EBM

Research
Evidence-based medicine for all:
BMJ Glob Health: first published as 10.1136/bmjgh-2016-000041 on 23 May 2016. Downloaded from http://gh.bmj.com/ on 28 April 2018 by guest. Protected by copyright.
what we can learn from a programme
providing free access to an online
clinical resource to health workers
in resource-limited settings
Yannis K Valtis,1,2 Julie Rosenberg,2 Sudip Bhandari,2 Keri Wachter,1,2
Marie Teichman,2 Sophie Beauvais,2 Rebecca Weintraub1,2,3
To cite: Valtis YK, ABSTRACT

Rosenberg J, Bhandari S, Key questions
The rapidly changing landscape of medical knowledge
et al. Evidence-based
and guidelines requires health professionals to have What is already known about this topic?
medicine for all: what we can
immediate access to current, reliable clinical resources. ▸ Evidence-based clinical resources (EBCRs) are
learn from a programme
providing free access to an Access to evidence is instrumental in reducing widely used by clinicians in high-income coun-
online clinical resource to diagnostic errors and generating better health tries to answer clinical questions during patient
health workers in resource- outcomes. UpToDate, a leading evidence-based clinical care.
limited settings. BMJ Global resource is used extensively in the USA and other ▸ UpToDate, a leading EBCR, has been linked to
Health 2016;1:e000041. regions of the world and has been linked to lower average length of stay and decreased mortality
doi:10.1136/bmjgh-2016- mortality and length of stay in US hospitals. In 2009, in US hospitals.
000041 the Global Health Delivery Project collaborated with ▸ Adoption of EBCRs in resource-limited settings
UpToDate to provide free subscriptions to qualifying (RLS) has lagged behind.
health workers in resource-limited settings. We
Received 14 February 2016 evaluated the provision of UpToDate access to health What are the new findings?
Revised 3 April 2016 workers by analysing their usage patterns. Since 2009, ▸ Removing the cost barrier to accessing
Accepted 21 April 2016 ∼2000 individual physicians and healthcare institutions UpToDate, a leading EBCR, leads to frequent use
from 116 countries have received free access to of the resource by a large and diverse set of
UpToDate through our programme. During 2013–2014, clinicians practising in low-income and
users logged into UpToDate ∼150 000 times; 61% of middle-income countries.
users logged in at least weekly; users in Africa were ▸ Clinicians practising in RLS seek evidence-based
responsible for 54% of the total usage. Search patterns information across a wide spectrum of topics,
reflected local epidemiology with ‘clinical with infectious disease and paediatrics capturing
manifestations of malaria’ as the top search in Africa, the largest share of interest.
and ‘management of hepatitis B’ as the top search in
Recommendations for policy
Asia. Our programme demonstrates that there are
▸ Access to evidence based clinical resources for
barriers to evidence-based clinical knowledge in
clinicians in all settings is an important compo-
resource-limited settings we can help remove. Some
nent of improved health care delivery. Enhancing
assumed barriers to its expansion ( poor internet
access may include removal of cost barriers as
connectivity, lack of training and infrastructure) might
well as technological barriers, such as Internet
pose less of a burden than subscription fees.
connectivity.
1
Harvard Medical School, ▸ Policy should support the development and pro-
Boston, Massachusetts, USA duction of EBCR content specific to LMIC health
2
Global Health Delivery INTRODUCTION priorities to ensure relevancy and utility.
Project at Harvard University, All health professionals face the daily chal-
Cambridge, Massachusetts,
USA
lenge of incorporating a vast and rapidly
3
Brigham and Women’s evolving body of medical knowledge into world: A 2012 study of over 15 000 medical
Hospital, Boston, their clinical practice. In 2014, providers were records from 26 hospitals in Africa and the
Massachusetts, USA faced with consuming new evidence from Middle East showed that 6.8% of all hospita-
over 5000 clinical trials.1 Alarmingly, prevent- lised patients experienced a medical error
Correspondence to
Dr Rebecca Weintraub;
able medical errors, which result partly from and one-third of them died as a result.2 In
Rebecca@ lack of access to or understanding of the best 2004, investigators in The Lancet asked, ‘Can
globalhealthdelivery.org available evidence, are common across the we achieve health information for all by
Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041 1

