for both formal and informal professional development, social networking, and collaborative knowledge development. Web 2.0 tools, and blogs in particular, offer opportunities to connect electronically with such events, facilitating social networking, connection and collaboration among individuals [28, 29, 30].

The decision to use blogs for interactive conference reporting grew out of three interrelated issues; experience of providing web-based conference reporting through webpages to share both the content and context of conferences and similar events, including digital photographs, with those who have been unable to attend [31]; a wish to explore the use of new technological possibilities to encourage virtual participation in such events; and a concern at the relative lack of use by health informatics organisations of the technologies they often advocate [32].

A purposively collaborative model for conference blogging has been developed that differs from the common form of single-author blog or conference report. It provides an environment for multiple contributors from the health informatics community to engage with formal and informal professional development activities previously only available to the limited numbers able to attend such events. The online communities can share resources or knowledge, develop tools to support interaction and dissemination, or seek to improve benefits to patients and improve health and health care. The approach has been developed over the period 2004-2007 at several international nursing informatics and health informatics events (see www.hi-blogs.info), and the basic model refined with the addition of other Web 2.0 tools to encourage interaction and participation, including the use of tools providing automatic text-to-speech production of audio files for each blog post, which are then available as podcasts.

4.2. Evaluating the use of blogs and success of the model The idea that "if we make it, they will come flocking" proved to be over-optimistic; a fair amount of effort is needed in publicising the existence of the blog, both in advance of and during the event. Even after the event, publicity can result in considerable hits on the site. The major time commitment comes during the health informatics event, when reports are being written and uploaded; and it is this that may be an obstacle that prevents active participation by more people.

The informal evaluation we have undertaken so far reveals that while many people are happy to read the blogs, find them valuable in terms of information provision, and think they are a good idea to be pursued and developed further, few actually contribute their own thoughts. We have found most of the contributors were people who are used to writing in other forms, often produced conference reports, and are relatively experienced in the health informatics field. Some informal feedback suggests those who are not experienced in "exposing 8

their thoughts in public" may be more reluctant to contribute. Those who were present at the event found both access issues and the variety of activities limiting their time available meant they did not read or contribute to the blog as much as they would have liked. Those who were not present required reminders that the service was available and were not sure what they would get out of the time and effort put into reading the blog. There is a need for more empirical studies to be held in order to determine the effectiveness of these applications and a willing openness to consider and learn about other emerging technological tools holding great potential for educational, professional, and collaborative purposes.

5. Some emerging Web 2.0 applications in health Web 2.0 applications offer opportunities for health professionals and patients to have open access to information and share ideas, questions, and opinions. Several Web 2.0 applications have been developed within the health domain, although most are targeted at specific audiences, ie, either patients and family carers, or health professionals, with few appealing to, or targeting, both and are in early stages of development and/or evaluation. Many blogs exist that are dedicated to health issues, some provided by patients sharing their own health and disease experiences (eg, "my Breast Cancer blog" - cancerspot.org), while others are provided by and for health professionals (eg, Clinical Cases and Images - casesblog.blogspot.com). Health 2.info (http://health2.info) is a health news platform, where users can post news and vote for the most interesting or popular items; the content is not managed by an individual or small group, but the site forms a social bookmarking space for any interested audience. Others blogs are devoted specifically to health informatics, eg, Informaticopia (www.rodspace.co.uk/blog/blogger.html), while HITSphere (www.hitsphere.com) provides a good aggregation of leading health and medical informatics blogs.

Blogs are not the only Web 2.0 application with utility in health. Yensen has explored using RSS feeds for providing current awareness tools on health issues [33], Perry has used free personalized home pages (eg, Pageflakes - www.pageflakes.com) for aggregating content and making it available in nurse education contexts [34]. There are growing numbers of health and informatics communities developing within large social networking sites (eg, Facebook - www.facebook.com), or being developed by end-users through tools such as Ning (www.ning.com), which allows creation of social network sites.

