Information freeway

By Andrea Niermeier, Contributing Writer, June 1, 2024

These days, discovery in medicine is a freeway of innovation, an autobahn in the science world where the pace is only limited by the speed of minds — and perhaps artificial intelligence — analyzing, inventing, and developing. The way this research has been disseminated and archived has also evolved over the years although not with the same swiftness. Barbara Mathes, MD, FAAD, chair of the International Journal for Women’s Dermatology governance committee expressed, “The world of publishing has changed dramatically in the last 10 to 15 years. At one time we were used to getting a subscription journal — whether we wrote a check or paid dues to a society — and received a paper journal in the mail.” These print models, funded by subscriptions and advertisement revenues, placed the financial burden on the readers or institutions who paid to access the information. With the science and technology explosion, governments, funders, researchers, and institutions around the world began to evaluate the science field’s obligation to make research more accessible, affordable, and equitable to the global public to advance medical knowledge and improve health care outcomes. This marriage of technology and social responsibility has transformed clinical publication over the last few decades.

Road to journal digitation

The rise in internet access in the 1990s allowed publishers to move content online, and in 1995 Dermatology Online Journal pioneered an open access journal dedicated to the reference and educational needs of the international dermatology community. Dr. Mathes commented, “At the same time that publishers were considering online publications, libraries were reconsidering how they purchased academic journals for their users. Prices of those journals had risen sharply because of diminished advertising.” The significant increase in subscription costs triggered a drop in circulation, leaving publishers to develop a solution that was financially sustainable for all stakeholders.

For some publications like the American Academy of Dermatology’s (AAD) Journal of the American Academy of Dermatology (JAAD), the solution was a hybrid publication model, with all articles online and some in print in their flagship journal. Dirk Elston, MD, FAAD, FCAP, editor of JAAD, highlighted, “Although there is some evidence that younger readers prefer electronic format, dermatologists still like print journals. It relates to how physicians do their work. Dermatologists are busy all day long and tend to sit down with a print journal on a weekend or whenever they have time to read.” However, Dr. Elston acknowledges the value of the electronic format. “We are in between two models right now. We publish an article in print but have barcodes in the article to access associated media with a smartphone.” Clifford Perlis, MD, FAAD, JAAD Publications Committee chair, also realizes the opportunities available with technology. “More than photos and graphs, now there are options for interactive features, including active utilization of algorithms and manipulating models. When you get away from page limitations, there is also more room to share raw data. Technology is changing the content of articles.”

“Journals traditionally have three functions — vetting, disseminating, and archiving knowledge.”

Although some publications like JAAD still provide print journals to their readers or subscribers, the economics of many journals require them to be fully online to be viable. “Certainly, new journals are hard pressed to publish in the old model,” Dr. Mathes pointed out. Newer Academy publications have followed this trend, with both JAAD Case Reports and JAAD International launching as online-only journals in 2014 and 2020, respectively. More recently, JAAD Reviews launched as an online journal in March 2024. Online journals have allowed publishers the opportunity to disseminate quality research without the worry of page counts, ink and paper costs, and postage. Lara Graf, MS, AAD director of medical journals publishing, explained, “We found we were turning away good research just from the perspective of not having enough bandwidth for it, or sometimes from the international perspective that it was a bit outside the scope of our flagship journal since a majority of our readership is in North America.” The online JAAD journals have provided more opportunity for quality research to impact clinical dermatology globally.

Not only has the pace of discovery called for more journals, but it has also commanded a greater dissemination speed, something online journals can provide. Dr. Elston delineated, “Journals traditionally have three functions — vetting, disseminating, and archiving knowledge.”

“Increasingly, the fourth mission is interpretation of knowledge, so it can be applied to clinical practice. Usually within a few weeks of acceptance, an article in an online journal can be published, allowing important information to be made available quickly.”

Opened pathways to information

As technology has allowed more journals to move online, multiple entities have pushed for public access to medical research to support innovation in health care. Globally, in 2002 the Budapest Open Access Initiative (BOAI) helped define the term “open access” and outlined the principles of free accessibility and usability. In Europe in 2018, cOAlition S, an international consortium of research funding and performing organizations, supported initiative Plan S, requiring that scientific publication resulting from publicly funded research grants be published in compliant, open access journals or platforms in 2021.

