Apomediation is a new socio-technological term that was coined to avoid the term “Web 2.0” in the scholarly debate [16
]. It characterizes the “third way” for users to identify trustworthy and credible information and services. The first possible approach is to use intermediaries (ie, middlemen or “gatekeepers”), for example health professionals giving “relevant” information to a patient. Trusted Web portals containing only information vetted by experts can also be seen as an intermediary. The second possibility is to bypass “middlemen” completely, which is commonly referred to as disintermediation. Examples are patients searching for information on the web, or travelers booking their flights directly on the booking system of an airline, bypassing travel agents. The third way, prevalent in the age of Web 2.0, is a special form of disintermediation: an information seeking strategy where people rely less on traditional experts and authorities as gatekeepers, but instead receive “guidance” from apomediaries, ie, networked collaborative filtering processes [16
]. The difference between an intermediary and an apomediary is that an intermediary stands “in between” (latin: inter- means “in between”) the consumer and information, meaning that he is a necessary mediating agent to receive the information in the first place. As a result, the credibility and quality of the intermediary heavily determines the credibility and quality of the information a consumer receives. In contrast, apomediation means that there are agents (people, tools) which “stand by” (latin: apo- means separate, detached, away from) to guide a consumer to high quality information and services without being a prerequisite to obtain that information or service in the first place, and with limited individual power to alter or select the information that is being brokered. While these distinctions are not absolute (in practice, there may be a mix of both and people move back and forth between apomediation and intermediation models), it has been hypothesized that they influence how people judge credibility, as elaborated in more detail elsewhere [16
In the health context, disintermediation (cutting out the middleman) means more direct access of consumers to their personal data (eg, in web accessible electronic health records—upper left circle of ) and general medical information (on the web—upper right circle of ). The traditional role of the middleman is to guide consumers to relevant and credible information (the intersection of both circles in the center of the diagram). Thus, the main problem of bypassing the middleman is that consumers may “get lost” in the vast amount of information and arrive at the wrong or irrelevant information (dotted arrows). Apomediation theory conceptualizes that “apomediaries” (which includes Web 2.0 approaches) can partly take over the role of the intermediary and “push” or “guide” users to relevant and accurate information (dashed arrows).
Apomediation in the health care field from the perspective of a patient.
The Web 2.0 environment is essentially an “apomediated environment”, meaning that all the issues related to the apomediation model, summarized in [16
], are relevant for Web 2.0 and Medicine 2.0.
Table 1 Issues in an apomediation vs intermediation environment .
Apomediation theory argues that apomediaries, such as users and friends in the case of Digg, can help users navigate through the onslaught of information afforded by networked digital media, providing additional credibility cues and supplying further metainformation. Other examples of apomediaries and apomediation tools include consumer ratings on amazon.com or epinions.com; technologies like PICS or MedPICS labels and its RDF successors that enable machine-processable dissemination and interpretation of user ratings [18
]; collaborative filtering and recommender systems as exemplified by StumbleUpon.com; and other second generation Internet-based services and tools that let people collaborate on a massive scale and share information online in new ways, including social networking sites, social bookmarking, blogs, wikis, communication tools, and folksonomies.
The Dynamic Intermediation-Disintermiation-Apomediation model (DIDA) (illustrated in ) argues that whether or not consumers prefer an apomediation or intermediation environment is highly situation-specific, and key variables in determining consumer preference for apomediation are autonomy, self-efficacy, and knowledge in a specific area for which information or support is sought. For example, a cancer patient may initially prefer an intermediary to satisfy his information needs, but with growing autonomy, self-efficacy, and knowledge, the same patient may later prefer Web 2.0 approaches to guide him to information deemed trustworthy.
Figure 4 Dynamic Intermediation-Disintermiation-Apomediation model (DIDA) .
Apomediation is not only important to the consumer as end user and the health professional as former intermediary. Both health professionals and scientists themselves are also switching from intermediaries to apomediaries. For example, two decades ago, researchers and health professionals still used intermediaries such as information brokers to conduct a Medline search for them, but then disintermediation took over, and they were able to search in PubMed directly. Today, these tools are complemented by “apomediaries”, for example shared bookmarking tools such as CiteULike, Connotea, or WebCite, where people receive pointers to recently published relevant literature based on what others with a similar profile and interests have cited or bookmarked.
In science, we are also witnessing an apomediation process (sometimes called “Science 2.0”), with changing roles for the former intermediaries such as journals and professional publishers. Much of the communication between scientists now takes place on the Web before an article is actually published [19
]. This onslaught of information necessitates the use of “apomediaries” (such as shared bookmarks) to guide users to relevant information on the Web. One can also predict that journals themselves will experiment increasingly with peer-review models that rely more on networked, bottom-up review processes, as opposed to relying on traditional “expert” peer-reviewers. Such models are not without challenges and require a cultural shift as well as strong incentives. Nature’s recent open peer-review experiment suggests that most researchers “are too busy, and lack sufficient career incentive, to venture onto a venue such as Nature
's website and post public, critical assessments of their peers' work” [20
These apparent failures highlight the problem that—as has been previously pointed out [16
]—what works for the entertainment industry, namely rating tools for users to rate movies, music, etc., may not necessarily work in the medical or scientific field. Productivity tools (including health applications) have to pass a different hurdle than “fun” applications such as Facebook – they have to be trustworthy, secure and people have to see an (immediate) benefit. There is the question of incentives for users to participate and to contribute constructively to a virtual community. Social networking sites such as Facebook or Myspace work because for young people it is important to be visible, and there is a considerable social and peer pressure for youth to have a presence and a positive “karma” or reputation on such sites, so much so that there is a grey market for users to “buy” virtual friends [21
]. This of course highlights another problem – which is that even networked “apomediation” models are liable to fraud and “Scam 2.0”. It is an open research question whether, and under which circumstances, apomediation models work better than intermediation approaches, and how apomediation models can be made less susceptible to fraud.