BMJ Global Health
Table 1 Most-used online evidence-based clinical high-income countries: among 16 122 health profes-
resources (EBCRs) by Global Health Delivery UpToDate sionals surveyed across 181 hospitals in the USA and
(GHD UTD) programme applicants Canada about clinical resource usage in the past
Resource Description Cost per year* 6 months, 53% of attending physicians and 77% of resi-
Medscape WebMD-owned site of Free dents had used UpToDate—one of the leading EBCRs;
original medical content 59% of physicians used online journals, 20% eMedicine
authored by physicians and 24% Micromedex.5
PubMed Database of abstracts and Free (abstracts Recent research has demonstrated a connection
citations maintained by only) between use of EBCRs and patient outcomes: Use of
the US National Library of UpToDate by physicians practising in the USA was
Medicine shown to increase performance in standardised exami-
HINARI WHO programme to Free or $1500 nations,6 and, most importantly, a 2012 US study showed
provide free or low-cost depending on that use of UpToDate at the hospital level reduced
access to over 15 000 country patients’ average length of stay and mortality.7
journals and 47 000 Recognising the proven importance of EBCRs, several
e-books for health initiatives have opened access to clinical, scientific and
workers in specific research content via online databases either for free or
countries at a low cost (eg, HINARI to institutions in low-income
Cochrane Global network of health Free 12 months countries), while others disseminate information from
professionals who after publicly funded research (eg, PubMed), or release full-
compile evidence and publication† text articles selected by the publishers or the authors.
author practice guidelines
Open-access publishers, such as BioMed Central, BMJ
for clinicians
Open, and organisations such as the Public Library of
New England Medical journal published $79‡ Science (PLoS) are dedicated to making the biomedical
Journal of by the Massachusetts
and scientific literature freely accessible and have devel-
Medicine Medical Society
oped new models of content creation and distribution.8
Dynamed Clinical reference tool $395 While important, these efforts offer a literature base that
written by physicians and
is often not exhaustive, and physicians report that a full
aimed targeted at health
article can be difficult to navigate, or even irrelevant,
professionals
during a clinical encounter.9 In addition, some websites
BMJ Medical journal published Free
including Wikipedia, Medscape and Epocrates offer free
by the British Medical
clinical content, but, as others have discussed, the
Association
quality, comprehensiveness and timeliness of this
The Lancet British Medical Journal $174‡
content varies.10
UpToDate§ Continuously updated, $499 In the midst of an ‘information age’, global health pro-
expert-authored clinical viders often lack access to the latest practical, lifesaving
content targeted at health
information.11 12 Getting information to the people in
professionals. Includes
the places where it is most needed is a delivery chal-
information on drugs and
drug interactions
lenge. We hypothesise that contributing factors may
*Indicative cost per year for an individual US-based physician.
include lack of reliable internet connections, low rates of
Source: resource websites, accessed on 1/10/2016. internet-capable device ownership and the high subscrip-
†New Cochrane Reviews become free 12 months after publication. tion costs of many EBCRs.13 14 An individual UpToDate
Entire Cochrane Library to become free by 2020, according to
strategic plan.
subscription for a US-based medical professional costs
‡Online-only version. $499 per year, while a subscription to the New England
§UpToDate was not one of the most used online EBCRs by GHD Journal of Medicine costs $79 per year (table 1). In 2013,
UTD programme applicants but is included here for comparison.
A detailed description of the most used EBCRs can be seen in
Tanzania spent $49 per person on healthcare ( private
figure 1D. and public expenditure combined).15 Hence, the
country would need to spend its entire healthcare
budget for 10 people to purchase one individual
2015?’ and, in 2006, the WHO identified access to infor- UpToDate subscription.
mation as a critical step towards improving population As part of the effort to address this information
health.3 4 bottleneck, in 2009, the Global Health Delivery
In response to this, private and public entities in high- Project at Harvard University (GHD) launched a pilot
income countries created numerous online evidence- programme with UpToDate to grant free subscriptions
based clinical resources (EBCRs) over the past decade to UpToDate content to physicians and health
that distilled research into guidelines for therapeutic workers in resource-limited settings (RLS). The pro-
choices and care (table 1). Uptake of such resources has gramme, called the Global Health Delivery UpToDate
been extensive among health professionals in several donation programme (GHD UTD) grew rapidly over
2 Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041

