110 AMWA Journal / V36 N3 / 2021 / amwa.org ABSTRACT Given their potential for engaging audiences, there has been increasing interest recently in the use of digital enhancements, such as video abstracts and infographics, for primary publica- tions in peer-reviewed medical journals. However, their uptake by authors and sponsors of medical publications has been mixed, with few top journals offering the possibility of publishing digital enhancements beyond supporting slides and lay summaries. Digital enhancements for primary manuscripts may pro- vide new opportunities for medical writers to expand their skills and services, but it is unclear whether medical writers receive and accept requests to develop digital enhancements regularly and what training they need to generate high-quality deliverables for their clients. Understanding the perspectives of medical publication professionals and their clients on digi- tal enhancements for peer-reviewed journals may help address misconceptions and concerns and identify more effective ways to create auxiliary digital content to support the dissemination of research findings. Here, a survey was conducted to gauge the overall interest in accompanying digital enhancements among medical publication professionals and their perception of their clients’ needs, determine the perceived value of these features, and identify barriers in development. The survey was created and posted on AMWA Engage, AMWA New England Chapter E-News, LinkedIn, and the MedComms Networking webpage. A total of 116 respondents completed the survey. About half had developed digital enhancements for primary publications, mostly for pharmaceutical companies, medical communication agencies, and other nonacademic organizations. Infographics and visual abstracts were the most frequently requested type of enhanced content. Although the respondents recognized the importance of digital enhancements to facilitate data visualization, approximately half reported not having specific training or experience to enable them to accept such assignments. For their clients, the main reasons given for not developing digital enhancements were cost and time con- straints, lack of interest, and author unavailability. The medical literature is essential to the communication of sci- entific evidence. In the past few decades, traditional print jour- nals have predominantly assumed electronic formats, allowing for wider access and outreach, and social media and digital tools are now important vehicles in content dissemination.1 A digital enhancement in the context of scientific publications is an online feature that is developed to aid in the visualization and interpretation of data. Infographics have been used for quite some time, particularly in patient education materials, and are effective channels for the communication of complex concepts. Infographics typically combine text with graphics, illustrations, and/or charts in a logical sequence to tell a story.2,3 Examples of infographics can be found here in https://www.fda.gov/media/82381/download and https:// www.who.int/reproductivehealth/publications/violence/VAW_ infographic.pdf?ua=1. Visual or graphical abstracts are schematic or animated representations of the content of an article, require less time and effort to create than infographics, and can be easily shared on social media.4,5 For examples of visual abstracts, see https://www.nejm.org/doi/full/10.1056/ NEJMoa2026845?query=featured_home and https://www.cell. com/cancer-cell/fulltext/S1535-6108(21)00339-1. Video formats have become very popular with the widespread availability of mobile and relatively inexpensive filming/recording devices.6 Different types of video abstracts can be viewed here: https://www.youtube.com/watch?v=vNIg0pah3wE, https:// players.brightcove.net/656326989001/default_default/index. html?videoId=5824269862001, and https://player.vimeo. com/video/301841421. In addition, “Twitter abstracts” (visual abstracts that are disseminated via Twitter) are gaining traction Patricia Fonseca, PhD, CMPP / Medical Writer/Translator, Cambridge, MA Digital Enhancements for Primary Medical Manuscripts: A Survey on Perceptions, Challenges, and Needs of Medical Publication Professionals R E S E A R C H https://www.fda.gov/media/82381/download https://www.who.int/reproductivehealth/publications/violence/VAW_ https://www.who.int/reproductivehealth/publications/violence/VAW_infographic.pdf?ua=1 https://www.nejm.org/doi/full/10.1056/NEJMoa2026845?query=featured_home https://www.cell.com/cancer-cell/fulltext/S1535-6108(21)00339-1 https://www.youtube.com/watch?v=vNIg0pah3wE https://players.brightcove.net/656326989001/default_default/index https://players.brightcove.net/656326989001/default_default/index.html?videoId=5824269862001 https://player.vimeo.com/video/301841421 