Gestion:Advocating for Open Access (English)

This document was prepared by:

• Dr Michaël St-Gelais, MD (family medicine physician who works in rural emergency medicine in Québec, president of Wikimedica)
• Dr Antoine Mercier-Linteau, MD, B. Eng., RMC, CFPC (family medicine physician who works in rural emergency medicine in Québec, vice-president of Wikimedica)
• Dr James Heilman, MD, CFPC (em) (emergency medicine physician in British Columbia, board chair and founder of Wiki Project Medicine, co-founder of Wikimedia Canada).

This work was originally written to be presented to TREKK, but generalized for other organizations on this page.

Executive summary

If you are reading this, we think that your organization would benefit from opening its content using an open access license from Creative Commons (CC), a standard in open licensing. In sharing its work under a CC-BY-SA license, your organization would allow for better diffusion, reuse and improvement of its publications within the medical world, the industry and the public. In turn, your organization would be able to profit from other open content and improvements made to its works as well.

In choosing a CC license, you should stay away from non-commercial (NC) and non-derivative (ND) license modifiers because they will exclude most of the healthcare ecosystem (private sector, NGOs and educational) and severely restrict the diffusion potential of its content. Your organization should also not try to come up with its own in-house license, but should pick a widely used and proven CC license.

Why open licenses ?

Because their use will help your organization get its material out to as many people as possible and allow for increased collaboration and sharing both within the organization, with outside partners and the public.

Which license do we suggest ?

The specific license we propose is Creative Commons By Attribution Share-Alike (CC-BY-SA) 4.0:

• CC: Creative Commons
• BY: the work must be credited to your organization
• SA: any derivative must be shared under the same license.

Any changes to the material are not endorsed by your organization. The license does not apply to any trademarks owned by your organization.

The authors of your organization also remain the sole copyright owner of all material published under an open license. Using an open license does not mean forfeiting all rights as an author. It is merely a mechanism for sharing content.

Creative Commons licenses are a group of licenses created by a US not for profit in 2002 to facilitate the spread of educational material. The open access movement initially began within journal publishing and has subsequently spread to many other forms of publishing from textbooks to websites.

Creative Commons licenses are used worldwide and is the most popular category of open licenses. They are easy to understand, are straightforward to use and are translated in many languages.

How to choose a Creative Commons license ?

Before choosing which Creative Commons license is best for your content, it is paramount to understand how they are built and what each modifier entails. In order of openness (from more to less), the following lists all CC licenses :

• CC0
• CC-BY
• CC-BY-SA
• CC-BY-ND
• CC-BY-NC
• CC-BY-NC-SA
• CC-BY-NC-ND.

Let's review what each modifier means:

• CC0. When affixed to a work, it is in the public domain. In doing so, third parties may modify-translate-remix-adapt-copy-paste-sell parts or the entire work without mentioning the original author.
• BY (“By attribution”). You must credit the work, include a link to the license, and indicate if any modifications have been made to the work. You should provide this information by any reasonable means, but do not suggest that the producer of the original content endorses you or the way you have used their work.
• SA (“Share alike”). In the event that you remix, transform, or create from the material comprising the original work, you must distribute the modified work under the same conditions, i.e. with the same license with which the original work has been published.
• ND “No derivatives”. In the event that you remix, transform, or create from the material composing the original work, you are not authorized to distribute or make available the modified Work.
  • We strongly advise against using this modifier. More on this further down.
• NC "Non-commercial". You are not authorized to make commercial use of this work, part or all of its component material.
  • We strongly advise against using this modifier. More on this further down.

CC licenses fall under an open spectrum. The CC0 license is the most open, while the CC-BY-NC-ND is the most closed and comes very near to the traditional "all rights reserved".

CC0, CC-BY and CC-BY-SA licenses are considered the open licenses which allow for maximum reuse of content.

CC License Compatibility

First, let’s define what compatibility of licenses means : it is the ease with which two or more works can be reused, modified, remixed or adapted with one another.

Licenses are not necessarily compatible with one another. The more we travel down on the openness spectrum (see the image above), the less compatibility there is.

CC0, CC-BY and CC-BY-SA licenses are most compatible with other licenses. Other licenses are less compatible.

A standard "all rights reserved" license is not compatible with CC licenses or any other licence for that matter. "All rights reserved" works cannot be reused in parts (except for the right to quote) or in whole. CC-BY-NC-ND is for all intents and purposes the same as an all rights reserved license.

While a work can be made of incompatible licenses (except all rights reserved and ND), building content in such a way is not advised as it greatly complicates sharing and transforming. Such a practice for example is forbidden by Wikipedia.