The United States also saw a movement for public access to research. In 2008, the National Institutes of Health (NIH) mandated that all researchers funded by the NIH submit an electronic version of their final peer-reviewed manuscripts, upon acceptance for publication, to the National Library of Medicine’s PubMed Central no later than 12 months after the official date of publication. In addition, NIH began requiring a Data Management and Sharing (DMS) Plan with grant applications submitted after Jan. 25, 2023, for research resulting in the generation of scientific data.

The 2013 Memorandum on Increasing Access to the Results of Federally Funded Research issued by the White House Office of Science and Technology Policy (OSTP) directed federal agencies and agencies with more than $100 million in annual research and development expenditures to develop a plan to support increased public access to the results of federally funded research. Then in 2022, taking into account learnings from the COVID-19 pandemic, OSTP went a step further, requiring that by the end of 2025 all federal agencies make all publications and their supporting data public and immediately accessible without an embargo on their free and public release. Additionally, it called for established transparent procedures to ensure scientific and research integrity and coordination with OSTP to ensure equitable delivery of federally funded research results and data.

“The open access model has allowed for more niche publications that could not have been successful in a subscription market because they are too small.”

While many agree that research outputs should be more freely accessible, getting consensus on how best to do that is difficult. Some subscription-based journals use a green open access model for federally funded research. In this model, a version of the subscription article is made freely available after an embargo period, normally 12 months, to make publishing the research financially viable for the publisher. The AAD, among other societies, has expressed concern over the new requirements set to take effect in 2025, predicting a negative impact on the subscription income of journals like JAAD and the AAD’s ability to fund the publication of the scholarly research that benefits the dermatology community.

Unlike the JAAD flagship journal — JAAD International, JAAD Case Reports, and JAAD Reviews all follow the gold open access model. In this model, the final version of the article is immediately available to read and download to everyone online. Graf commented, “This model is the top standard for open access today, and we have worked closely with our publisher Elsevier to balance the needs of our members and organization to fund these publications.” The gain in popularity of the open access model can be seen by the rise in the number of open access journals over the last 20 years, increasing from 22 journals in 2002 to almost 17,000 in 2021 (doi.org/10.1007/s11606-023-08307-z). It is estimated that more than 2,000 new open access journals are now launched every year. Open access journals allow access to more data without having to pay for subscriptions, increasing the dissemination and potentially the impact of an article. Likewise, Dr. Mathes suggested, “The open access model has allowed for more niche publications that could not have been successful in a subscription market because they are too small. The beauty of open access is that it allows physicians in other specialties to see the scientific research happening in dermatology, something they may not seek out without a subscription, encouraging collaboration and exploration with other specialties and disciplines.”

While open access journals are untethered from print and mailing costs, Graf warned that these are just a few of the expenditures in publishing, which also include hosting websites, managing rights, and processing manuscripts, as well as labor costs. “On the altruistic side, few disagree that research should be published in a very open, transparent manner and available to anyone who wants it. When we get down to the brass tacks, money is needed to support the costs of publishing, and finding the balance is complicated.”

Authors paying the toll

One way that publishing companies have financially supported open access is by moving from “pay-to-see” to “pay-to-be,” allowing readers to access articles completely free of charge but imposing a fee on authors to publish their research in an open access journal. These article processing charges (APCs) range from $200 to more than $10,000 depending on the journal and publisher (https://guides.library.uab.edu/openaccess). “This has created what some would call an equity paradox. While making journals and published research more widely available is great, the flipside is that it could potentially limit who can publish because of the cost to authors, particularly those from lower resource countries or smaller institutions,” Dr. Perlis suggested. Also, this APC could potentially be unexpected if an author chooses to submit to a subscription journal, but the article is deemed more appropriate for a sister open access journal.

