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Man FROM THE EMERGENCY ROOM TO THE BOARDROOM, Jonathan N. Adler, M.D., is committed to the practice of medicine. As a physician, lecturer, and president and chief medical officer of eMedicine, he balances all endeavors with one goal in mind: fostering better medicine.
BY KIM RIBBINK
JON Adler PharmaVOICE The demands of medicine mean physicians are required to spend many hours of their days absorbing the latest research on their own area or areas of expertise or conducting and offering research of their own. While it’s one thing to remain cur rent, it’s quite another to take on the added challenge of passing on that information to students, other pro fessionals, and the general public. Jonathan N. Adler, M.D., finds the time to do all that and more. He works clinically as an emer gency physician, gives lectures, and participates in the emergency medicine department at Mas sachusetts General Hospital, while also serving as president and chief medical officer of eMedicine, a Web based clinical knowledge source for physicians and other healthcare professionals. It’s a difficult balance, Dr. Adler admits, especially since he also has obligations to his family. But it is a balance that he seems to manage with aplomb. Uncharted WATERS Throughout his career, Dr. Adler has shown a predilection for forging paths into new or less wellknown territories. Before turning to medicine, Dr. Adler studied aerospace engineering. He credits this nontra ditional background with giving him the abil ity to look at situations from a different point of view and to find unorthodox solutions to timeproven challenges. Having made the decision to study medicine, Dr. Adler found himself drawn toward emergency medicine. Part of the attraction was his active nature. Another attraction was the newness of the discipline. “Emergency medicine is the youngest spe cialty and at the time I started my training there were only 66 programs in emergency medicine in the U.S.,” he says. After complet ing his training at Christ Hospital in Chicago, Dr. Adler set his sights on academia, and land ed at Massachusetts General Hospital. “At the time I joined the group there were no other residency trained emergency physi cians on the staff,” he says. “And while the hospital had been taking care of emergencies since 1811, it hadn’t developed an academic emergency medicine program. I got to partic ipate with a fantastic group of very enthusias tic and interesting colleagues to create a new residency training program.” On top of his vast experience as an emer gency medicine physician and in teaching medical students and residents, Dr. Adler has had extensive experience writing and with edi torial projects. After completing his residency training in 1992, Dr. Adler coauthored a book with eMedicine Founder Scott Plantz, M.D., FAAEM, on emergency medicine. “With the book, `Emergency Medicine Pearls of Wisdom,’ we created a different for mat, one that was more firmly based in educa tional theory,” he explains. “The book allowed people to learn facts, and to assimilate kernels of information into a body of knowledge, the purpose of which was to help people with board review exams or for residencybased training.” That book eventually became part of Boston Medical Publishing, from which eMedicine sprang. In addition, Dr. Adler was involved with writing and editing two emer gency medicine books for Lippincott Williams & Wilkins. Worlds COLLIDING With his diverse background as a practic ing emergencymedicine physician, in teach ing medical students, and establishing the Mass General residency training program, and as a writer and editor of medical books, chap ters and papers, Dr. Adler has been able to bring invaluable knowledge and experience to eMedicine. “I’ve been very active in teaching both medical students and residents,” he says. “I have been through the medical process myself, which helped me determine what tools need ed to be created to improve the educational process. That experience was compounded by my involvement as an educator, working very closely with students and residents in training. Those experiences were instrumental in creat ing my view of what we wanted eMedicine to become as a learning and educational resource.” eMedicine is a cuttingedge tool that con tains information on disease states, research, and cures and treatments for a wide audience. The site, which was launched in 1996, is described by the company as the largest and most current clinical knowledge base available to physicians and health professionals. His experience as an associate editor for the Journal of Emergency Medicine helped Dr. determine what tools needed to be created to improve JON Adler PharmaVOICE Adler identify the editorial process for eMedicine. The appeal of eMedicine to healthcare pro fessionals and pharmaceutical companies is the quality of its product, and, as chief medical officer, one of Dr. Adler’s primary roles is qual ity control. To that end, he supervises the peer review process, and has been involved in the creation of tools to improve the standard of topics covered. “At the outset, we felt it was important to have accountable peer review,” he says. “Scien tific journal articles usually