The table below shows the compatibility of the licenses between them. The vertical axis is the license of the work being produced and the horizontal axis is the license of the content we want integrated in the work.

As shown in the table above, CC0, CC-BY and CC-BY-SA are the most compatible.

Use of the Non-commercial Mention (NC)

We strongly recommend against adding the NC mention as what constitutes a commercial use is extremely ambiguous and confounding. The following examples illustrate this.

• A university professor wants to use an image or content from an NC source. University courses are not free. Does this constitute a commercial use?
• Wikimedica (CC-BY-SA) wishes to organize a continuing education activity by remixing NC material. Does this constitute a commercial use?
• A medical non-profit wants to sell a book to students to prepare for their exams. Proceeds from the sale will be used by the non-profit to fund software development. Can it use NC material ?
• A presenter at a conference wishes to use content from a NC source. Is this a permitted use? Continuing education credits are sold and the presenter is paid.
• Doctors are very frequently incorporated. Would an incorporated doctor have the right to prepare a document for his patients inspired by an NC source or to simply give an NC resource to his patients? Are the doctor's professional activities considered a commercial activity since he is remunerated to do so? The delivery of such a document would however be favorable to productivity, patient safety and satisfaction.
• A community pharmacist wishes to give a document to his patient related to advice for sinusitis with the NC mention. Is this use allowed? A family physician working in a private clinic sees a patient with mild TBI. Can he give a handout sheet with the NC mention? A for-profit hospital in the US wants to reuse NC content, can they ?
• In Canada, educational institutions are generally public. However, it is different elsewhere in the world, where many educational institutions are private. Could a university in Haiti, Congo, Morocco, Switzerland, Belgium or France reuse NC content? It is not certain. It also depends on the laws in each state. With a choice of CC-BY or CC-BY-SA licensing, they can adapt and reuse this content. In a context of North-South equity, the NC mention is an obstacle for the transfer of knowledge to countries less developed than ours.
• An EMR provider wants to use a clickable text protocol within its computer system to offer it to its customers (who are also physicians). It could be TREKK’s Anaphylaxis protocol. If this content was under an open license, but with an NC mention, the EMR provider could probably not reuse this protocol: even if access to the form is not necessarily paying, the fact of making it available provides a commercial advantage to their product, so it could potentially be considered a commercial use. If the protocol is in CC-BY or CC-BY-SA, the EMR provider can make the protocol available to its users, as long as its cites his sources and puts it in CC-BY and CC-BY-SA inside the EMR.
• An EMR supplier who would like to integrate into their interface recommendations from a practice guide which is not licensed CC0, CC-BY or CC-BY- SA would not have the right to do so. The EMR supplier would have to start the practice guide from scratch, which constitutes a loss of productivity, especially since the EMR suppliers are not specialists in the field: they have to rehire professionals to redo a homemade guideline when the work has already been done by a third party. Use of a CC0, CC-BY, or CC-BY-SA license promotes content reuse by EMRs. EMR providers are important players in the medical landscape.

Here is what Creative Commons mentions in relation to the NC modifier.

“CC’s NonCommercial (NC) licenses prohibit uses that are “primarily intended for or directed toward commercial advantage or monetary compensation.” This is intended to capture the intention of the NC-using community without placing detailed restrictions that are either too broad or too narrow. Please note that CC's definition does not turn on the type of user: if you are a nonprofit or charitable organization, your use of an NC-licensed work could still run afoul of the NC restriction, and if you are a for-profit entity, your use of an NC-licensed work does not necessarily mean you have violated the term. Whether a use is commercial will depend on the specifics of the situation and the intentions of the user.”

Reading the above, one realizes how vague and ambiguous the NC modifier is. A non-profit organization cannot simply reuse NC works. Use with a public university doesn't necessarily mean non-commercial. Conversely, a private sector company can possibly reuse NC works. What Creative Commons suggests is that if in doubt about what is considered commercial use, it is best to contact the copyright holder or simply avoid using its sources.This is an administrative burden which hinders collaboration.

More often, what producers usually want when affixing the NC modifier to their content is not to prevent anyone from profiting off of it, but rather prevent profiting from it without contributing back. This is the intent of the Share alike (SA) modifier. To illustrate this principle, let’s take a football helmet manufacturer that wants to pack patient handouts about concussion with their products. They could reuse one from your organization, adapt it for adults and share it back (as mandated by the SA) for others to reuse. Your organization could also benefit from their efforts into improving the handouts for their kids line of helmets.