Several web 2.0 sites have been developed for physicians. Sermo (www.sermo.com) is an online community exclusively for physicians to share content and discuss issues, while PeerClip (www.peerclip.com) provides for health literature review and interaction with peers for health professionals. MDPIXX (mdpixx.com) is a Web 2.0 site for physicians from around the world, facilitating interchange of medical images and videos which can be evaluated by the medical community, and for creating, discussing and evaluating clinical cases, and can be used for research purposes and telemedicine services.

Mashups (hybrid web applications that combine data from several sources into a single integrated tool) are increasingly popular Web 2.0 applications; many are based on the use of Google Maps (maps.google.com) for data presentation. There are currently few health-related mashups, although HEALTHmap (healthmap.org) exemplifies what can be done. It is a global disease alert map, developed by infectious disease researchers, that shows where more than 50 diseases have been reported around the world, and how "hot" an outbreak is, based on the number of reports.

6. Health 2.0 and beyond In the current state of dynamic flux of health care systems and web technologies, a brief discussion of how the two might be linked, and how the future of health care might develop is pertinent. The definition of Health 2.0 is still under discussion, and while it has been, perhaps too simplistically, described as the application of the Web 2.0 phenomenon to health care, others believe it to be much more, and to have potentially profound implications for the whole nature of the healthcare industry in all countries, and the ways in which patients and health professionals interact. Health 2.0 may go far beyond just the pervasive social networking technology of Web 2.0 to support a complete reinvention in the way that health care is delivered. A current working definition is that Health 2.0 is a "new concept of healthcare wherein all the constituents (patients, physicians, providers, and payers) focus on healthcare value (outcomes/price) and use competition at the medical condition level over the full cycle of care as the catalyst for improving the safety, efficiency, and quality of health care" [35].

Shreeve suggests that Health 2.0 is "all about Patient Empowered (not the misnomer ’Consumer Directed’) Healthcare whereby patients have the information they need to be able to make rational healthcare decisions" [36], and that interoperability of health information will be a crucial determinant of success or failure of the movement. O’Grady believes that the most important aspect of using Web 2.0 in health care is the use of social software, which will promote collaboration between patients, their caregivers, and health professionals [37]. The development of Personal Health Record (PHR) systems (such as Microsoft® HealthVaultTM, Google Health and myPHR - http://www.myphr.com) will raise many issues for the future nature of health care. Health 2.0 is a new concept; how it will evolve remains to be seen, and especially whether it will provide a revolution in health care, but health informaticians need to be involved in the discussions and processes.

6.1. Some challenges, opportunities and implications of Web 2.0 for health and informatics As health information websites become increasingly interactive, offering more opportunities for building communities around specific health and disease issues, new challenges will emerge that will necessitate research and discussion. One issue of concern to some is the impact on the relationship between the patient and the health professional [38]. Web 2.0 applications offer opportunities for health professionals and patients to have open access to information and share ideas, questions, and opinions. While the increasing use of the Internet by patients to access health information, and associated issues of the quality and reliability of information (often explored within what is known as "consumer health informatics"), are important, they are excluded from discussion here, as they merit detailed exploration within their own rights. Issues of information quality, reliability, access, the roles of "gatekeepers", as well as the impact on the relationship between the patient and the health professional, have generated much discussion while mediated through "Web 1.0" websites (see, for example, the Journal of Medical Internet Research - www.jmir.org), and new research issues are likely to arise through the application of Web 2.0 technologies.

Many view the key elements of Web 2.0 as being community and interaction - the "social technologies"; it is in these areas that the greatest opportunities arise for change, but also the greatest challenges exist to current practices. Web 2.0 tools will, it is claimed, increasingly allow for the development of new models of collaboration and group practice in medicine, nursing, and other health professions. As communication is key to good clinical practice in all health professions - clinicians communicating with patients and with other clinicians and healthcare personnel - Web 2.0 applications can be explored to provide increasingly collaborative care. Together with new forms of collaboration will come opportunities to imagine new ways of working, based in greater access to more information, much of which is user-generated and context-specific to the health needs of individuals. This will present challenges in the ways in which we store, access and use the rapidly increasing amounts of information. New patterns of interaction and working might help to break down some of the artificial barriers that lead to medical errors, and might encourage cross-disciplinary improvements to patient care, medical education and research. However, many of these suppositions are yet unproven and will require research as well as attempts to use them in real life. Such new approaches also pose challenges, in particular to people wedded to current patterns of power relationships within the interaction between patients and health professionals, and among health professionals. New attitudes and mindsets, that see these new forms of interaction as liberating, rather than threatening, will not be easily adopted by all [6].

