Monitoring the Health of Paid Content for Physicians

Salon.com, The Wall Street Journal Online, Variety.com, and ConsumerReports.org may be interesting case studies about charging for online content, but none are ideal.

The ideal case study concerns content that’s truly vital to readers, whether wired or wireless, on PCs or PDAs, in HTML or PDF formats, anywhere in the world.

Ask Kent R. Anderson, executive director, international business and product development, for The New England Journal of Medicine (NEJM).

In print for nearly two centuries and online since 1996, NEJM is published by the nonprofit Massachusetts Medical Society. It’s one of the world’s preeminent peer-reviewed professional journals and the oldest continually published, most widely read, and most widely cited medical journal in the world.

NEJM’s editors, headed by Editor-in-Chief Dr. Jeffrey M. Drazen, a professor at Harvard Medical School, consider the publication’s print and online editions to be complementary. The online version offers content and services print can’t support but that are important for time-starved medical practitioners who want to stay atop best medical practices.

Online, NEJM uses a hybrid of free and paid-access content. The table of contents is always free. Each month, the full text of a few featured articles are free, as are abstracts, extracts, and summaries of all others. But to view the full text or PDFs of all articles, users must subscribe.

An online user can purchase either an online-only subscription or a combined online/print subscription. Subscription rates vary according to the user’s professional level in the medical industry and country of residence. That sliding scale is traditional for the print edition and was carried over to the online version.

“We’ve traditionally offered different [print subscription] pricing for trainees. They’re students, and we want to make NEJM affordable,” Anderson said. “Earlier this year, we introduced pricing tiers online for physicians in training — residents and medical students — and subscription rates have picked up in these areas in response. Cannibalization hasn’t occurred. It seems that people self-segment, and another option is exactly that, a choice for price-conscious readers who had no other choice before.

“Initially, we thought online-only would be most attractive to subscribers overseas. But we soon discovered that U.S. physicians found the online-only subscription option on their own, without any promotion,” said Anderson. “So we accepted their choice and began promoting it domestically, overcoming the cannibalization fear.”

An online-only U.S. subscription costs a physician $99, a resident practitioner $59, and a medical student $49 per year. NEJM also offers free online access to medical practitioners in 120 economically disadvantaged countries (as defined by the World Health Organization). Rates for a combination print/online subscription likewise vary, but according to postal costs for mailing editions to a subscriber’s country of residence.

“We have a loyal and growing online audience,” said Anderson. “Because we’re published every week, we measure unique users on a weekly basis. During the academic year, we average about 250,000 unique users every week.” The print edition has about 250,000 readers as well, for a combined weekly readership of approximately 500,000 worldwide.

NEJM has converted about 3 percent of its online traffic into paying online subscribers.

“We have a ‘pull-through’ approach to engaging online users. We wanted to give them a reasonable set of services just for registering with us,” Anderson said. “About four years ago, the best we could do was offer some content free of charge and offer our email table of contents alert. This was about the time the open access movement was suggesting a six-month period for research articles. Since we’re weekly, we didn’t see any problem with this, as this represents 26 issues for us.

“Now, we’re developing a portfolio of services that has enough breadth for us to consider more options for registrants,” Anderson continued. “But in those early days of creating a registration tier, access to research articles after six months seemed like a reasonable thing to offer.”

Besides access to the full text of all articles, NEJM offers subscribers access to its archives back to 1993 (with abstracts available through 1975), the ability to setup a personalized archive of NEJM content and customized email alert services, plus up to 20 free Continuing Medical Education (CME) exams per year through the NEJM site.

The weekly CME program launched in April 2002. Said Anderson, “We provide real-time response, links to the areas of the article in which the preferred responses are discussed and an evaluation process, as well as online transcripts.” NEJM has processed over 200,000 exams since the program launched, but only about 5 percent of subscribers use the service.

“We’ve found that it deepens their reading of articles, and some 40 percent of people completing the exam evaluations say that the educational process our CME represents has changed their clinical practice,” said Anderson.

NEJM recognizes the PDA is taking the place of the “fat little notebook” in the coat pockets of many physicians. A subscriber can use a wired or wireless PDA, or other handheld devices, to access full texts of the current NEJM plus the archive of all articles back to 1996, arranged in 51 topics. A subscriber can also use a PDA to request a PDF of an article (including medical imagery) be emailed to his PC.

“Our PDA services are a little different than the usual,” Anderson explained. “No syncing tables of contents or the like. We have a version of each article created from our XML that creates a device-agnostic version for download. Users can use any number of readers to read the resulting text. We’ve had about 95,000 articles downloaded since this debuted about two years ago. Users like our review articles and tend to refer to them multiple times after downloading them.”

NEJM allows nonsubscribers to purchase individual articles. An article’s full text in a PDF costs $10. Articles with CMEs can be purchased with the exams online for $15. NEJM delivers about 25,000 articles to nonsubscribers each year.

Anderson wouldn’t disclose any overall revenue or profit figures for NEJM’s online edition. I’ve heard reliably that the site, with a small staff splitting its time between print and online, has seven-figure revenues.

“I’m very enthused about the future of electronic media in communicating medical research results and educating physicians and trainees,” Anderson said. “The rate at which de facto standards like PowerPoint, digital video, and MP3 are propagating themselves hints at new forms of editorial expression emerging and being easily adopted. It’s the best way to communicate rapidly with a large and growing audience.

“The habits of trainees show that they will expect completely linked information access for their entire professional lives. It sometimes makes my head spin, but then I get back to taking it step by step. That’s the only way to untangle this future we’re headed toward, I guess.”

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