& Methods


& Conclusion



Orthogate - The Rationale For An Internet Gateway Site In Orthopaedics

Contact Person: Myles Clough (cloughs@wkpowerlink.com )


Fig 1 shows the readership of www.orthogate.com main page from April to October 1998

readers.jpg (59645 bytes)
Note steady growth of readership with a doubling around the end of June 1998. This may be related to publicity efforts at the Canadian Orthopaedic Association meeting. However, the absolute numbers, (peak 1510/week) is still not very high. The figures do not take into account pageviews on the www.orthogate.org site or visits to Orthogate pages other than the front page. However, as reviewed below, it is not very likely that readers are coming to other components of the Orthogate site directly as there are few links into the interior of the project and few enough to the front page.

Links to Orthogate and Orthogate Sites from the rest of the Internet are noted in table 2. The following sites were searched for in AltaVista using "link:www.orthogate.*" (for example) as the search string. A sample of the webpages linking to the orthogate site was examined and classified as "Internal" if it was also an Orthogate site or one of the founding sites.

Table 2 Number of Links to Orthogate Sites (Oct.10th 1998)


# links

URL searched *


Orthogate 214 www.orthogate.* 23/40
OWL (at Kamloops) 128
www.virtualkamloops.com/cloughs/orthlink.html &
www.netshop.net/~cloughs/orthlink.html (old URL)
OWL (at Orthogate) 8 www.orthogate.com/owl 8/8
Bone Home 196 www.bonehome.com 12/30
Belgian Orthoweb 454 www.belgianorthoweb.be 10/40
Wheeless Textbook 755 medmedia.com 1/20
World Ortho 3059 www.worldortho.com 45/50
IndiaOrth 53 www.indiaorth.* 16/20
Hand World 197 eatonhand.com 13/40
OrthoSearch 54 www.orthosearch.com  14/20
OrthoGuide 31 www.orthoguide.com 8/20
ISOST 56 www.isost.org 19/20
Residency Ring 13 www.orthogate.org/orthores 5/13

* Indicates a "wildcard" in the search string. Thus www.orthogate.* will collect links to www.orthogate.org and www.orthogate.com The search also picks up links which are longer than the specified string; thus www.orthogate.org/manifest.htm will be picked up by searching for www.orthogate.*

Note  the well established foundation sites, BoneHome, Wheeless, Belgian Orthoweb, Hand World (formerly Eaton Hand Surgery), World Ortho and the original OWL site are linked to by a large number (>100) of pages outside the Orthogate Project itself. By contrast the newer sites in the Orthogate project have fewer links overall and a high proportion of these are from other Orthogate sites. This is particularly true of OWL at Orthogate and ISOST.

Contrast this with other orthopaedic "library" and links collection sites selected from the Hardin Meta Directory list of Orthopaedic 27 sites with large links collections. Very few of these links are internal to the site; all have links from the Orthogate group of pages.

Table 3 Links to non-Orthogate Orthopaedic Index sites (Oct.10th 1998)


URL searched

# links

Hardin MetaDirectory Orthopaedics www.lib.uiowa.edu/hardin/md/ortho.html (new address)
www.arcade.uiowa.edu/hardin-www/md-ortho.html (old address)
Karolinska Institutet Musculo Skeletal Diseases www.mic.ki.se/Diseases/c5.html 152
MedMark Orthopaedics medmark.org/os/os2.html 3
MedWeb Orthopedics www.gen.emory.edu/medweb/medweb.orthopedics.html 81
Yahoo/Health/Medicine/Orthopedics www.yahoo.com/Health/Medicine/Orthopedic/ 50
Cliniweb Musculoskeletal Diseases www.ohsu.edu/cliniweb/C5/C5.html 46
Slack Inc. Orthonet www.slackinc.com/bone/orthonet.htm 120
Medical Matrix Orthopedics www.medmatrix.org/SPages/Orthopedics.asp 19

*These sites are referenced 27 - 34

None of these index pages compares in scale to the OWL/Orthogate/Orthosearch/Orthoguide database of over 3000 orthopaedic links. However several of them receive substantial attention in terms of pages linking to them from elsewhere on the Internet. All of these pages are parts of larger collections of medical and other links and will remain on the Internet in competition with Orthogate because of their intent to cover the whole of medicine.

Quality Criteria

The quality criteria which guide Orthogate are founded on the OMNI list of quality criteria 64 . These have been accepted by the project as a whole as an ideal to strive for (Table 4). The OMNI criteria are grouped under the headings of Context Evaluation,  Content Evaluation, and Access Evaluation. We have added some general categories, the appeal of a site to the international and multilevel users of Orthogate and adherence by the site to medical ethics, particularly non-interference with existing doctor-patient relationships and the maintainance of confidentiality.