BMJ Global Health
Figure 1 Description of applicants to GHD UTD programme. (A) Cumulative number of total applications to GHD UTD
programme by continent (including individual and institutional applications). ‘Application analysis’ refers to application data
collected between March 2013 and December 2015, which was used for the analysis in figure 1C, D. ‘Usage analysis’ refers to
usage data collected between January 2013 and December 2014 and was used for the analysis in figures 2 and 3 and table 3.
(B) Map of the world showing country chosen by applicants as ‘main location of practice’ and number of associated applications
from each country.(C) Location of primary medical education of applicants as specified in application. (D) Use of other
evidence-based clinical resources as specified by first-time applicants in application. GHD UTD, Global Health Delivery
UpToDate donation programme.

BMJ Global Health
Figure 2 Patient case vignettes from GHDonline private community. ARDS, acute respiratory distress syndrome; GHD, global
health delivery; US, ultrasound; UTI, urinary tract infection.
the past 6 years. Analysing UpToDate usage data and PROGRAMME OVERVIEW
information from subscription applications, we Subscription application and screening
provide here an overview of the programme. The aim GHD used its existing online platform, GHDonline.org
of this analysis was (1) to explore whether the —a virtual professional community of over 17 000
removal of the cost barrier can catalyse uptake of healthcare delivery professionals worldwide—for grant
EBCRs among global health professionals, (2) to administration. In order to be eligible for a 1-year free
examine how frequently global health professionals subscription to UpToDate, applicants had to: (1)
who obtain free access to UpToDate log in and (3) to deliver medical care, medical education or related ser-
describe the medical topics of interest among grant vices to poor or underserved populations outside the
recipients. USA, (2) have at least intermittent internet access, (3)
Figure 3 Frequency of usage and topics of interest among GHD UTD users. (A) Histogram showing percentage of users
accessing UpToDate at specified frequencies. (B) Share of total usage by topic of medical specialty. Each topic accessed was
assigned to a medical specialty using UpToDate’s table of contents. GHD UTD, Global Health Delivery UpToDate donation
programme; GI, gastrointestinal; Ob/Gyn, obstetrics and gynaecology.