use blinded peer review, so authors don’t know who reads their material. We believe in the reverse, which is accountable peer review, so authors know who their editors are, editors know who the author i s , a nd t h e names of all appear on the article . The editors have more account ab i l i ty, and because this is dynamic con tent, they are obligated to make sure it’s cur rent, maintained in good shape, and is accu rate.” Professional users can email the editor and HOWWOULDYOUDESCRIBETHE STATEOFTHE INDUSTRY? These are wonderful times. There have been unbelievable develop ments and improvements in terms of evaluation and treatment and even basic understanding of medical diseases that physicians in an earlier time just weren’t fortunate enough to have. Coupled with that is the explosion of digital technology.Part of what I find very satisfying is being able to create something like this resource,eMedicine. WHATARE SOME OFTHE BIGGEST CHALLENGES FACING THE INDUSTRYTODAY? The first is hubris.There is a natural tendency because of the wealth of information,new drugs, and new treatments to think that we’re really getting somewhere.But there are many diseases we don’t fully under stand, that we can’t treat, that are still causing tremendous morbidity and mortality on a worldwide basis; we have a long way to go. There are other practical issues. It’s wonderful to create great diagnostic and treatment capabilities, but these are all tremendously expensive and represent a huge drain on resources.Very rich countries can somehow moderately manage to afford healthcare, but for the rest of the world these innovations still are very inaccessible. The tremendous cost of healthcare is the secondlargest challenge. INYOUR CAREER,WHOHAS HADTHEMOST SIGNIFICANT INFLUENCE ONYOU? My adviser as a graduate student at the University of Colorado in Boul der was Dr. Marvin Luttges. He was bright and patient and lenient and he had a tremendous ability to let us, as graduate students, muddle through on our own. He didn’t tell us how to do everything, which he was fully capable of doing.That really provided an educational founda tion. We had to figure out how to solve problems. He was a very big influence onmeandunfortunately hepassedawayat avery youngage. A 360degree perspective IN AN EXCLUSIVE INTERVIEWWITH PHARMAVOICE,JONATHANN. ADLER,M.D.,PRESIDENTAND CHIEF MEDICALOFFICEROF EMEDICINE, PROVIDESHISVIEWOFTHEHEALTHCARE INDUSTRY. DR. JON ADLER Dr. Alasdair Conn, who is the chairman of the emergency depart ment at Mass General,has been a very positive influence on me,both in the clinical setting because of his ability to remain calm under fire, and as a role model in an administrative area,because he’s very good at what he does. He’s encouraged me to pursue the things that I’ve wanted to do, including eMedicine, even though it’s made me less available to the department.He gave me tremendous opportunities. All the things that I was able to pursue, were positions that came from him. ASTHERECIPIENT OFNUMEROUSAWARDS,OFWHICH AREYOUTHEMOST PROUD? In medical school I received, two years in a row, the Creative Contribu tion to the Field of Medicine from the Adler Foundation — no relation. I had come up with a novel line of research to investigate.That prob ably, on some level,helped encourage me to realize I could start to think outside the box, and not be afraid to pursue lines of research or ideas that are a little different. In the first year of our newly established residency training pro gram at Harvard, I received an award for Best Role Model from our res idents. That had a lot of personal meaning to know that the people I was working with and training viewed me as a role model. Jon Adler has shown a predilection for into new or less wellknown territories. JON Adler PharmaVOICE “Because the content is on the Web, we are not constrained by page length or image size, which limited other publishing means, and can create search tools and other capabilities that allow people to access what they want,” he says. The goal from the beginning, he notes, has been to present information in such a way that professionals can glean the data they require without being forced to wade through exhaus tive references. “The analogy that I use, because of my experience in aerospace engineering, is of a fighter pilot,” he says. “A fighter pilot has plenty of information at his finger tips — a wall of gauges and dials and instruments. But sometimes a critical decision needs to be made quickly. There’s a headsup display, which summarizes the information needed. The pilot can choose the data he wants dis played in different circumstances, and can rapidly get to the kernels needed to help him take action. That’s what eMedicine was designed to do — allow people to quickly access data of interest.” Dr. Adler’s central role in establishing eMedicine as a highly respected, muchtapped resource has earned him enormous respect. “Jon has done three critical things to help bring eMedicine to where it is today,” says Deryk Van Brunt, Dr.PH, eMedicine’s CEO. “One has been the recruitment of highly qual ified physicians; two has been to create a struc tured definition of how evidencebased con tent should be generated; and three was formulating a system to