Companies are legal entities that contribute to society by driving progress and paying taxes. They are pharmaceuticals, private clinics, EMR providers, medical device providers, private airborne services, continuing education organizations, and many more in this category. They are key players in the healthcare ecosystem and deserve to be included in the push towards opening and sharing content. The software industry, where closed source was the norm decades ago, led the way in transitioning to open licenses and did so at the turn of the millennium. This move vastly increased the pace of technological advances and without it, the very device you have in your pocket or on which you are reading this text would never have seen the light of day. The internet actually came into existence when organizations decided to openly share standards and knowledge.

We are all in the business of providing better healthcare to our fellow humans and the private sector is a definite stakeholder in this mission. The development of new molecules and new devices for the benefit of our patients come from the private sector. By cutting them off, we deprive ourselves of an invaluable contributor to the open movement. For example, the Massachusetts Institute of Technology (MIT) is a private American university which has published a phenomenal amount of open license course material since 2001, showing private interests can give tremendously to the open movement.

Open content is not an obstacle to profit making, but rather serves as a catalyst for innovation. Let's say a company wants to reuse semantic data produced by Wikimedica (shared under CC-BY-SA) to build an artificial intelligence for healthcare professionals. The company that would create this artificial intelligence could keep its algorithm private and all rights reserved, but the semantic data behind the algorithms would still be CC-BY-SA. Any improvements made to the semantic data would be shared under that same license. Other businesses could then reuse that improved content to build competing AI health solutions.

Building the next healthcare revolution (AI) on closed standards will only spell uncontrollable cost hikes, vendor lock-ins, conflicts of interest, privacy violations and ethical issues. An open ecosystem will make great strides toward ensuring a healthy balance between profit and public service. For that to happen, the private sector needs to get onboard the open movement.

In short, the NC modifier :

• makes reusing and sharing very complicated
• will potentially exclude most organizations from benefiting from the open license.

No derivatives (ND)

We strongly advise against the use of this mention in your choice of license. If you add this notice to your license, all that can be done with your content is to distribute it. For example, one could print a document your organization produced for distribution, but I cannot remix-copy-paste-translate-adapt-modify it.

Licenses marked ND are not compatible with any other CC license. They are almost like a standard “all rights reserved” license.

In-house licenses

Some "in-house" licenses wishing to imitate CC licenses (such as Canada’s open government licence) may be compatible with Creative Commons licenses, but they are rare. They must be exceedingly well written to risk reusing them. One forgotten word and that makes all the difference. In the presence of an ambiguity in the words chosen, we must consider the work as “all rights reserved”. We do not recommend this approach. Ensuring compatibility between a custom license and a CC license involves literacy in copyright law and sometimes intellectual property lawyers. Something most organizations don’t have easy access to.

If you choose to do so, we would strongly suggest you to check the license of the “Base de données publique des médicaments” of the French government. It is a CC-BY equivalent. What is particularly appreciated is that they mention that their license is compatible with a standard CC-BY license directly in the license. If your organization prefers an in-house license for their content, it would be important to add a mention of that sort.

Who has transitioned to open licenses ?

There is a worldwide transition to open licenses, here are a few examples of entities that have made the jump.

• The Open Education Consortium brings together hundreds of universities and educational institutions that publish under open license course material. Among the most prestigious members are the Johns Hopkins Bloomberg School of Public Health, the Université Numérique (France), the Massachusetts Institute of Technology (MIT), the Organisation internationale de la francophonie, the University of Michigan, the African Virtual University and hundreds of others.
• NASA has several open access initiatives. All images produced by NASA are in the public domain. NASA has several open portals: https://data.nasa.gov/, https://api.nasa.gov/ , https://code.nasa.gov/ , https://www.nasa.gov/open .
• Anything produced by US government employees in the course of their work is in the public domain. (CC0 equivalent).
• Quebec’s government has an action plan for open government.
• The government of Canada also has its open government portal. They use an in-house license equivalent to CC-BY. Thousands of pages and datasets are available for individuals and businesses to innovate on.
• In the European Union, scientists and researchers benefiting from public funding for their projects from research organizations and institutions have to publish their work under an open access license.
• The French government now obligates all scientific studies financed by public funds to be published in open access.
• More than 5000 scientific journals (PLOS ONE, BioMed Central, etc.).
• Here are other actors who publish under a Creative Commons license in the medical field:
  • NIH Public domain
  • CDC Public domain
  • emDocs CC BY 4.0
  • Wikipedia CC-BY-SA
  • Wikimedica CC BY SA 4.0
  • MDWiki.org CC BY SA 3.0/4.0
  • EMsimcases CC BY SA 4.0
  • WikEM CC-BY-SA
  • UNESCO CC BY 3.0
  • International League Against Epilepsy CC BY SA 4.0
  • BC Emergency Medicine Network CC BY SA 4.0
  • Ddxof CC-BY-SA
  • WikiMSK CC-BY-SA - an initiative of the ''New Zealand College of Musculoskletal Medicine''
  • Base de données publique des médicaments CC-BY equivalent - offers thousands of drug monograph by the French government
  • StatPearls CC-BY-NC-ND
  • LITFL CC BY NC SA 4.0
  • Radiopaedia CC BY NC SA 3.0
  • Dr. Smith’s ECG Blog CC BY NC 4.0
  • Canadiem CC BY SA NC 4.0
  • Thepocusatlas CC BY NC 4.0