BMJ Global Health
be able to provide evidence that they or their organisa- where applicants received their medical education, as
tions could not afford to subscribe otherwise and (4) well as the names of other EBCRs they regularly used.
be proficient in English. The last condition was neces- Hence, data in figure 1B, C represent applications
sary as UpToDate content is currently available only in received between March 2013 and December 2015.
English. Usage data: UpToDate provided the authors
Qualified applicants filled out an online application de-identified usage logs of all active GHD UTD users
on GHDonline that included questions about them- during the period 2013–2014. These logs only indicated
selves, their organisation and the patient population the country of origin of the user if there were at least five
they serve. Applicants submitted a letter stating why they subscriptions from that country to preserve anonymity.
needed free access to UpToDate and a reference to Logs tracked all online and offline activity of users on any
confirm the veracity of their responses. Applicants also device (searches, clicks, reading of pages/figures, etc).
chose between an individual subscription (associated Ebola data: To compare the search behaviour of GHD
with a unique username and password) and an institu- UTD programme participants to that of the general
tional subscription (associated with a unique IP address public, we retrieved global Google search data from
so that anyone on a particular institution’s network Google Trends on 11/28/2015 (https://http://www.
could access it). GHD and UpToDate staff reviewed all google.com/trends/explore#q=ebola) and data on the
applications to ensure they were complete, accurate and number of confirmed Ebola cases from the US Centers
met eligibility criteria. UpToDate staff then sent an for Disease Control website (http://www.cdc.gov/
email to all approved applicants containing their user- vhf/ebola/outbreaks/2014-west-africa/cumulative-cases-
name and password (for individual subscriptions) or graphs.html).
instruction on how to set up an institutional subscrip- Usage vignettes: We reviewed qualitative data from one
tion. All individual subscriptions came with the option of the GHDonline.org questions asking users to describe
to download ‘Mobile Complete’, an offline mobile a patient case where UpToDate was helpful in determin-
version of UpToDate that allowed users to browse ing the correct diagnosis or treatment plan.
content without a connection to the internet.
During their 1-year subscription, we asked users to Data analysis
answer 12 questions on the GHDonline online commu- We analysed usage data in terms of ‘sessions’. We
nity pertaining to their experience with UpToDate, as defined a ‘session’ as a time period using UpToDate,
well as offer any feedback they had for the programme. initiated by a unique log-on of a user to the UpToDate
At the end of their subscriptions, we invited all users to website (on a computer), the UpToDate mobile site, or
submit a brief renewal application to extend their sub- the UpToDate mobile application (on a mobile device)
scription if they wished to do so. and terminated when the user actively logged off, closed
the application or remained inactive for more than 3
Outreach and dissemination hours. Since of hacking attempts known to UpToDate to
We promoted the GHD UTD collaboration to global download large amounts of UpToDate content using
health professionals through a page on GHDonline and computer software, we excluded from our analysis any
through an email to all GHDonline users. In addition, sessions in which more than 10 actions were taken in
UpToDate created a link on the company website the span of the last 100 ms of the session duration (indi-
(http://www.uptodate.com) informing visitors of the cating faster activity than a human can normally initi-
existence of this programme for health professionals in ate). We also excluded from our analysis one
RLS and a promotional video that was also posted on institutional account, which exhibited abnormally high
the UpToDate website. Lastly, The Boston Globe wrote an activity during 2 months of the study period and was
article describing the programme.16 determined by UpToDate to be likely hacked. Average
daily usage frequencies per user were calculated as total
Information collected number of user sessions over study period divided by the
Application data: We collected demographic information number of days with an active account. Subsequently,
about participants and their organisations using an average usage was assigned to frequency categories as
online Google Form application as part of their applica- shown in table 2.
tion for a free UpToDate subscription. We anonymised
data by deleting all identifying information from the
Table 2 Explanation of frequency category assignments
data set before conducting any research activities.
Informed consent for the use of these data was not Average daily
obtained from applicants, as the Harvard University usage (ADU) Frequency category assigned
Institutional Review Board (IRB) deemed this project ADU>1 Once a day
exempt from full review due to the anonymous nature 1≥ADU>1/7 Once a week
of the data. In this analysis, we present application data 1/7≥ADU>1/30 Once a month
from the period 2009–2015. In March 2013, the applica-
1/30≥ADU Less than once a month
tion was changed to include questions on the location

6
BMJ Global Health

Table 3 Most read topics among Global Health Delivery UpToDate (GHD-UTD) users by continent
Africa Asia North America South America
Rank Term Frequency Term Frequency Term Frequency Term Frequency
1 Clinical 404 Overview of the 154 Epidemiology, microbiology, 161 Pre-eclampsia: clinical 57
manifestations of management of clinical manifestations and features and diagnosis
malaria hepatitis B and case diagnosis of typhoid fever
examples
2 Treatment of severe 394 Overview of 147 Metronidazole (systemic): drug 156 Epidemiology, 41
falciparum malaria hypertension in information pathogenesis and clinical
adults manifestations of Ebola
Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041
and Marburg virus