maintain that content — and this is huge because no one has ever done it before.” eMedicine continues to be a work in progress. In late August, the company rolled out its new user interface making the content easier to access and more understandable. “We’re at a great transition — we’re start ing to look at becoming profitable,” Dr. Adler EMEDICINE FORMATION 1997 TO PRESENT.President and chief medical officer, eMedicine, which was spun off from Boston Medical Publishing in 1997. Involved in developing eMedicine’s proprietarypublishing system.Begins authoring and editing eMedicine’s first book 1992 TO 1993. Establishes Boston Medical Publishing with Dr. Scott Plantz.BMP’s first book published. ACADEMIC APPOINTMENT 1993. Instructor of Medicine, Harvard Medical School, Boston HOSPITAL APPOINTMENT 1993. Assistant in Emergency Medicine,Massachusetts General Hospital,Boston ADMINISTRATIVE APPOINTMENTS 1994TO 1999. Associate Program Director, Massachusetts General Hospital,Harvard Affiliat ed Emergency Medicine Residency, Boston 1994TO1998.Course Director, Emergency Medicine Senior Clerkship at Massachusetts Gen eral Hospital,Boston EDITORIAL POSITION 1998TO2001. Associate Editor,Journal of Emergency Medicine, Elsevier Science Inc.,NewYork EDUCATION 1988TO 1989:General Surgery Internship, Emanuel Hospital, Portland,Ore. 1988:M.D.,University of Colorado School of Medicine 1983: M.S., University of Colorado College of Engineering Sciences (Aerospace Engineering Sciences) 1980:B.A.,University of Colorado College of Arts and Sciences POSTDOCTORALTRAINING 1989 TO 1992: Emergency Medicine Residency, Christ Hospital and Medical Center, Oak Lawn, Ill., Affiliate with Rush Medical College,Chicago Parallel pursuits JONATHAN N. ADLER, M.D. — RESUME author directly. “I see those emails,” Dr. Adler says. “So if there’s a problem with the topic, or any concern about the quality or accuracy, we can address that right away.” Dr. Adler also created an evaluation system so all professionals can score each article. Responsibility for handling the large vol ume of data associated with the eMedicine pro ject was not completely new to Dr. Adler. His duties as associate program director of Mas sachusetts General Hospital, Harvard Affiliated Emergency Medicine Residency involved a huge administrative challenge — ensuring that 265 hours of educational time throughout the year was allotted, planned, and slotted. “That ended up being good crosstraining for the eMedicine project because of the vol ume of content,” he says. “eMedicine is obvi ously much larger and complex, but that pre vious experience was very good in terms of learning to manage large projects that require attention to detail.” Dr. Adler describes the creation and devel opment of eMedicine as one of the “largest col laborative educational healthcare projects undertaken.” The eMedicine Clinical Knowl edge Base provides coverage of 7,000 diseases and disorders, and includes contributions from almost 10,000 physician authors and editors. The evidencebased content provides practice guidelines in 62 medical specialties, and is kept current around the clock. All of eMedicine’s original content undergoes four levels of physi cian peer review plus an additional review by a Pharm.D. “It’s tremendously satisfying to play any role in helping elevate the quality of care that’s being delivered to patients,” Dr. Adler says. “That’s what it boils down to in terms of eMedicine’s role in healthcare.” eMedicine, which can be viewed at emedicine.com, began as part of Boston Medical Publishing. The Website’s first work was the Emergency Medicine Volume, a conglomera tion of 735 articles with about 500 contributing physicians. The project, which took a little more than a year to bring to fruition was, Dr. Adler says, the turning point for the company. The genesis behind eMedicine was to pro vide healthcare professionals with current, accurate, credible medical information that physicians and the public could use to make better medical decisions. “The fundamental problem that we were addressing was a need for current content,” Dr. Adler says. “Text books are out of date the day they reach the bookstore shelf. We wanted to create a new entity that would fill that need for comprehensive content that summarized the current understanding about a medical condition.” Dr. Adler credits Dr. Plantz, eMedicine founder, and Jeff Berezin, the chief technical officer, with leveraging the power of the Web to create an authoring environment. JON Adler PharmaVOICE says. “The next stages for us are to continue to evolve the content, our working relationship with the corporations, and enhance the user experience,” Dr. Adler says. In addition to the new user interface, the company plans to roll out a natural language search function, a “fuzzy logic” search feature, wireless access, and enhancements to its PDA and Palm download functions. Another innovation, which Dr. Adler says he had a modest role in enhancing, is the group publishing system, or GPS, a patented software technology. “Through GPS we can interact with all the content, add authors and delete authors, add topics, assess how everyone is coming along, and set the progress and email all the authors and editors who are involved in the