OrganizedWisdom's approach was similar to Mahalo.com's strategy, except that OrganizedWisdom focuses exclusively on health related search terms and employs physician reviewers into its training and review process.

Dr. Macdonald is president of Employee Health Programs, based in Washington, which provides physician reviewers.

He is a physician reviewer for Physicians' Review Network, Inc., an independent medical review organization.

The state's physician reviewers said a patient with those kinds of injuries would reasonably have been expected to survive.

Asked if the missteps caused Mr. Rosenbaum's death, Vicki Zeldin, a spokeswoman for the State Health Department, said: "What our physician reviewers here are saying is that one would reasonably expect that a patient with these kinds of injuries would be most likely to survive.

Gerace serves as a physician reviewer for Physicians' Review Network Inc., an independent medical review organization.

The physician reviewer said he was "frustrated" by the patient's unwillingness to make the "cost-effective" decision.

When physician reviewers conducted follow-up interviews with doctors whose cases were deemed inappropriate, the proportion deemed inappropriate dropped to 23 percent and those considered equivocal rose to 35 percent.

The analysis was directed by Dr. Lawrence C. Kleinman of Children's Hospital in Boston, who sometimes serves as a physician reviewer for Value Health Sciences.