Functional Design of an Ontology --- Relationship of the i2b2 ontology to star schema

Recent posts to this blog have discussed ontologies and description logics . As mentioned earlier, the OWL-DL and OWL-Lite sub-languages of the W3C-endorsed Web Ontology Language (OWL) are based on a description logic. A tool for editing and creating ontologies, Protégé, was also described.

In the present post, I’d like to describe the functional design of the ontology used by i2b2, a collection of open-source software tools for the collection and management of project-related clinical research data. That is, this post will present an introduction to what’s under the hood.

Data storage

i2b2 data is stored in a relational database, usually either Oracle or SQL Server and always in a star schema format, a design proposed initially by Ralph Kimball in the 1980s. It is named this because of the appearance of the final database schema diagram that looks like a star (see figure below).

Notes: Ralph Kimball and I were formerly regular contributors to now-defunct DBMS Magazine. A brief introduction to the star schema format is given in the OLAP section of my article Using Neural Networks and OLAP Tools to Make Business Decisions. (See the bibliography at the bottom of this blog)

{click on the images above for larger views}

A star schema contains one fact and many dimension tables. The fact table contains the quantitative or factual data, while the dimension tables contain descriptors that further characterize the facts.

Facts are defined by concept codes and the hierarchical structure of these codes together with their descriptive terms and some other information forms the i2b2 ontology (also called metadata).

i2b2 ontology data may consist of one or many tables. If there is one table, it will contain all the possible data types or categories. The other option is to have one table for each data type. Examples of data types are: diagnoses, procedures, demographics, lab tests, encounters (visits or observations), providers, health history, transfusion data, microbiology data and various types of genetics data. All metadata tables must have the same basic structure.

The structure of the metadata is integral to the visualization of concepts in the i2b2 tools, as well as for querying the data.

In healthcare, a logical fact is an observation on a patient. It is important to note that an observation may not represent the onset or date of the condition or event being described, but instead is simply a recording or a notation of something. For example, the observation of ‘diabetes’ recorded in the database as a ‘fact’ at a particular time does not mean that the condition of diabetes began exactly at that time, only that a diagnosis was recorded at that time (there may be many diagnoses of diabetes for this patient over time).

The fact table contains the basic attributes about the observation, such as the patient and provider numbers, a concept code for the concept observed, a start and end date, and other parameters. In i2b2, as shown in the figure above, the fact table is called observation_fact.

Dimension tables contain further descriptive and analytical information about attributes in the fact table. A dimension table may contain information about how certain data is organized, such as a hierarchy that can be used to categorize or summarize the data. In the i2b2 Data Mart, there are four dimension tables that provide additional information about fields in the fact table: patient_dimension, concept_dimension, visit_dimension, and provider_dimension.

Scalability

Once a database grows to over 10 million items, the advantages of a star schema can start to take hold. The first consideration is the speed and integrity of the queries. When one exceeds 0.5 billion rows in a database, it becomes important to have the data expressed in very large indexes. Very large indexes are only possible with very large tables. If one has several hundred or thousand tables in a database (easily attained in large transaction systems), one will have at least one index on each table resulting in several hundred or thousand small indexes. Joins between 100‐1000 indexes for each query will result in slow performance (hours), while joins between 3‐4 indexes, even representing 100’s of millions of rows, will be fast (seconds). Furthermore, the integrity of queries in a transactional database is also compromised because queries can often be answered through several paths in a circular manner.

The second consideration is the need for a large analytic database to constantly absorb new data. The database schema does not change as new data sources are added. New data will result in additional rows added to the fact, patient, and visit tables. New concepts and observers will result in new rows added to the concept and provider tables. But new columns and tables do not need to be added for each new data source. This is very useful in large projects where there are many tools depending upon a specific database schema. A strategy where the database grows by adding rows for new data rather than adding new tables and columns allows tools developed to work with one kind of data to also work with a new source of data.

The third advantage of the star schema is the ability to manage the metadata of a large analytic database. Metadata is used to perform queries, and if it is incorrect a query will be profoundly affected. For example, if one wanted to find all the patients with diabetes, but left out one of the codes used to represent diabetes in a database, none of those orphaned patients would be counted. The detection of orphaned concepts is easily achieved in the star schema by, for example, joining the fact table to the concept and provider tables and reporting those fact table concepts and providers left out by the join.