However, all of this speculation as to the benefits that might arise is premised in health and medical informatics professionals being aware of, and having the skills in, developing and using Web 2.0 technologies. Two seemingly contradictory, but interlocking, factors raise challenges for the future existence or nature of health informatics. On the one hand, Web 2.0 applications are increasingly designed so that the end-user requires only basic computing skills to use, or even develop, applications. Today, almost anyone can set up a blog, or a wiki, or input content to many types of Web 2.0 application, due to the ready availability of suites of online tools (for example, Google Apps). Some of these skills would very recently have been seen, and perhaps still are seen, as the skills of health informatics and computing professionals. Even the health informatics specialisms focused around classification of data and terminologies are being potentially bypassed by the emergence of user generated tagging systems such as folksonomies. On the other hand, there is still little evidence of health informatics professionals and organisations making significant use of Web 2.0 applications. While there have always been and continue to be individual pioneers exploring new and emerging technologies, few health and medical informatics organisations have used Web 2.0 applications to engage with their members, deliver 10

services, or explore the development of health-specific applications. Unless these issues are addressed, we run the risk of health informatics being bypassed as a profession, and its relevance increasingly questioned.

One way in which health informatics as a discipline might ensure its future relevance is that, if Web 2.0 is seen as the web being a platform on which applications run, we might begin by identifying common health care and health informatics desktop applications (if such exist), and explore how they might be migrated to run on the web. Electronic and personal health records are already being developed to be web-based; might other applications, for example telemetric monitoring within e-health applications, access to digital images benefit from web 2.0 tools (APIs, RSS feeds, etc) to improve access and use? However, there must also be consideration of the potential problems (unauthorised access, security and privacy, ownership of data, etc) of moving such applications to the web, and whether they might be more reliable or less if they are remotely hosted.

6.2. Towards discussing and developing a research agenda Health informatics professionals and practitioners will have a range of interests in the potential application of Web 2.0 technologies and approaches. While many will be interested only in the day-to-day implications of using Web 2.0 applications, others will wish to explore the more technical aspects and develop and customise applications. Others, not necessarily all from academia, will be interested in research, from a wide range of paradigms and perspectives, and while we cannot, in this time of dynamic change, be too prescriptive on the nature of the research to be undertaken, we need to start to explore and develop a research agenda.

Some useful ideas have already been discussed [17], especially with reference to the implications in formal educational environments. Many claims have been made for what Web 2.0 will allow or facilitate, in terms of collaborative working, productivity, and new ways of interacting and working, but many of these have still to be tested in real healthcare practice and education settings. Experience and limited evaluation of promoting the use of blogs for professional development[28] shows that the proposed benefits of Web 2.0 applications are not yet readily translated into reality; this itself offers many opportunities for research from a variety of perspectives.

Web 2.0 applications, and their speed of development and change, themselves have implications for the nature of research that might be possible. Large, long-term, formal research studies are unlikely to be of value in many cases (where the technology changes before the research protocol is agreed, for example), and researchers are likely to need to creatively develop new research approaches - a form of "research 2.0".

While a developing research agenda for the nature and implications of social technologies in the health domain and health informatics will encompass many questions, a few are offered here to start discussions: • What are the implications for the nature of electronic, online, and/or personal health records of the increasing willingness of many to openly share personal information through social networking? • How will increasingly living in the public gaze (through social networking technologies, virtual environments, etc) influence the nature of identity, privacy and security? • What are the implications for research and scholarship when our students and young professionals view Google and Wikipedia as their first stops of choice when searching for information? • What does "plagiarism" mean when sharing and re-use of resources is actively encouraged? • How will patient control of their own data and electronic records affect the nature of the relationship between patients and health professionals?