disease
3 Initial assessment 353 Overview of medical 138 Trimethoprim-sulfamethoxazole 151 Clinical manifestations 38
and management of care in adults with (co-trimoxazole): drug information and diagnosis of acute
acute stroke diabetes mellitus pancreatitis
4 Overview of the 348 Serologic diagnosis 133 Treatment regimens for 143 Shock in adults: types, 35
therapy of heart of hepatitis B virus Helicobacter pylori presentation and
failure due to systolic infection diagnostic approach
dysfunction
5 Overview of 347 Treatment and 127 Tetanus 133 Chronic otitis media, 35
hypertension in adults prevention of cholesteatoma and
typhoid fever mastoiditis in adults
BMJ Global Health
Users who accessed UpToDate once only during their Medscape (22%), PubMed (7%) and HINARI (4%;
subscription were assigned to the ‘one time-only’ figure 1D and table 1).
category.
For the topic analysis, we used a table of contents pro- Usage frequency
vided by UpToDate, which assigned each topic title to a During the period 2013–2014, 45 institutional and 405
particular primary medical specialty. We counted topics individual GHD UTD users logged on to UpToDate for
appearing more than once in the same session once. ∼150 000 unique sessions. Usage rose steadily during the
Medications are not classified into primary medical spe- study period. Patient vignettes suggest that UpToDate
cialties by UpToDate, so we excluded all articles covering proved useful as a clinical resource. (With permission
specific medications from this analysis as well as articles from the authors, please see four such clinical vignettes
that had been deleted from UpToDate or whose title in figure 2). Users from Africa accounted for 54% of the
had changed at the time of the analysis. In the end, we usage. Across the world, the top countries were Rwanda
included 390 595 article topics out of 494 650 total arti- (19% of total usage), Haiti (10%), Zimbabwe (8%) and
cles accessed in this analysis. Mozambique (8%). The 45 institutional accounts were
We used Microsoft Excel and Stata SE V.14 for all data responsible for 55% of total usage. On average, 20% of
analyses. all users logged on at least once per day over the dur-
ation of the study, and 41% of users logged at least once
per week (figure 3A).
RESULTS
Topics of interest
Applicant demographic characteristics
Medical specialties that attracted a particularly high
Between its inception in 2009 and the end of 2015, the
interest among our users included infectious disease
Global Health Delivery UpToDate donation programme
(14% of total usage), paediatrics (14%), obstetrics and
(GHD UTD) received 1948 unique applications for
gynaecology (6%), and gastrointestinal medicine (6%;
access. The programme’s growth picked up significantly
figure 3B). In table 3, we list the five most popular topic
after 2013, potentially due to the growing awareness of it
titles in each category and the frequency with which they
(figure 1A). Approximately 82% of applications received
were accessed over the 2-year period of the programme.
during the study period met eligibility criteria and were
Lastly, to assess user interest in Ebola during the global
awarded a 1-year free subscription to UpToDate. Of
outbreak, we plotted the search volume for the term
applications considered, 94% came from individuals and
over 2014. We compared it with the search volume
6% from institutions. Institutions had a wide range of
for the same word on Google by the general public
affiliated physicians (from 5 to 300 clinicians per institu-
(figure 4). Interestingly, searches for ‘Ebola’ peaked
tion). Applications represented a total of 116 countries
earlier on GHD UTD than Google.
from six continents (figure 1B). The plurality of appli-
cants (36%) completed their medical education in Africa
(figure 1C). Almost half of the applicants (48%) indi- DISCUSSION
cated that they had access to no other online evidence- Our work demonstrates that removing the subscription
based resources, while some mentioned accessing fee barrier enabled almost 2000 health workers from
Figure 4 Search volume for

‘Ebola’ among GHD UTD users
and general public. Cases:
number of confirmed cases in
Guinea, Sierra Leone and Liberia.
Source: US CDC. Google:
normalised worldwide search
volume of the term ‘Ebola’ on
Google. Source: Google Trends.
UpToDate: normalised worldwide
searches containing the word
‘Ebola’ among GHD UTD
subscription recipients. GHD
UTD, Global Health Delivery
UpToDate donation programme;
US CDC, US Centers for Disease
Control.

