When NEJM.org launched more than 20 years ago, it contained abstracts of new research articles. Full text of all the articles came along two years later, creating a near replica of the print journal, viewable online. This “page on the World Wide Web,” a 1996 editorial noted, was “a work in progress.”

Indeed. Today, when 2.5 million users connect to NEJM.org each month, they meet up with audio, video, and interactive features that were unthinkable 20 years ago, all available on a handheld device. And the website allows NEJM to be readily available around the world, including in low-resource countries where we grant full access at no charge.

NEJM has steadily mined the capabilities of online publishing by continually adding new features that expand understanding of new research and hone skills. These include peer-reviewed instructional Videos in Clinical Medical; complex Interactive Medical Cases; podcasts and interviews; and Image Challenge, Case Challenge, and Clinical Decisions. All provide new avenues for learning, teaching, and sharing of ideas. From the very first video on NEJM.org in 1999 — an echocardiogram of conjoined twins in utero — NEJM has used video, as the editors have noted, to “convey biomedical information in a way that print cannot.”

Online publishing also has sped dissemination of urgent public health information and research swiftly and widely, as during outbreaks of Zika and Ebola viruses, through rapidly assembled articles, images, and webcasts. The capability to publish massive supplements and research protocols online brings new depth, new transparency, and is opening the door to data sharing.

Executive Editor Edward Campion, M.D., has been on the front line throughout, having previously served as deputy editor and online editor. Here he addresses opportunities and challenges of online publishing shared today by journals and libraries.

Q. You have said, “Being online has changed what a medical journal is and what a medical journal does.” How so?

It used to be all about articles. Now, in addition to articles, we have video, audio, and features that are interactive, participatory, and engaging. Some include polls and commenting, and they are very popular. But they also require real engagement, with the potential for very real educational benefits.

For example, more than 2,000 people have read a recent Case Challenge and taken the poll on the most likely diagnosis. We also received several hundred comments about the case. A clinician must really focus and engage to read this case description from the MGH Case Records. This particular case, about a man with acute liver injury, is not an easy one, and the majority of people answered with the wrong diagnosis. Sometimes 80 to 90% choose the right diagnosis, and sometimes only 20% do. Once the Case Challenge closes, participants can read the full case discussion and see the correct final diagnosis along with the evidence that supports it.

These are read by practicing physicians, by those in combined academic/research positions, and by residents/trainees. In some centers, these cases are discussed by trainees who work together to understand the details and the differential diagnosis and to solve the diagnostic challenge. They know that every case describes a real patient.

 Q. What current feature of NEJM.org was unimaginable to you just a few years ago?

Quick Takes. These short animations are only about 2 minutes long, and they summarize the key messages of a new research article. These are totally original to NEJM. When I first heard the idea, I thought it was a little wacky for the New England Journal of Medicine to be doing animated summaries. But they’re very popular. They’re fun to watch. And they provide effective summaries about the methodology and the essential take-home messages of research articles. We now publish a Quick Take every week. (The 115 to date are available here).

Q. What is the most popular online feature?

The weekly Image Challenge. For a medical person, it is irresistible, and you are drawn right in. You see the image of a rash or an abnormality on an angiogram. You may think you know what it is, but you want confirmation. You study the image and take the quiz in just a few seconds. You choose from five options until you get it right — at which time you see a short paragraph explaining the image. So, you are testing yourself and you’re learning. Some of the images are of unusual diseases, but they are all from actual patients, submitted by their physicians.

We’ve had the Image Challenge for over 10 years. Typically, about 25,000 people take the quiz in its first week. All Image Challenges remain on the site. Some have been taken more than 100,000 times. We also publish two Images in Clinical Medicine each week. Well over 1,000 are now on NEJM.org.

Q. How has NEJM’s evolution paralleled changes in medical education, scholarship, and research?

Everything is going in the direction of more hands-on engagement and learning to use tools — less passive learning and more active exploration. This is evident in our interactive features. As librarians know better than anyone, the amount and the availability of information has increased exponentially, more than anyone could ever imagine. That presents challenges and complexity, as well as changes for the better.

For example, 10 years ago it was ridiculous to think physicians would be using Wikipedia. But Wikipedia has increased the breadth and depth of its medical information with basically good quality, especially on obscure topics and rare disorders. Patients certainly use it and other online medical information all the time. If you want a first look or a reminder about something unusual, Wikipedia generally has a reasonably good first summary. But would you go there to learn how to treat pneumonia? No, it’s not very useful. For in-depth information on a clinical topic and for recent research, physicians and researchers want to go to NEJM.org and the other leading journals.

Q. Amidst this information explosion, do medical journals and medical libraries share some of the same challenges? How might we work toward our shared goals?

Librarians are about information and learning, and that’s what NEJM is about. Librarians can help introduce and lead students, faculty, and trainees to our information as well as to what is published by others.

With the explosion and deepening of what’s presented on our websites, we’ve got a lot of moving parts. In the old days, when NEJM was defined by what was in each issue, on paper, it was easy to know what was there. Now we have all kinds of resources on the site. It is a challenge to be aware of it all, how to find it, how to best use it, and how to retrieve it again in the future.

Even what an article is has changed and gotten deeper: In addition to the article, there is supplementary information — the protocol, the statistical analysis plan, supplementary analyses, and supplementary figures and tables. For researchers, or anyone who wants to get deep into a study, these provide essential details far beyond what is in the traditional article format. The amount of information being published with our research articles is sometimes 2-, 3-, or 10-times more than is in the article itself. That supplementary information is easily available with nearly every research article. In earlier times, a reader had to contact the authors to request this kind of in-depth supplemental information. But now it’s published with the article and is just one click away.

Of course, it is a lot of work for authors to compile supplementary data and protocols. Librarians may be able to play a role in creating effective supplements for research publications.

Data sharing also is very much in mind, and we are exploring ways to operationalize it so that the original data behind the article will be available for other researchers. We’re committed to making data sharing part of what we do and continue to seek input from the many constituents involved.