approval process,” he explains. “Through this process we have a wonderful area — a book control center — which in part has allowed us to leapfrog past traditional publishers.” Finding RESOURCES Because eMedicine reaches such a vast audience, it has become an attractive source for the pharmaceutical industry to reach out to physicians. Part of eMedicine’s funding is derived from investors, part from subscriptions and sales, and part from corporate sponsorship. One of eMedicine’s first investors was Tenet Health care, which owns about 129 hospitals in the U.S. A subsequent round brought funding from Omnicom, a holding company, and HIG Capital, a venture capital fund out of Florida. In addition, there are corporate sponsor ships from a number of pharmaceutical, biotechnology, and device manufacturers. “Since we have relationships with our physician users, corporate sponsors can take advantage of that relationship to help them educate people about their products and offer ings,” Dr. Adler says. Through this relationship with a large number of contributing physicians, one of the things that the company is starting to explore is ways to help pharmaceutical companies reach this audience by helping sponsors create their own content, or educationally directed materials or continuing medical education. “As the site continues to evolve and the relationships with the companies evolve we’ll find more and more ways to work closely together,” Dr. Adler says. Another innovative partnership collabora tion is eMedicine’s integrated microsite. “A corporate sponsor can place its active Website — albeit somewhat smaller than the average Website — within the medical con tent,” Dr. Adler explains. “It’s all above board, it’s clearly identified as sponsoredadvertising material. This information benefits our users because when they go to an eMedicine article, they usually are on a mission. The user may see some information that they would like to pur sue while they’re reading specific content. Users seem to like this. They’re accessing the content, they’re clicking onto the sites.” Some of those integrated microsites have been developed through inhouse interaction with corporations, while others are the result of a relationship with agencies, such as iFron tier, an online ad agency that works primarily in the pharmaceutical arena. As well as the microsite, eMedicine offers an opportunity to pharma companies to spon sor an entire specialty area. A third source of revenue for the company is iMedicine.com, the subscription model of the site. “We have about 120 institutions that cur rently subscribe to the institutional offering,” Dr. Adler says. A fourth, and still growing source of rev enue for the company is sale of CME content via Palm or PDA download. Through the company’s medical education center, it offers about 40,000 hours of medical education credits, including 10,000 Category 1 AMA PRACME for physicians, 10,000 CEs for nurses, 10,000 CEs for pharmacists, and 10,000 OCEUs for optometrists. In the future, eMedicine also plans to offer CEHs for prehospital providers, respiratory therapists, and physical therapists. F PharmaVoice welcomes comments about this article. Email us at firstname.lastname@example.org. THE GOAL To provide healthc are professionals with the inf ormation they need, at the p oint of care, to make sound clinical decisions that will improve outc omes, save liv es,and deliver c ostefficien t care. eMedicine’s products represent a vast educational repository that empowers physicians and other medical professionals to make bet ter decisions at the point of care, and to support their medical and clinical research.Knowledge delivered at the pointof care can reduce errors, enhance patient safety, and reduce medical costs. TARGET MARKETS Physicians . About 95% of physicians are online (524,000 users). . They regularly use the Internet (average 5.4 hours per week). . They use the Internet to search literature databases (81%), search for information about drugs (66%),and take CME courses (45%). Institutions, including hospitals,medical schools,government, and military . More than 6,000 U.S. hospitals, of which only 5% use online clini calmanagement systems. Implementing decisionsupport systems is the major goal of most hospital systems. Products . Clinical Knowledge B ase — 7,000 evidencebased, peerreviewed articles covering 62 specialties, with each chapter undergoing five lev els of peer review, including four physicians and one Pharm.D.;10,000 academic physicians recruited; 85% of editors are program directors, department chairs, research directors and/or journal editors. . PointofCar e Tools — streaming more than 30,000 multime dia/images,100 clinical calculators,DDX search allowing users to type in symptoms and get differential diagnoses, PDA and wireless appli cations for high portability. . Patient Education Mat erial — 500plus diseasespecific chapters and current articles,which are physician authored andpeer reviewed. . Continuing E ducation — 40,000 hours of CE for physicians, nurs es, pharmacists, and optometrists; more than 6,500 category 1 CME courses. . Distribut ed Publishing and K nowledgeTools — guideline,pro tocol,and formulary agents. eMedicine:A resource for healthcare professionals