A sample ontology query for diagnosis

To find all the patients that were diagnosed with migraines, use this query:

Select distinct (patient_num)
From observation_fact
Where concept_cd in
(select concept_cd
from concept_dimension
where concept_path like '%Neurologic Disorders (320-389)\(346) Migraine\%')

Note: The material in this post has been taken largely from the following i2b2 pages, which should be consulted for further details:

https://www.i2b2.org/software/projects/ontologymgmt/Ontology_Design_Doc_13.pdf

https://www.i2b2.org/software/projects/workbench/i2b2Workbench_Description.pdf

https://www.i2b2.org/software/projects/datarepo/CRC_Design_Doc_13.pdf

Semantic Interoperability, EHR, etc. are of little use to someone whose claim is denied by his or her insurance company

Founded in 1945, Kaiser Permanente is this nation’s largest not-for-profit health plan, serving more than 8.6 million members, with headquarters in Oakland, California.

This blog has carried a prominently-placed electronic health records (EHR) video outlining some of the excellent information technology work that's being introduced by Kaiser Permanente.

So, given the placement of this video, I feel a responsibility to add here the reality that Kaiser Permanente's technology is only one facet of a system that daily makes decisions about who can and who cannot get health care.

The California Nurses Association/National Nurses Organizing Committee has just released new data that reveals more than one of every five requests for medical claims for insured patients, even when recommended by a patient’s physician, are rejected by California’s largest private insurers. (The Kaiser Permanente Health Plan membership in California is greater than 6 million.)

This is data that the health insurance companies have wanted to hide, and it’s just now becoming available. It documents that these insurance companies have denied, in California alone, 45 million claims since 2002. Some of these rates ranged as high as 40 percent (for UnitedHealthcare’s PacifiCare). And other large, giant insurers like Blue Cross, Health Net, CIGNA, and Kaiser were all in the range of 30 percent (Kaiser Permanente's denial rates is 28 percent). This report shows a clear pattern of very high denials by the very insurance companies that people depend upon to assure that they get the care they need when they need it.

There are a variety of reasons insurance companies claim why they make these denials: in the end though, it’s a war that goes on between the insurance companies and the doctors and the hospitals. (Note: Attorney General of California Jerry Brown has announced he’s going to conduct an investigation into the business practices of these companies and why these denial rates are so high.)

A recent piece in the Los Angeles Times quotes a spokeswoman for the California Association of Health Plans, responding to the data that the California Nurses Association/National Nurses Organizing Committee has just released, saying, “It appears [that] a good deal of the so-called denials are merely paperwork issues.”

It seems to me that even if you put the best face on the California Association of Health Plans' response, what it demonstrates is how much waste (aka administrative overhead) there is in the health insurance industry. It's been suspected for some time now that one-third of every healthcare dollar goes to waste and to enforcing claims denials in the United States..

The game is sometimes rigged in favor of the house

High-speed trading: some institutions, including Goldman Sachs, have been using superfast computers to get the jump on other investors, buying or selling stocks a tiny fraction of a second before anyone else can react. Profits from high-frequency trading are one reason Goldman is earning record profits and likely to pay record bonuses.

And there’s a good case that such activities are actually harmful. For example, high-frequency trading probably degrades the stock market’s function, because it’s a kind of tax on investors who lack access to those superfast computers — which means that the money Goldman spends on those computers has a negative effect on national wealth.

So, what's this got to do with information technology in healthcare? Possible, nothing. Remember, however, that one of the stated goals of EHR is to deliver better healthcare at lower cost.

I believe that we should keep in mind that technology - not high-speed computers per se - doesn't always benefit society. As I mention - without much elaboration - in my July 22 post, "EHR / EMR has the potential to facilitate the execution of today's healthcare scams. So, for the time being, we might well have a reason to temper our enthusiasm for the inevitable computerization of our still-largely-paper-bound healthcare records systems."

The coming evolution of wireless local area networks (in healthcare, academe and elsewhere) means better video, voice, and data

Wireless local area networks are about to become more pervasive because greater numbers of end users are going to be more favorably impressed than ever with their performance and greater numbers of administrators are going to be more favorably impressed than ever with their cost/benefit ratio. The emerging Wi-Fi standard, 802.11n, is behind these changes.