UNESCO is also in favor of open access. According to them, open access :

• increases the visibility, use and impact of research (can increase citations between 200-600 %)
• improves the speed, efficiency and effectiveness of research
• facilitates access to articles for scientists
• stimulates interdisciplinary research
• allows computer processing of scientific literature and facilitates the search for information via metadata
• enhances transparency in the funding of scientific research and allows a better understanding of outstanding scientific topics
• offers visibility to researchers in developing countries
• enhances the accountability of public institutions
• fills the gaps in access to knowledge between north and south
• allows the construction of knowledge databases and the reuse of previously published results

• allows members of the liberal professions, practitioners and actors in the commercial sector, as well as the interested public, to benefit from research.

Benefits for your organization

Transitioning to an open license will open up the ability to more easily and clearly collaboratively create content both with other free open access medical education (FOAM) organizations and within your organization. This works both ways: your organization will more easily reuse content from other open access resources (listed above) which in exchange will reuse your organization’s content more easily.

Having an open access license will increase your organization’s readership and the reuse of its content.

Here are some concrete examples of what the impact of publishing your organization’s content on an open license (CC-BY-SA).

• A BC hospital can adapt your handouts to their province and host these handouts on their own website without getting explicit permission beforehand.
• An NGO can translate the patient handouts into Punjabi for that language group without getting explicit permission beforehand.
• An EMR provider could integrate your order sets into their EMR.
• A hospital could reuse your order sets to create their own with minimal work, saving the expense of making their own.
• Wikimedica could adapt your content in French on its website (Wikimedica’s mission is to make high quality point-of-care articles for healthcare professionals).

Risks for your organization

One concern that has been raised regarding the use of open licenses is that one will not have recourse if someone misuses your organization material. However, generally those inclined to misuse someone's work care little about copyright and will misuse material no matter the license. Moreover, claiming any endorsement from your organization in the misuse of said material constitutes an infringement on its trademark and can be dealt with by law proceedings, same as currently.

Another concern that has been raised is around trademarks. Moving to an open license does not affect any trademarks your organizaiton may hold and the organization's ability to enforce these remains exactly how it was. A logo or wordmark may be under an open license and still fully covered by trademark.

One last concern is that of finality. In the future, should your organization decide to become all rights reserved again, it will be able to do so onward from that decision. There are however some caveats.

• Open licenses cannot be revoked, all material previously published under that license will remain as such. Since your organization has full ownership of all the content it publishes, all new versions of that content will be all rights reserved.
• Works made of remixed CC-BY-SA content will have to remain CC-BY-SA or that content will need to be removed.
• On a case-by-case basis, all remixed content of CC-BY-NC origin will have to be analysed to see if the new usage constitutes a commercial activity.

How to change your organization’s license ?

This can take many forms.

• Your organization can add to the footnote of its website the CC mention. For example, see https://www.bcemergencynetwork.ca/
• If your organization holds the complete copyright of its prior documents, your organization can republish its works by adding the CC license in the footnote.
• If your organization doesn’t hold the complete copyright of their prior documents :
  • it can publish future documents in the new CC license by adopting an internal policy
  • if all authors agree, anterior documents can be republished in the CC license.

Our final recommendations

Here is a summary of our final recommendations for your organization.

• We recommend you to choose either a CC0, CC-BY or CC-BY-SA license for maximum compatibility and impact.
  • In our opinion, it would be best to use CC-BY-SA, because others could use your material, but it would be mandatory for them to share the result in CC-BY-SA as well : this creates a cycle of sharing in open access.
• We recommend against the ND or NC mention.
• We recommend against the use of an in-house license.