https://player.vimeo.com/video/301841421 AMWA Journal / V36 N3 / 2021 / amwa.org 111 as a rapid means of disseminating research findings to a wider audience.7 Written lay summaries are digestible forms of presenting data to patients, nonspecialist health care providers, or the public. Lay summaries require no expertise in terms of graphic design and have been embraced by several publishers as important elements of research articles.8-10 Examples of different formats of lay summaries can be found in https:// www.acpjournals.org/doi/10.7326/P21-0006 and https://link. springer.com/article/10.1007/s13300-018-0531-0#Sec1. Other digital enhancements accepted by biomedical journals include audio abstracts, which are voice recordings summarizing an article, and interviews with the authors, in either video or audio format, in which the authors have a conversation with an interviewer about their research findings. For audio and video interviews, see https://jamanetwork.com/journals/ jamaophthalmology/pages/jama-ophthalmology-author- interviews and https://www.mayoclinicproceedings.org/ video-archive-2021. Given their ease of access and potential for engaging audi- ences,11-13 there has been increasing interest in recent years in the use of digital tools for data dissemination, and this inter- est was greatly amplified by the COVID-19 pandemic and the increase in virtual congresses. Regarding primary publica- tions in peer-reviewed medical journals, the uptake of digital enhancements by authors and/or pharmaceutical companies sponsoring the development of scientific publications has been mixed. Digital enhancements for primary manuscripts may pro- vide new opportunities for medical writers to expand their skills and services. Understanding the main advantages and limita- tions of digital features may help address misconceptions or concerns about the development of auxiliary digital content to enhance the communication of research findings. The main objective of this survey was to gauge the overall interest and demand for accompanying digital enhancements among medi- cal writers and other publication professionals. The second- ary objective was to determine the perceived value of digital enhancements and identify barriers to their development. METHODS A survey targeting medical writers and other professionals involved in the development of primary manuscripts for peer- reviewed journals was developed using Google Forms. The 25-question survey, which took no longer than 10 minutes to complete, was shared on AMWA Engage, the AMWA New England Chapter E-News, and the LinkedIn pages of AMWA, the AMWA New England Chapter, MedComms Networking, the Publication Plan, and the Medical Writers Corner. In addi- tion, the survey was disseminated directly in the MedComms Networking online newsletter. Permissions to advertise the survey were requested as needed. Responses were accepted from August 25, 2020, to June 1, 2021. The survey included 24 multiple-choice questions and a comment box (question 25) to collect feedback from respon- dents. Some questions allowed for more than one answer to be selected. All questions allowed respondents to add in their answers, if different from the choices provided; there were no mandatory questions. Information captured in the survey included demographic data (ie, region, role, therapeutic areas, and years of experience), the number and type of enhance- ments developed, the perceived benefits and main obstacles encountered before and during the development of digital enhancements, and metrics deemed relevant to evaluate their impact. Awareness, interest, and determining factors in the decision-making process were assessed for academic com- pared with nonacademic sponsors and/or authors. The com- plete survey is included as a supplement. RESULTS As of June 8, 2021, a total of 116 responses had been received; the majority of the respondents were based in Europe (59%) and North America (35%). The top 3 roles (n = 114) were medi- cal writers (66%), publications planners (29%), and editors/ proofreaders (25%) (more than one option could be selected). The vast majority of respondents (97%) were employed or worked as freelancers, and most worked full-time (72%); 62% had more than 10 years of work experience, and only 3% reported having less than 2 years of experience in the field. The most common therapeutic areas (n = 114) in order of preva- lence were oncology (52%), neurology (28%), respiratory dis- eases (26%), and cardiology and endocrinology (approximately 24% each) (more than one option was allowed). The majority of the respondents were employed by medi- cal communication agencies or contract research organiza- tions (37%) or worked as freelancers (35%); a small portion of respondents were affiliated with academic institutions and other medical and educational organizations (10%) (Figure 1). 