The examples of 802.11n networks outlined in this post are taken from the healthcare industry and education, but they apply equally well to any networked environment -- and, today, that means just about every environment. Healthcare, especially, with its stringent security requirements, large files like X-rays and changing physical environment caused by portable equipment will benefit from this nascent wireless standard as much and sometimes more than any other field.

With the ubiquitous coverage that 802.11n promises, doctors and nurses will have full network access whether at the patient’s bedside, in wards, or in the waiting areas. Office workers and others ancillary staff will be able to move their laptops and other mobile devices from their desks to a conference room or to a cross-campus facility, more often than not seamlessly.

While 802.11n is not expected to be ratified before Q4 of this year at the earliest, draft versions of 802.11n are already making it possible to run bandwidth-hungry applications like VoIP and video streaming. The draft 802.11n products currently on the market demonstrate a significantly higher throughput and improved range. And, the 802.11n standard promises to achieve as much as 5x the throughput and up to double the range over legacy 802.11 a/b/g technology.

At this level of throughput and range performance, 802.11n can support multimedia applications, with the ability to transport multiple high-definition (HD) video streams, while at the same time accommodating Voice over Internet Protocol (VoIP) streams and data transfers for multiple users with high Quality of Service (QoS) and latest generation security protections in place. In enterprise, campus and municipal networks, 802.11n offers the robustness, throughput, security and QoS capabilities that IT managers have come to expect from wired Ethernet networks. But, wireless devices have this one additional attribute: they are not tethered to a wall jack like wired ones and that makes all the difference in the world.

I've linked to a number of videos so that you can see some of this functionality in action:

http://www.youtube.com/watch?v=B5z3_GzCsCU
http://www.youtube.com/watch?v=5HQH49fo2qE
http://www.youtube.com/watch?v=USeund3jyPA&feature=related

It is well documented that wireless performance varies based on a variety of factors such as the type of applications delivered over Wi-Fi or the physical challenges presented by building materials or architectural configurations. Cisco’s lab testing engineers have consistently reached connection data rates of 300 Mbps per 802.11n radio. This data rate typically translates to a throughput rate of 185 Mbps for sustained periods of time.

Video

Before the introduction of 802.11n, a healthcare organization that needed to stream high-definition (HD) video for mobile diagnostic services would be limited to only two HD streams at a time over a wireless network. Even then, an 802.11g network would not be a reliable transport medium for HD streaming video. Previous standards, such as 802.11b, did not have the necessary throughput capacity for any HD video streams.

802.11n allows for the distribution of seven times more video streams than 802.11g networks (Table 1). Such an increase in the throughput rate can truly mobilize applications such as bandwidth-intensive, video-streaming applications. With 802.11n, organizations like the healthcare provider mentioned earlier can dramatically increase the number of simultaneous mobile diagnostics that can be performed. The result is a significant improvement in medical staff productivity, resource utilization, and patient satisfaction (due to shorter wait times), all of which leads to greater profitability.



* In real-life network deployments, Cisco 802.11n solutions have maintained a consistent throughput peak of 185 Mbps. Unfortunately, when it comes to video streaming over Wi-Fi, contention reduces the available throughput per 802.11n radio to roughly 140 Mbps.

** A typical DVD-quality video stream requires about 5 Mbps of throughput. A high-definition video stream requires double the throughput—that is, about 10 Mbps.

8x More Users

The transformative nature of wireless networking drives -- and also feeds -- an insatiable appetite for network-connected devices. Most of us today have at least one Wi-Fi-enabled device, but many of us are starting to carry more than one -- for example, a dual-mode phone, a laptop computer, and a digital camera. We are also becoming accustomed to finding an available network that we can connect those devices to while at home, at work, or on the go, which in turn drives the need for ubiquitous network connectivity.

The proliferation of these network-connected devices is creating an undeniable need for high density deployments as more and more users connect to the same network with multiple devices for different reasons. This need is only exacerbated in areas where people tend to congregate in large numbers for business, education, entertainment, or other reasons.

Consider a large lecture hall where many students congregate during class and are connecting to the wireless network with their laptop computers in order to download the instructor’s presentation slides and notes or conduct parallel, online research on the discussion topic of the day.