We are already seeing some of these issues being explored and discussed, even if there is not yet a great deal of formal research [39]. There is emerging evidence that patients are using social networking technologies to seek health information because they trust their fellow patients more than they trust health institutions and professionals [40] - these trends themselves will have profound implications and provide significant areas for research to validate the initial findings. The potential research agenda is huge, has profound implications for the nature of healthcare and health informatics, and health informaticians need to be actively engaged or they risk being marginalised.

7. Conclusion This paper has presented an overview of some Web 2.0 tools, based in a particular view of Web 2.0 that focuses on the "social technologies" elements [7, 8, 12]. However, while many of these tools, and related wider application of the underlying approaches, hold promise for application within health informatics, and potential to develop health care applications and scenarios, there is a need for much further exploration, thinking, testing and evaluation. This will include through formal research studies in order to establish "best practice models" for using these emerging technologies and in development of appropriate tools for use in health settings [5]. However, the current rate of development of Web 2.0 means that action research based in exploration "on the fly" may be more appropriate in many instances.

We also need to adopt a critical approach and to ask whether any of this is really new. It may not be in terms of what we are trying to do (communicate, interact), as email lists and discussion forums for health professionals, patients, etc, have existed for over 15 years. The new Web 2.0 technologies may allow better ways of doing some of these things - and faster ways of sifting the relevant information. Uncritical adoption of any of these technologies is not being proposed, and the paper poses questions that the global health informatics community need to explore.

Acknowledgements I am grateful to colleagues within the IMIA Web 2.0 Exploratory task force, who have discussed some of the issues raised here, and whose ideas have helped to inform my thinking. In particular, I wish to acknowledge the ideas of Gunther Eysenbach and Chris Paton.

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9. Appendices 9.1. URLs cited in the text

URL Website Clinical Cases and Images A blog for a case-based curriculum of clinical http://casesblog.blogspot.com cases and images. Del.icio.us

A web-based social bookmarking service for http://del.icio.us storing, sharing, and annotating web bookmarks. Facebook

http://www.facebook.com A social networking website. Google Docs

A web-based suite of applications, including word http://docs.google.com processor, spreadsheet, and presentation tools.

Google Maps http://maps.google.com

A web-based mapping service application and technology that powers many map-based services, and mashups and embedded maps on third-party websites via the Google Maps API (application programming interface). Health informatics blogs portal A website collating examples of developing a

http://www.hi-blogs.info collaborative model for blogging health informatics events. Health 2.info A social networking site for providing health-

http://health2.info related news items, sharing links and stories, and for voting and commenting on submitted items. HEALTHmap A web-based application that brings together disparate data sources to provide a unified and

http://healthmap.org comprehensive view of the current global state of infectious diseases and their effect on human and animal health (uses the GoogleMap API). HITSphere A website that provides combined feeds from

http://www.hitsphere.com healthcare, medical, and clinical informatics and information technology (IT) industry blogs. Informaticopia

A blog of eclectic news and views on health http://www.rodspace.co.uk/blog/blogger.html informatics and elearning. MDPIXX

A website for exchanging medical images and http://mdpixx.com videos, and creating and discussing clinical cases, my Breast Cancer blog

A cancer patient ’s personal blog of their ’journey http://cancerspot.org with breast cancer ’ myPHR An online ’personal health record ’ system

http://www.myphr.com developed by the American Health Information Management Association (AHIMA). MySpace

http://myspace.com A social networking website. Ning

An online platform for users to create their own http://www.ning.com social websites and social networks. Pageflakes An Ajax-based ’start page ’ that permits combination of content from a range of sources

http://www.pageflakes.com (RSS/Atom feeds, notes, del.icio.us bookmarks, social networking tools , email and user-created modules).

PeerClip An online tool that enables physicians to share

http://www.peerclip.com medical literature and interact with peers (currently in invitation-only beta). Sermo An online community for physicians to discuss

clinical issues and challenge or corroborate each http://www.sermo.com others opinions, thus applying col lective knowledge to achieve better outcomes for patients. Slideshare A web-based service for sharing presentations and

http://www.slideshare.net slideshows (PowerPoint, OpenOffice and PDF files). YouTube

A video sharing website where users can upload, http://www.youtube.com view and share video clips.