While some researchers have expressed concerns about APCs, Graf asserted that publishers and societies have been committed to finding solutions. “We are working with our publisher to engage more with our authors, members, and constituents about open access. While we have moved into the open access space, we have not been as loud about providing education on the reasons and purposes for the fees.” Both the AAD and Elsevier have taken steps to alleviate some of the costs for authors. For example, AAD members get a 25% discount on APCs, and editors can grant a limited number of waivers for invited papers. Also, authors from Research4Life-eligible locations are encouraged to apply for a publication fee waiver. Elsevier fully waives all fees for authors from 69 countries and gives a 50% discount to authors from another 56 countries. Moreover, Elsevier has read and publish, or “transformative,” agreements with several institutions to support affiliated authors who wish to publish open access.

Generally, authors have more options than paying out of their pockets. Dr. Mathes noted that sometimes the cost of publishing can be built into an industry or government grant, such as an NIH grant. “If this research is important and disseminating the research is important, the sponsor has to realize that a cost is involved in that.” She also stated that in journals that attract international authors, collaboration is encouraged so authors can share the publication fee.

While sliding scales and supporting agencies have made publishing opportunities more equitable, Dr. Perlis cautioned that these plans are only the start of a solution to successfully fund open access journals, one that may also have to closely consider the peer-review process. “Conducting a thorough peer review takes a lot of thought, effort, and time — time that a reviewer could be spending on their own research or with their family.” With both an increase in research to be vetted and the pressure for it to be vetted more quickly, Dr. Perlis foresees the need to address this changing landscape. While some parts of the scientific community have begun to use pre-print platforms to expedite information to the public, especially during the COVID-19 pandemic, these repositories with unvetted data are not a substitute for peer-reviewed articles in academic journals.

Careful navigation of the publishing world

With more venues than ever to disseminate research, Dr. Elston calls for authors to be scrupulous. “Authors have a choice,” he emphasized, “and that begins with whether to publish in a subscription or open access journal.” Furthermore, he advises authors not only to consider the audience they are trying to reach but also how the goals or missions of potential journals align with their own. While credible open access journals publish important clinical research, predatory journals also exist. Dr. Elston stressed the importance of identifying the red flags of predatory journals, which may include high-pressure solicitation for submission, unclear or egregious fees, poor peer-review process, outdated or unprofessional website appearance, invented metrics, or false index claims.

Taking the time to investigate whether a journal is indexed in Clarivate or listed on the Directory of Open Access Journals (DOAJ) is good practice. Dr. Perlis explained, “What you will see with time is that open access journals will be stratified the same way subscription journals are. Some journals will be treated with more respect and legitimacy based on impact factor.” While JIF continues to be an important measure of the number of citations each year as well as the overall quality of the journal and its impact on clinical practice, Drs. Elston and Perlis also highlighted additional ways technology is now being used to determine a journal’s impact, including how many articles are opened and read, reached by search engines, and cited in social media. This impact on the field of dermatology, Graf affirmed, is what drives the AAD. “Expanding JAAD into niche journals is about being able to publish more research and giving more researchers — whether they are young in their career, mid-career, or late in their career — the opportunity to get their work published. JAAD’s mission is helping dermatologists improve patient outcomes and this is a key reason why the AAD has embraced the open access model.”

For the future of clinical publishing, most see an avenue paved by the open access model. As artificial intelligence (AI) continues to evolve, Dr. Perlis acknowledged the compatibility of AI and open access, with research published without a paywall. “No single physician or researcher has time to read every article on atopic dermatitis this year. However, AI can potentially synthesize this information for the clinician.” This is in addition to the potential for generated research or reviews. For now, that kind of assistance is still down the road. “AI is not currently good at distinguishing quality data from poor-quality data, or even from totally made-up references. It does not track down information to a primary source or verify and validate references and methods,” Dr. Elston articulated. These skills of discernment, in a time when physicians and researchers are racing to keep pace with the traffic of exploration, may be more important than ever, Dr. Perlis feels. “Years ago, when it was expensive to publish and circulate material, every last word was scrutinized. Now we don’t have those limitations.” On the fast track of scientific breakthroughs, giving pause may be a novel idea.

Additional DermWorld Resources