If we assume that this large lecture hall is equipped with three 802.11g access points today, the students in the classroom and their connected devices would be sharing an available bandwidth of 22 Mbps by load balancing these users and devices across the three available access points. Now suppose that all these students were required by the instructor to use a “blackboard” type of application to download presentation notes transcribed onto slides in real time. The application would require a consistent bandwidth of 5 Mbps in order to provide a good user experience, and the result would be that only 12 students (four students per access point) would be able to use the application effectively in the classroom.

Suppose we were to replace these three 802.11g access points with three next-generation, 802.11n access points. The system-level bandwidth in the classroom would increase substantially and more than 96 students (32 users per access point) would be able to connect to their wireless network and expect to have a consistent application experience.

In fact, a one-to-one replacement of access points is the most prevalent migration scenario to 802.11n for organizations that want to increase their deployment density. User density becomes an even more complex problem to solve when network users are demanding different bandwidths to run their specific applications. It is not hard to imagine how airport terminal or conference room hotspots, where users run a variety of mobility applications, would benefit from next-generation wireless. Not only would it allow more users on the network, but it could also improve their individual user experience.

Cisco testing has shown that on a systemwide basis, adding devices (users) onto the network may at some point create some throughput loss, up to 5 percent, which will result in slightly fewer additional users being able to use the network. That is why the number of users is not entirely aligned with the expected performance improvement we see from migrating to 802.11n.

9x Faster

Even though Internet or Intranet video streaming and higher user density are both compelling reasons to migrate to 802.11n, the vast majority of companies migrating to next-generation wireless will do so because of the raw performance improvement their users will experience daily. Extensive field testing has shown that sustained throughput performance of 802.11n wireless networks is 185 Mbps. However, in many cases during those field trials, a sustained upper limit of 198 Mbps has been observed.

Companies migrating to a next-generation 802.11n wireless network can expect to experience an improvement in performance that is up to nine times faster than 802.11g technology for the mobile applications used today. Furthermore, many applications, such as scheduled data backups and large file transfers that were previously performed over the wired network, will now be mobilized. These performance improvements increase overall employee effectiveness and productivity and in turn shorten the 802.11n investment payback period, while increasing the return on investment.

There is no doubt that the emergence of 802.11n will also bring about an influx of bandwidth hungry mobile applications that could not be enabled wirelessly until now.

802.11n vs. gigabit Ethernet

Of course, 802.11n speeds still fall far short of those of gigabit Ethernet. However, downloading an 8MB file over 802.11n should take about 4 seconds if there are 10 users on a given access point, compared to less than a second for both fast and gigabit Ethernet. Even with 20 users per access point, the file download times ranged from two to eight seconds -- still satisfactory for most users.

Although latency is up to 20 times higher than that of gigabit Ethernet, the difference will not be enough to impact VoIP. The same can be said of jitter, the amount of variation in the arrival times of VoIP packets. Jitter can be as high as 150 times that of gigabit Ethernet, but who cares? Again, the difference will have little impact on jitter-sensitive applications such as VoWLAN [voice over WLAN] because the absolute value is so small compared to the VoWLAN jitter budget.

See http://www.youtube.com/watch?v=WXELBG9oakk

This video, the first in a 4-part series on VoIP, is not about wireless, but the concepts, which apply to both wired and wireless networks, may be of interest .

More reliable

802.11n is not only faster, it’s a lot more reliable because it uses “MIMO” -- Multiple Input, Multiple Output — technology. It means, in effect, you have multiple antennas working. So, if a signal doesn’t get through going in one direction, you’re able to send it another way with another antenna, and the signal is more likely to get through. This use of multiple antennas also can mean fewer "dead spots" in coverage.

Better security

802.11n also has better security, with stronger encryption, than 802.11g. That makes 802.11n particularly attractive to small- and medium-size organizations, which don’t have the level of IT resources that larger organizations do.

And, fortunately, all of today's wireless network security best practices still apply to 802.11n. It's important to realize, however, that 802.11n may also raise business risk simply by supporting more users and applications across larger areas. In short, the same old attacks may now be far more disruptive to your business.

Ultimately, 802.11n networks can be made just as secure as -- if not more secure than -- yesterday's 11a/b/g networks. But, this takes awareness and follow-through.

Caveat emptor

Like yesterday's 802.11a/b/g standards, the 802.11n high throughput standard employs 802.11i "robust security." In fact, all Draft n products are required to support Wi-Fi Protected Access version 2 (WPA2) -- the Wi-Fi Alliance's test program for 802.11i.