BMJ Global Health
100 countries to access and use UpToDate, a leading EBCRs in the context of medical education, using incen-
tives or ‘nudges’ to promote use of EBCRs by clinicians,
EBCR. The fact that the majority of users accessed
UpToDate very frequently (more than once a week) and or creating locally specific EBCR content to increase its
read a wide spectrum of topics supports the hypothesis relevance.
that there is demand for EBCRs in low-income and Exploring what our users viewed on UpToDate can
middle-income countries (LMICs). While users shared provide useful insights in the knowledge gaps of profes-
salient examples of how UpToDate helped them sionals in RLS and guide future attempts to create
improve their clinical practice, it will be important for EBCR content targeted to those professionals. Topics
future research to test more formally the health outcome such as heart failure, stroke, diabetes and hypertension
gains associated with EBCRs in RLS and whether the were popular among all global health professionals,
quality of care provided by global health professionals likely correlated with the rising burden and prioritisa-
using EBCRs is better than the quality of those who do tion of non-communicable diseases in RLS. It could also
not. Measuring care outcomes, surveying patients and be argued that many national programmes have created
providers, and using clinical vignettes and audit patients clear and well-distributed guidelines for the treatment of
to understand providers’ knowledge and practice are pos- priority infectious diseases such as HIV, malaria and
sible ways in which these questions could be addressed.17 tuberculosis, and hence, doctors are less likely to turn to
There are several limitations to our analysis that merit UpToDate for information on the management of those
discussion: First, according to WHO estimates, there are diseases. One limitation of our study is our inability to
more than 100 000 physicians working in low-income separately analyse behaviour of those exclusively using
countries;18 yet, only 1948 health workers applied for UpToDate and those using UpToDate and other EBCRs.
access to our programme. Our programme did not Our data sets were aggregated and anonymised to
address the demand side of the information bottleneck. adhere to ethical standards.
A lack of training on use of EBCRs, absence of an How else can this usage data inform clinical delivery
evidence-driven culture in medical education and poten- and public health? Investigators have recently shown
tial lack of relevance of existing EBCRs to local clinical interest in using online search log data to make epi-
challenges, are important to note and to explore in demiological predictions. Researchers at Google showed
future research (table 4). The relevance, or lack thereof, that general public searches for flu symptoms and medi-
of EBCRs in general, and UpToDate in particular, to cines can be used to accurately predict the spread of the
LMIC clinical needs has not been evaluated: It is pos- influenza epidemic in the USA.19 Some have suggested
sible that UpToDate’s recommendations on clinical care that UpToDate search data may provide an even better
are different from, and even in conflict with, local prac- prediction of the flu epidemic, as physicians are better
tice and guidelines. It is also possible that UpToDate positioned than the general public to identify appropri-
recommends the use of diagnostic procedures and ate searches for the presenting symptoms.20 21 These
therapeutic interventions that are unavailable in LMICs findings provide for the possibility of UpToDate search
due to high cost or other constraints. In those cases, use logs to serve as inexpensive epidemiological surveillance
of UpToDate might not be helpful to the practising clin- in RLS should the density of UpToDate-using providers
ician. As access to mobile and broadband internet across in resource-limited geographies increase.
Africa and other developing regions increases and the In 2013, the Institute of Medicine reported that only
prices of internet-capable devices fall, demand gener- 54% of care provided in 12 large US cities followed exist-
ation will be a more significant barrier. Potential inter- ing Clinical Practice Guidelines—the best available evi-
ventions to increase demand could include introducing dence for the treatment of a particular disease at the
time.22 Gawande23 suggested that changing clinical prac-
tice is a slow and cumbersome process that requires
removal of barriers as well as person-to-person mentor-
Table 4 Our working hypothesis on contributing factors to ing, talking and nudging. It is clear that cost is one
the disparity in use of evidence-based clinical resources
barrier to EBCRs that will need to be removed to realise
(EBCRs) between high-income and resource-limited
settings11–14
the vision for evidence-based medicine for all. We are
hopeful that the next steps towards this vision will be
Disparities in demand
bigger and broader and close the knowledge gap quickly.
Disparities in supply generation
Lack of reliable internet Lack of training on use of Acknowledgements The author would like to thank Peter Bonis, Elie Baron,
connections EBCRs Denise Baslow and Wolters Kluwer for the generosity in providing the free
Low rates of internet- De-emphasizing of evidence- UpToDate subscriptions. The authors would also like to thank the GHD UTD
capable device ownership based medicine in medical users, who gave us permission to publish their case vignettes. They also
education thank Marie Connelly, Aaron Beals and Aaron Vanderlip for building the
private community for the GHDonline UpToDate recipients. The authors would
High subscription cost of Lack of relevance of existing like to thank Sidney Atwood (Brigham and Women’s Hospital) for his help
many EBCRs EBCRs to local clinical with data analysis. They would also like to thank Stephen Kahn and Paul
challenges Farmer for their vision and mentorship.

