To appreciate just how much access to health information has changed in the past ten years, imagine that you had the same symptoms for appendicitis, but in 1995. Where would you have looked?

Well, unless you were very pro-active, you probably didn’t look anywhere. You left that up to your doctor. And where did your doctor look for information? Medical journals and books, such as The Lancet, one of the oldest peer-reviewed medical journals in the world, and Gray’s Anatomy, a text many are aware of thanks to television.

Both The Lancet and Gray’s Anatomy, in addition to 4,000 other journals and books, are published each year in more than 20 languages by Elsevier, which dubs itself “the world’s leading publisher of science and health information.” Not to mention one of the oldest – Elsevier was founded in 1880 and its archive now contains a staggering seven million publications. (Even more staggering, as of today, Google returns over a billion web pages for the keyword search for ‘health‘.)

Brian Nairn was, until very recently, CEO of Elsevier Health Sciences. In his eight years as CEO, the company grew from $670 million to $1.5 billion. That tremendous growth has also attracted a great deal of criticism from Elsevier’s detractors who claim that subscription costs as high as $14,000 per year limit access to important health-related studies to only the wealthiest doctors and institutions. Elsevier was singled out in a Summary of Actions by Stanford’s Academic Council as engaging in “exploitive or exorbitant pricing.” The document calls for Standford’s libraries to consider dropping subscriptions to Elsevier’s publications and encourages faculty to not contribute articles, editorials, or reviews to high-cost research publications. Cornell University cancelled the majority of their Elsevier journal subscriptions in 2004, citing “an unsustainable pricing model, prohibitive selection options, and the financial impact on the library’s ability to purchase other journals as reasons for its decision.”

Brian Nairn

Brian Nairn at Rockefeller’s Making the eHealth Connection conference

Nairn was the keynote speaker for week two of the conference series. His talk focused for the most part on how Elsevier’s publishing strategy of training materials for medical students has evolved over his eight years as CEO. You can watch excerpted videoclips of Nairn’s keynote address here and here.

Brian Nairn agreed to sit down with me here at the Making the eHealth Connection conference to discuss the disruptive force of the internet from a publisher’s point of view as well as what needs to be done to get quality medical training material distributed more widely in the developing world. The following transcription is an edited, abridged version of our 30 minute talk, which is available in its entirety as an mp3 file. (Actually, almost its entirety – the first five minutes are missing.)

DS: Elsevier as a publishing house goes all the way back to the 1500’s. It’s amazing to think that the publishing industry really didn’t change that much from then until just about 10 years ago and then all of a sudden it has changed so much.

BN: Yeah, that’s right. When I joined Elsevier health eight years ago they were in the process of completing their first online book. It was on medical terminology. It’s just amazing that today all of our nursing and most of our health professions training material is available online. Technology has created, for us, the ability to become really a much more useful partner than we were able to be in the pure text publishing era.

DS: Now that almost all of your materials are online, you’re already thinking of the next platform, the mobile phone. What opportunities and challenges do mobile phones present that differ from traditional computers connected to the net?

BN: I know you can’t call students’ studying behavior ‘workflows’, but the real challenge is to move our content so that it fits more within their workflow in the broadest sense. So the first move there was really to move the content to the internet so the students could have all of their textbooks with them on their laptops. Which you couldn’t do with the textbooks.

DS: That’s right, one medical textbook is larger than most laptops these days.

BN: Yeah. So it was clearly a big step forward to move to online access. But it was important to include all of the features that people use in text books – the underlining and highlighting and notes in the margins. We were very careful to make sure that we took advantage of the technology, but still enabled students to continue with their learning habits they’ve developed. We also took advantage of the technology to offer new features. Things like multi-book search and note-sharing.

As we continued to evolve, and with the iPhone’s release, it became obvious that this was another tool, another channel that we could get our content over. We started off about a year ago with small bits of content on the iPhone like study questions and skills, which included videos of those skills. Then the question became, what kind of products would you want to take and put on the iPhone? The first one was medical terminology and obviously the iPhone is a tremendous device for that with the sound and the visual. You can hear the pronunciation of the words, which are often difficult. When you read them you might not be saying them properly. We have also produced anatomy flash cards, another example of what the iPhone is particularly well suited for.

So rather than moving everything over to the iPhone, what we’ve really looked at is content or courses that can really take advantage of the audio and video components that are enhanced in that kind of medium. There are 41 medical procedures that your average intern will ever do. Being able to show animations on the one side and streaming video on the other with good text in between has been a really valuable learning tool. We completed that procedures project in the fall of last year and we have no gone on to add orthopedics and another specialty. We have been in discussion with Duke University, so as we are developing the product, the iPhone procedures manual will actually go into beta with Duke residents starting in September and they will use it in the ward. Again, so there you’re getting advantage of mobility as well as the audio and video capabilities of the iPhone.

DS: This conference is specifically focused on developing countries. How can these new technologies and new opportunities benefit developing countries and not just US medical schools?

BN: What we would like to see is the creation of an opportunity where we could use the mobile phone as a leapfrog technology to get around the issue of remote access for those community caregivers in remote communities in, say, Sub-Saharan Africa. But if we were to take, for instance, our nursing content which is now available online, is there a leapfrog technology in these poorer countries where we could get the content and skills concepts into a mobile environment where they could be distributed to a community in, again, let’s say, Africa?

DS: What do you see as the obstacles standing in the way of making that happen?

BN: I think what’s standing in the way at this point is identifying a definitive opportunity. Identifying a defined user set. You know, it’s very easy to talk about “nurses in Africa”, but that doesn’t enable you to create a product. I think it’s about identifying an opportunity that involves partnerships, a clear end-user community, and a clear need.

DS: So here is a much more specific question: why is the beta test of the iPhone application going to be at Duke University and not at the University of Nairobi Medical School?

BN: It’s a simple answer: because we have regular contact with Duke University. Because we would need to find partners to distribute to the University of Nairobi.

DS: How does that happen?

BN: For example, the presentation we just saw of HIFA. Clearly that’s a potential partnership where you could develop a very clear action team to do exactly what you’re saying.


That is just about the first ten minutes of our conversation. We go on to discuss a lot of copyright issues, including whether or not Elsevier would have a problem if medical texts were translated into other languages for non-commercial uses. We also discussed the relative pros and cons of open access publishing and commercial publishing and whether the National Institutes of Health and other research funders’ should require open access publication of the research the commission. Finally, Nairn (who just had knee surgery) offers his insight into modern day medicine from the perspective of patient rather than publisher and discusses the challenges that lie ahead for his successor at Elsevier.