Table 4 Quality Criteria

Appeal Of interest to an orthopaedic surgeon, trainee, general practicioner, allied health worker and/or patient
Ethics Adhering to medical ethics
International The site should offer relevence to orthopaedists of all nations
Context Evaluation
Scope Is the subject area relevant to Orthogate users?
Audience Is the material for the right audience at the right level?
Authority Identification, qualifications and institutional backing of the author
Citation of sources
Reputation of supporting institution or publication
Provenance Previous print publication or posting history
Archiving; version/revision history
Content Evaluation
Coverage Substantive, adequate coverage. Annotated Links. Complete in itself
Accuracy Factual or opinion? Evidence of bias? Referee or monitor
Currency Currency of the information and frequency of updating
Uniqueness Original or derived? Available in other media? Mirrored?
Access Evaluation
Accessibility Always available worldwide? Retrieval time. Down time
Access restrictions Based on time or geographical restrictions? Login/registration requirements.  Notification of cookies
Charging Amount
Special requirements Does use of the resource require specific software or hardware?
Reliability Of software once installed
Copyright Is the information public domain?
Language English version? Availability of other language versions?
Design Is the resource layout and structure functional, consistent and appropriate?
Can the site be searched?
User support Documentation, FAQ and contact information available?

The criteria for inclusion in the OWL list of links has always been much looser, viz. the editors' opinion that the resource would be of interest to orthopaedic surgeons and/or, patients. The above criteria are seen as a possible structure for evaluating the quality of the material referred to. It is not currently practical to apply these criteria to all 3000 sites listed in OWL. We see three levels of adherence to these ambitious standards. Material posted on Orthogate "in house" should comply with these criteria; resources which can be fully evaluated, should be posted and notified as compliant with our standards or not as the case might be. Other sites which have not been evaluated against these standards should have no comment attached. As the sites listed with Orthogate undergo review it is hoped to increase the proportion which have been evaluated. Meanwhile the criteria themselves and the practicality of applying them will be under review.
Stilberg et al 61 suggest 4 areas of concern (authorship, attribution, disclosure and currency) and the Health on the Net Foundation 62 promotes 8 principles as described in the HON Code. These quality standards for the Internet are compared to the OMNI  63 60 criteria 64 expanded for Orthogate in Table 5. These cover Stilberg's criteria and the HON Code principles. As might be expected in a site with a predominent concern over the value and accuracy of content, run by people whose opinion about content has some validity, there is extra emphasis on international, multilevel appeal, applicability, content and accessibility.

Table 5 Comparison between Quality Criteria of Internet sites

Stilbergs criteria61 HON Code62 OMNI Criteria64 expanded for Orthogate
Authorship Principle 1 Professional origin
Principle 6 Contactibility
User Support
Attribution Principle 4 Supported by reference to source material. Authority
Disclosure Principle 7 Disclosure of commercial support
Principle 8 Advertising Policy stated
Currency Principle 4 Update information posted Currency / frequency and regularity of updating
  Principle 2 Supports doctor/patient relationship Ethics
  Principle 3 Confidentiality Ethics
  Principle 5 Balanced, evidence based claims Coverage
Accessibility and usability
Access restrictions
Charging policy
Special requirements
Software reliability
Design and layout / user interface
User support / documentation

Relationship between ISOST and Orthogate

Construction and maintenance of a gateway site is exhausting, time consuming and expensive. With an annual budget projected in the hundreds of thousands (US$) for staff, equipment and administration, it is clear that the project cannot be financed solely from the founders. Nor, with the number of other interested orthopaedic surgeons amounting to about 100 can this group carry the costs for long. Unless this effort is rapidly recognised by the granting agencies as worthy of academic support and funding, the only viable source of funds is commercial. We envisage sponsorship and advertising on the site and some user-pay services in addition to the free gateway services. These could include provision of full text journal articles, consulting for web site construction, help with searches for orthopaedic material and the hosting of CME material. The need for large amounts of money makes it likely that venture capital would be the most likely start-up source and that in its turn means that the site must be run for profit. This aspect is in apparant conflict with the group's desire that the site be run for the benefit of the subject of orthopaedics. We felt that some conflict was inevitable but that our aims could be sustained if the Internet Society of Orthopaedic Surgery and Trauma operated as a non-profit learned society analagous to the other subspecialty societies in our speciality. ISOST would then have direction and policy control over the site but licence the running of it to a for-profit management corporation (Orthogate Inc.) The creation and delineation of these institutions has taken up a lot of time and attention but we believe that the foundation of the project (ownership of the intellectual property) must be secure before we advance very far. ISOST will have many other activities apart from directing Orthogate; papers for the inaugural scientific meeting in Febuary 1999 have already been called for.

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