18% 37% 3% 35% 7% Pharmaceutical/biotechnology and medical devices company Medical communications agency/ Contract Research Organization Academia Freelancer Other* Figure 1. Survey population per professional setting (N = 116). *Includes medical societies, journal publishers, and nonprofit research and/or educational organizations. https://www.acpjournals.org/doi/10.7326/P21-0006 https://www.acpjournals.org/doi/10.7326/P21-0006 https://link.springer.com/article/10.1007/s13300-018-0531-0#Sec1 https://jamanetwork.com/journals/jamaophthalmology/pages/jama-ophthalmology-author-interviews https://www.mayoclinicproceedings.org/video-archive-2021 https://link.springer.com/article/10.1007/s13300-018-0531-0#Sec1 https://www.mayoclinicproceedings.org/video-archive-2021 112 AMWA Journal / V36 N3 / 2021 / amwa.org More than half of the respondents (53%) had developed digital enhancements professionally (ie, created the concept, produced content, or reviewed the deliverables). Of these (n = 62), the majority provided these services for clients in the life sciences or medical communication industry (92%). Among respondents who had not developed enhancements for primary manuscripts (n = 55), only a small proportion (7%) reported not having an interest in doing so. For respondents with digital enhancements in their professional portfolios, 37% typically worked on 1-2 of these types of projects per year, with 28% indicating working on more than 5 enhancements in 1 year. A total of 49% reported receiving more requests for developing enhancements during the COVID-19 pandemic, and 49% saw no change in these requests (n = 63). The most frequently developed enhancements (n = 62) were infographics/illustrations (76%) and visual/video abstracts (74%) (more than one option was allowed) (Figure 2). The perceived benefit of digital enhancements by medical com- munication professionals (n = 115) was improved data visu- alization and comprehension (60%), followed by increased interest in primary publication (21%) and increased access (13%). For the clients, as reported by the respondents (n = 102), the value of digital enhancements was to stimulate interest in the primary publication (36%), to increase data access to a wider audience (29%), and to improve data visualization and comprehension (22%). Approximately 5% of the respondents did not see a benefit but noted that their clients inquired about these enhancements because they were a requirement provided by the target journals of the primary publications. Although respondents working for nonacademic clients (n = 66) reported that their clients mostly rejected proposals to develop digital enhancements because of cost (73%) and time (49%) constraints, concerns about enhancements being perceived as promotional (34%) were also reported. Clients in the academic or nonprofit sector (n = 26) mostly reported to the respondents about concerns related to the unavailability of authors (69%), concerns about the time needed to develop enhancements (50%), and concerns about the associated costs of development and publication (42%). The unavailability of peer review or specific metrics for enhancements were only deemed relevant for clients in the nonacademic setting (Table). Approximately 63% of the respondents (n = 114) reported proposing the development of digital enhancements to clients; of those who suggested (n = 70) enhancements depending on the type of project or whenever applicable to the manuscript, the majority (79%) suggested these features to nonacademic clients only. The main barriers for medical communication professionals (n = 109) in the development of accompanying digital features were a lack of specific training and/or expe- rience (45%), a lack of time or insufficient pay (21%), and unclear/absent instructions from the journal (20%) (Figure 3). Not surprisingly, 46% claimed they would accept this type of assignment if they had adequate training, with 26% mention- ing better guidance from journals regarding the requirements for submission of enhance- ments and 16% noting the importance of spe- cial pay rates to accept these services (n = 110). Respondents (n = 108) thought that ade- quate dissemination of the enhancement with the manuscript (eg, visible link next to the man- uscript) would be the determining factor in the Figure 2. Most frequently developed digital enhancements (n = 62). More than one option could be selected. *Summary slides with audio commentary. **Video or animated abstract with/without voice-over and/or images/charts. 