BMJ Global Health
Contributors YKV designed the research questions, analysed the data, drafted 7. Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US
and revised the paper. JR revised the draft paper. SB and KW administered hospitals. J Hosp Med 2012;7:85–90.
the GHD UTD donation programme and revised the draft paper. MT 8. Chan L, Costa S. Participation in the global knowledge commons:
challenges and opportunities for research dissemination in
administered the programme, contributed to data analysis and revised the developing countries. New Library World 2005;106:141–63.
draft paper. SB helped launch the GHD UTD collaboration, administered the 9. Ajuwon GA. Use of the internet for health information by physicians
programme and revised the draft paper. RW initiated the GHD UTD for patient care in a teaching hospital in Ibadan, Nigeria. Biomed
collaboration, oversaw the administration of the programme, designed the Digit Libr 2006;3:12.
research questions and revised the draft paper. YKV and RW are guarantors. 10. Heilman J. Open access to a high-quality, impartial, point-of-care
medical summary would save lives: why does it not exist? PLoS
Funding UpToDate subscription donations were provided by Wolters Kluwer. Med 2015;12:e1001868.
YKV received funding from the Scholars In Medicine Office of the Harvard 11. Aronson B. Improving online access to medical information for
Medical School and from the Onassis Foundation during the completion of low-income countries. N Engl J Med 2004;350:966–8.
12. Van Essen C, Mizero P, Kyamanywa P, et al. HINARI grows: one
this study. The Abundance Foundation supported faculty and staff time to step closer to health information for all. Trop Med Int Health
implement this programme. 2014;19:825–7.
13. Sheets L, Callaghan F, Gavino A, et al. Usability of selected
Competing interests None declared.
databases for low-resource clinical decision support. Appl Clin
Ethics approval Study found exempt from review by Harvard University Inform 2012;3:326–33.
14. Mazloomdoost D, Mehregan S, Mahmoudi H, et al. Perceived
Institutional Review Board.
barriers to information access among medical residents in Iran:
Provenance and peer review Not commissioned; externally peer reviewed. obstacles to answering clinical queries in settings with limited
Internet accessibility. AMIA Annu Symp Proc 2007;11:523–7.
Data sharing statement No additional data are available. 15. World Bank Databank. Health expenditure per capita (current US$).
Accessed online in 1/16. http://data.worldbank.org/indicator/SH.XPD.
Open Access This is an Open Access article distributed in accordance with PCAP
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, 16. Weintraub K. Second opinions, anywhere, The Boston Globe 2010:
which permits others to distribute, remix, adapt, build upon this work non- Mar 1. Accessed online in 2/16. http://www.boston.com/business/
commercially, and license their derivative works on different terms, provided healthcare/articles/2010/03/01/collaboration_links_doctors_in_
developing_countries_with_digital_colleagues/
the original work is properly cited and the use is non-commercial. See: http://
17. Das J, Hammer J, Leonard K. The quality of medical advice in
creativecommons.org/licenses/by-nc/4.0/ low-income countries. J Econ Perspect 2008;22:
93–114.
18. World Health Organization Global Health Observatory. Accessed
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To cite: Valtis YK, ABSTRACT

Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041 1

2 Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041

Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041 3

4 Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041

Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041 5

BMJ Global Health

and Marburg virus

Figure 4 Search volume for

Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041 7

8 Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041

Valtis YK, et al. BMJ Glob Health 2016;1:e000041. doi:10.1136/bmjgh-2016-000041 9

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