The good news: All 802.11n WLANs built from scratch can forget about WEP crackers and WPA (TKIP MIC) attacks, because every 802.11n device can encrypt data with AES. The catch: WLANs that must support both old 802.11a/b/g clients and new 802.11n clients may be forced to permit TKIP. Doing so makes it possible for older non-AES clients to connect securely. Unfortunately, 802.11n prohibits high-throughput data rates when using TKIP.

It is therefore best to split old 802.11a/b/g clients and new 802.11n clients into separate SSIDs: a high-throughput WLAN requiring AES (WPA2) and a legacy WLAN that allows TKIP or AES (WPA+WPA2). This can be done by defining two SSIDs on a virtual AP or by dedicating different radios on dual-radio APs. This is only a stop-gap measure, however. As soon as you can retire or replace those legacy devices, do away with TKIP to improve both speed and security.

Forward and backward compatibility

The IEEE 802.11n specification is now stable and converging. Many vendors have stated that their Wi-Fi CERTIFIED 802.11n draft 2.0 products are planned to be software-upgradeable to the eventual IEEE 802.11n standard. The industry now needs assurance that these new products interoperate with each other and that they are backwards compatible with and friendly to the legacy 802.11a/b/g systems. The Wi-Fi CERTIFIED program delivers this assurance.

Devices eligible for certification implement most of the mandatory capabilities in the IEEE 802.11n Draft 2.0 specification. In addition, certain optional capabilities are covered under the certification testing, if implemented in the device. The certification defines and verifies out-of-box behavior of draft 802.11n devices. It also tests for backwards compatibility with and protection of legacy 802.11a/b/g networks from potential disruption by 802.11n. Security and QoS testing are mandatory for the Wi-Fi CERTIFIED 802.11n draft 2.0 products.

Comparing Wi-Fi and WiMAX

Some people describe the difference between Wi-Fi and WiMAX as analogous to the difference between a cordless phone and a mobile phone. Wi-Fi, like a cordless phone, is primarily used to provide a connection within a limited area like a home or an office. WiMAX is used (or planned to be used) to provide broadband connectivity from some central location to most locations inside or outside within its service radius as well as to people passing through in cars. But, be forewarned: just like mobile phone service, there are WiMAX dead spots within buildings.

From a techie POV, the analogy is apt at another level: Wi-Fi, like cordless phones, operates in unlicensed spectrum (in fact cordless phones and Wi-Fi can interfere with each other in the pitiful swatch of spectrum that's been allocated to them). There are some implementations of WiMAX for unlicensed spectrum but most WiMAX development has been done on radios which operate on frequencies whose use requires a license.

Wi-Fi CAN operate at distances as great as WiMAX, but there's a reason why it doesn't. Radios operating in the unlicensed frequencies are not allowed to be as powerful as those operated with licenses; less power means less distance.

Though both offer wireless data connectivity, there are more differences than similarities. Check out the following comparisons:

Coverage Range

The coverage range of Wi-Fi 802.11n is about 400 meters in open spaces but will be lesser indoors. For WiMAX 802.16e, coverage distance can be metro-wide and can be more than 50 km.

Speed

Wi-Fi 802.11n was developed to provide faster speed (around 300 Mbps) than the a, b and g variants of this standard. WiMAX on the other hand can handle speeds up to 70 Mbps. It should be noted however, that for both standards, available bandwidth is dependent on many factors such as the distance from the base stations or access points, RF environment and the number of users connected.

Quality of Service

802.11n and WiMAX have different Quality of Service (QoS) mechanisms. This feature is standard in WiMAX and utilizes a method based on type of connection between the base station and the user device. Wi-Fi has introduced a QoS mechanism where certain traffic flows can be prioritized over others. For example, VoIP or video streaming applications may be given priority over ordinary web surfing.

Target Market

Wi-Fi, including 802.11n, was primarily developed for wireless local area networks (WLAN) with a limited coverage area. It has found popular usage in last-mile delivery or consumer applications, such as hotspots in public places, offices or at home. WiMAX, on the other hand, was developed primarily for wireless metropolitan area networks (WMAN) with coverage ranges of up to several kilometers. Service is usually subscription-based and provided by telco operators intended for business users. Example applications are as backhaul for wide area networks or internet connection for ISPs.