45% 20% 21% 14% 23% 47% 74% 76% Interview with author(s) Audio slides* Visual abstracts** Infographics/illustrations Table. Reasons for Rejecting Digital Enhancements Industry Clients (n = 66) Nonindustry Clients (n = 26) No Perceived Value 12% 15% May Be Perceived as “Promotional” 34% 4% Journal Does Not Offer Peer Review 9% 0% Copyright Issues Related to Enhancement 21% 4% Insufficient Dissemination by Journal (eg, Link Not Easily Visible) 14% 8% Hosted Externally to Journal (eg, Commercial Video Platform) 12% 4% Journal Does Not Collect Specific Metrics 6% 0% Cost (eg, Production Costs, Journal Fees) 73% 42% Time and Resources Needed for Development 49% 50% Authors Unavailable 27% 69% A maximum of 3 options could be selected. Industry clients: pharmaceutical, biotechnology, or medical device companies, contract research organizations, or medical communications agencies. Nonindustry: academia, medical societies, or individual authors. AMWA Journal / V36 N3 / 2021 / amwa.org 113 decision to develop digital enhancements for nonacademic clients (64%), which was followed in importance by the avail- ability of useful metrics specific to the enhancement (50%). However, for those providing services to clients in academia and nonprofit entities (n = 60), journal assistance (60%), adequate dissemination (48%), and no or reduced fees for hosting the enhancement (47%) were referred to as factors that could influence a decision to develop enhancements. The most relevant enhancement-specific metrics for medical publication professionals (n = 113) were the total number of views/downloads (56%) and the time spent viewing the enhancement (30%); 55% of the respondents reported they would use the total number of views/downloads as a measure of the impact of digital enhancements to promote this type of service to clients. In the open-ended responses, the respondents recognized that demand for digital features will continue to grow and spe- cifically mentioned the difficulties in demonstrating the over- all benefit compared with the cost to clients as well as issues related to open access and copyright. DISCUSSION This survey was conducted to learn about the impact of digi- tal enhancements on the practices of professionals involved in the development of primary publications, and the responses obtained provided a glimpse of the challenges encountered in the field of biomedical publications. Despite the current interest in digital formats, which has been intensified by the COVID-19 pandemic, and increasing research attempting to measure their value, digital enhancements for peer-reviewed primary publications do not seem to have a significant presence outside the context of medical communication agencies and sponsors of scientific publications in the life sciences industry. Although sponsors seem to recognize digital features as effective means of disseminating scientific data, there are oftentimes issues to address that do not relate to content or the choice of the most adequate format for the data in question, namely the journal’s capacity for hosting enhancements and requirements, the timing of submission of the enhancements, the availability of peer review, the visibility of the enhance- ments, and copyright licensing. For medical publication professionals, accepting requests to develop these features may involve advising hesitant clients or authors, discussing benefits and concerns, and integrating the development process for digital features into the timeline for the core manuscript. Some journals may request the sub- mission of an enhanced content piece with a manuscript, but if the manuscript is rejected, the enhancement developed may not be in the correct format for another journal. For these rea- sons, clients and authors may see enhanced features as a poor use of their time and budgets. In addition, different practices by journals in terms of how digital enhancements are displayed on their websites (eg, as supplementary materials, as links to external websites, or prominently displayed with the article) may hinder access. Authors also face barriers to sharing digital content online, as the copyright license for the enhancement may be owned by the journal. Moreover, nonacademic sponsors may have restrictive policies on sharing content online, which may par- tially explain the low level of engagement of academic co- authors in the development of enhanced digital content in these industry-sponsored publications. Authors, sponsors, and medical communicators alike would certainly benefit from having detailed guidance, assistance, and quantitative data from journals hosting digital enhancements. Finally, there is currently a lack of evidence regarding the best strategies to effectively disseminate data and engage the target audience through digital channels. In the future, digital enhancements may be as standard as traditional writ- ten abstracts in journal articles, ultimately benefiting their audiences. Limitations This study had some limitations. First, there was selection bias owing to how the survey was advertised to medical publica- tion professionals. Most respondents were experienced profes- sionals who may have had a distinct exposure to this type of publications compared with less “seasoned” professionals. In addition, the survey may have captured the responses of those already developing or with an interest in developing digital features. Second, biomedical publication professionals from other geographic regions other than Europe and North America as well as professionals working in nonprofit, academic, and edu- cational backgrounds were poorly represented, which may be 45% 20% 21% 14% No specific training experience No clear or absent instructions from journal Lack of time or insufficient pay Other Figure 3. Main barriers for medical communications professionals (n = 109). A maximum of 3 options could be selected. 114 AMWA Journal / V36 N3 / 2021 / amwa.org explained by the only relatively recent rise in medical writing services in Asia14 and the traditionally low presence of these professionals at research centers and universities. Finally, the open-text format of some of the questions added a level of complexity to the analysis of the responses, as some of the answers added were the same as the ones provided, but with different wording, and others did not fit into the context of the questionnaire (eg, interactive posters for congresses). CONCLUSION Digital enhancements may add value to primary publications, but many barriers persist and hinder a wider uptake by medi- cal communication professionals and their clients. Although nonacademic clients may be particularly concerned about the return on investment, the cost and time invested in the devel- opment of these features pose challenges to both academic and nonacademic clients. Medical communication professionals are uniquely posi- tioned to provide clients and authors with much needed support in creating visual and digital enhancements for pub- lications, but confidence in their own expertise to guide the development process falls below expectations. Professional societies such as AMWA could potentially contribute to meet the needs for specific training in the development of digital enhancements in the form of continuing education activities. Acknowledgment The author thanks all the respondents for their valuable feedback and comments and thanks Pete Llewellyn for disseminating the survey in the MedComms Networking online newsletter. Author declaration and disclosures: Patricia Fonseca is an employee of Excerpta Medica. This survey was conducted independently. The opinions expressed in this article are those of the author. The author received no honorarium, fee, or other form of financial support related to the development of this article. 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Accessed June 30, 2021. https://www. pharmaceutical-tech.com/articles/medical-writing-services-in-asia- recent-developments-and-trends LEARN MORE ISMPP University, “Visual Medical Communications,” Webinar presented on January 29, 2020: https://www. ismpp.org/complimentary-ismpp-u-webinars Boston University, Certificate in Visual and Digital Health Communications: https://www.bu.edu/academics/met/ programs/graduate-certificate-in-visual-digital-health- communication/ Graphical abstracts: https://www.cell.com/pb/assets/raw/ shared/figureguidelines/GA_guide.pdf Twitter posters: https://www.youtube.com/watch?v=fQDL8r3r_d4 Plain language summaries: https://www.envisionthepatient.com/plstoolkit/ Tools: Canva Infographic (https://www.canva.com/), PiktoChart (https://www.piktochart.com/), Motifolio (https://www.motifolio.com/), Mind The GRAPH (https://mindthegraph.com/) mailto:pfonsecamedical@gmail.com https://www.wiley.com/network/professionals/healthcare-publishing-trends/396901-a4-wp-publishing-in-the-digital-era https://doi.org/10.1016/j.teln.2019.09.003 https://www.ismpp.org/complimentary-ismpp-u-webinars https://www.bu.edu/academics/met/programs/graduate-certificate-in-visual-digital-health-communication/ https://www.cell.com/pb/assets/raw/shared/figureguidelines/GA_guide.pdf https://www.youtube.com/watch?v=fQDL8r3r_d4 https://www.envisionthepatient.com/plstoolkit/ https://www.canva.com/ https://www.piktochart.com/ https://www.motifolio.com/ https://mindthegraph.com/ https://doi.org/10.1097/SLA.0000000000002277 https://static1.squarespace.com/static/5854aaa044024321a353bb0d/t/5a527aa89140b76bbfb2028a/1515354827682/VisualAbstract_Primer_v4_1.pdf https://www.audiovisualresearch.org/science-film/validity-of-video-abstracts/ https://doi.org/10.3163/1536-5050.104.3.011 https://doi.org/10.7554/eLife.25410 https://doi.org/10.1111/bjd.12760 https://doi.org/10.1371/journal.pone.0224697 https://doi.org/10.1017/cem.2018.436 https://doi.org/10.1002/bjs.11307 https://www.pharmaceutical-tech.com/articles/medical-writing-services-in-asia-recent-developments-and-trends