Today, Dell customers can add an Intel wireless module that supports Wi-Fi and WiMAX to Dell's Studio 17 and Studio XPS 16 for $60, according to Dell's Direct2Dell blog.

But, wireless broadband networks based on WiMAX are only available in three U.S. cities: Atlanta, Baltimore and Portland, Oregon. That means most users won't get any benefit from adding WiMAX cards to their Dell laptops unless they live in one of these three cities. Over time, more U.S. users will get access to WiMAX networks as operator Clearwire expands coverage to more cities.

HP, the world’s largest laptop maker by units, does not offer WiMax as an option on any notebooks.

Of course, you can always use a USB modem. Sprint’s U300 USB modem, which supports both 3G and Mobile WiMax, is $80 with a two-year contract

Detailed reference on 802.11
http://www.intel.com/standards/case/case_802_11.htm

Early use of 802.11n at M.I.T. and a medical center
http://www.computerworld.com/action/article.do command=viewArticleBasic&articleId=9111000

Social networking and search engine optimization: E-Marketing for the healthcare and related industries

This post will take a limited look at social media and search engine optimization in the context of the healthcare and related industries and how some of their entities are using these new technologies.

As we all know, social media can be used by healthcare professionals and the public to talk about a biotech company's products and brand. But biotech companies, as a general rule, have avoided social media for various reasons, including the lack of guidance from regulatory bodies like the FDA on remaining compliant while using social media approaches and difficulties measuring results, tracking popularity and audience activity.

In fact, many companies’ internal legal and regulatory teams stifle the kind of free communication social media affords because of ever-present fears of the increased scrutiny and legwork that come with associated obligations like adverse event reporting.

But there are ways to use social media tools that avoid these kinds of quagmires and stand to deliver real value to biotech companies and others. This is actually where the true beauty (flexibility) of technology is. Some entities are using indirect approaches (such as creating unbranded Facebook pages) or even emerging social media tools like Twitter for non-traditional advertising forays, such as making “announcements” about products and activities (e.g., twitter.com/boehringer and twitter.com/novartis).

Caveat Emptor

Before you launch a campaign that depends on a particular social media (or any other) application, understand it well. A case in point: currently, more than 60 percent of U.S. Twitter users fail to return the following month, or in other words, Twitter’s audience retention rate, or the percentage of a given month’s users who come back the following month, is currently about 40 percent. To be clear, a high retention rate does not guarantee a massive audience, but it is a prerequisite. There simply are not enough new users to make up for defecting ones after a certain point.

Compare Twitter to the two heavily-touted behemoths of social networking when they were just starting out. When Facebook and MySpace were emerging networks as Twitter is now, their retention rates were twice as high. Twitter has enjoyed a nice ride over the last few months, but it will not be able to sustain its meteoric rise without establishing a higher level of user loyalty.

A pharmaceutical company

Consider the pharmaceutical company Pfizer's roll out of a pan-European digital campaign encouraging people to stop smoking using social media (see why their campaign is an example of viral marketing, later in this post).

Pfizer is trying to engage its audience through the use of social media channels where their audience is (i.e. Twitter and Facebook). This makes even more sense in Europe, where smoking is probably more prevalent and more acceptable, especially among younger folk.

Traditional marketing vs. social media

IMHO (In My Humble Opinion / In My Honest Opinion), a big difference between traditional marketing and the social media used by Pfizer is that the former really doesn’t take as much effort after the launch of the campaign, other than to monitor and analyze; whereas with social media, the big effort really starts at the launch, as the tools are designed to facilitate interaction and engagement in order to develop an ongoing relationship with the customer. And like with any kind of relationship, it takes effort, empathy, and regular communication in order for it to blossom and grow. A one time effort with no continuing engagement will lose the interest of the social media audience very quickly, especially if it’s just marketing/advertising in disguise.

An entire community

Social networks helped cause the FDA to rescind the ban on concentrated morphine:

The FDA demanded that the production of concentrated liquid morphine be stopped. Nine days later, they changed their mind and rescinded the decision. It's amazing that the FDA reversed course in what seemed to be record time. The entire palliative care community, including their organizations, physicians, patients and families presented a united front of dissent, which helped persuade the FDA. They used social networks, like blogs, Twitter and Facebook to rapidly spread the message as well as the ramifications surrounding the announcement.

Search engine optimization et al

E-marketing techniques such as search engine optimization (SEO), analytics and content monitoring offer organizations control over website content and promotion, while at the same time allowing them to use social media merely as a pointer to their website -- the more traditional source of information. In contrast to the activities at social networking sites, activity at these destination websites can actually be measured, categorised ... and all sorts of other nice things that marketing managers, analysts and executives like to do!

So, the general idea is to make your own sites (the entity, service, product or others you may have) the central information storage area. Whatever you want to promote, either directly or indirectly, lives there (where regulatory uncertainties are less daunting). But, of course, you have to ensure that all your content is of interest to the audience you're targeting and to search engines.

So, first you need to search engine optimize your content. This entails activities such as:

* finding out exactly what you want to promote
* compiling a list of keywords and phrases you want to use for that
* exploring the popularity of such keywords and identifying others which may be relevant but you are not using
* establishing a final list of keywords to be used
* ensuring that your website content contains the above keywords

Doing so will help you write and expose information which is in demand, in line with what you want to promote and that the public and healthcare professionals can easily find online. For an easy-to-read guide to SEO practices, see "Search Engine Optimization" by Rebecca Lieb (2009).

Next, ensure that your search engine optimized website can now track visitors and their actions: what they see, where they go, what they click on and the path they follow. This is where analytics come in. You’ll want to analyze your Web server logs or utilize third party tools such as Google Analytics to measure any activity on your website. Being aware of and understanding this activity can provide invaluable information, including market trends, personal preferences, regional/organisational statistics and a lot more.

Controlling the message

You’re now ready to turn to social media. Social media tools can now be used without hesitation when they are used to point to traditional and existing information already on your site, rather than to talk about your subject matter or organization in an open and uncontrolled forum.

So, for instance, if your website contains a wealth of well-exposed information related to a specific therapy area, people will find it and could start talking on social media about it as an information resource. This in turn will lead to more traffic to your site, from both healthcare professionals and the public, which can be measured, analyzed and classified according to your needs.

The proof is in the pudding

If you have a well optimized website, visitors to your site will spend more time there and tend to return. You can measure these parameters before and after optimization, using tools like Google Analytics to determine the extent of this success.

The general idea, therefore, is to use good, search engine optimized content to attract attention, analytics to measure it and social media as an extra channel for directing people to your site. Country-specific challenges remain, however.

Regulations in some countries, ABPI guidelines in the UK for example, may interpret this use of social media as promotional and hold you responsible for any links leading to your site, regardless of whether they are informational/educational or truly promotional. However, the fact is that even without social media being used as an extra communications channel, nothing spreads the word about your sevices, products or other content better than a well developed and SEO optimized site.

Viral marketing

Some call the practice of “re-directing” people to your website “viral marketing” instead of social media. Viral marketing facilitates and encourages people to pass along a marketing message.

Postscript I: Social networking at hospitals and other healthcare organizations

Hospitals can (and are) using social media to achieve certain of their goals. Ed Bennett of the University of Maryland has put together a very comprehensive list of social networking sites hosted by hospitals including their use of Facebook, Twitter and YouTube. YouTube looks like the most common but many are moving forward with Twitter. Some have clearer strategies with Twitter and other Web 2.0 tools than others. Most are using Twitter for health advice, others as an abbreviated version of press releases. It remains to be seen where this will go in the future - how it might be used in emergency communication or employee communication.

At the time of this posting, Mayo Clinic has about 5000 fans on its Facebook page -- interesting posts from patients, family members, and physicians. Its Facebook site includes information on the Clinic, links to various web sites, videos, and more. But, most important, it has "The Wall" -- that empty page where you can write your thoughts, wishes, and other posts.

St. Jude's Hospital has over 25,000 fans and it appears that there are many hospitals on Facebook that have created their own pages. By comparison, Target stores has 173,000 fans, Starbucks has 987,000 fans, and Nike has over 1.1 million registered fans, to name just a few in the "power brands" category.

Postscript II: Website optimization

The relatively new field of website optimization (not to be confused with the search engine optimization discussed above) uses specialties such as statistics, user experience testing, and cognitive psychology to get visitors to convert (i.e., do what you want them to do, once they've landed on your site). I talk about this topics in my recent article Statistical and Financial Considerations in Website Optimization. There's a link to it at in my selected bibliography at the bottom of this blog, for anyone who's interested.