Focusing on health information: how to assess information quality on the internet.

Focusing on health information: how to assess information quality on the internet. Introduction IN MARCH 2002, THE BRITISH MEDICAL JOURNAL The British Medical Journal, or BMJ, is one of the most popular and widely-read peer-reviewed general medical journals in the world.[2] It is published by the BMJ Publishing Group Ltd (owned by the British Medical Association), whose other (BMJ BMJn abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift ) PUBLISHED ACOLLECTION of articles around the theme of quality assessment of healthinformation on the internet. The number and variety of the BMJ articlesreflect the amount of work being carried out in the field of healthinformation generally, and more specifically in health information onthe internet. Contributors to the issue were affiliated withorganisations as diverse as the European Commission and NHS NHSabbr.National Health ServiceNHS(in Britain) National Health Service hospitals inthe United Kingdom This article has recently been split into multiple articles entitled: List of hospitals in England List of hospitals in Wales List of hospitals in Scotland , with job descriptions ranging from'researcher' to 'medical student'. With theexception of two authors working in the area of eHealth (potentially alink to librarianship or information management) there was norepresentation from our field. However, the general literature of librarianship and informationscience includes material about the quality of information on theinternet. Journals in our field, such as Health Information andLibraries Journal and the Journal of the American Society forInformation Science and Technology (JASIS&T) carried articles in2002 that discussed the topic. However, these publications are somewhatspecialised. Health Information and Libraries Journal is aimed at adiscrete audience involved in health libraries and JASIS&T is verymuch a research-oriented publication. Two issues emerge: firstly, it would be useful if practitionersfrom all types of libraries were aware of work on the quality ofinformation on the internet. While the information needs of libraryusers, particularly those of public library users, vary greatly, itwould be fair to assume that some of these need health information andwill use the internet to find it. Awareness of the work being done inassessing the quality of information on the internet is important toensure that the services librarians provide access to are useful and addvalue for their users. This is unlikely to occur if the discussion aboutinformation quality on the internet is being published in journals thatfew practitioners read (Ali, 1985; Haddow, 2001; Klobas, 1991).Secondly, by bringing it to the attention of practitioners andinformation managers it is hoped that they will consequently take anactive role in the discussion about information quality on the internet;their unique perspective as organisers and facilitators of access toinformation will broaden the debate. This article was written to outline the primary issues that aredriving the quality discussion, to identify some of the useful toolsalready developed to assess quality and to illustrate, using an exampleof a small study, why it is important that librarians are aware of theseissues. What is 'quality'? Any measure of information quality is attended by a myriad ofindividual characteristics and contexts that affect perceptions of whatthe term means. In traditional publishing channels, it has rarely beenused to qualify information. To some extent, this is due to thepublication process itself, which generally works as a filter to ensurequality (Eysenbach, 1998). For example, librarians and informationmanagers rely upon reputable publishers, booksellers, subscriptionagents and reviewers who form a natural framework for providing (in mostcases) credible advice to achieve collections of quality. Information on the internet challenges these traditional measures.As any internet user Internet usern → internauta m/fInternet userInternet n → internaute m/fknows, the webpages retrieved by a search enginecan vary from highly scholarly to totally irrelevant. But in this massthere will be information relevant to a specific need, written orcreated by competent authors and organisations with credibility in theirfield. For some areas, such as information-seeking and retrievalresearch, the quality of information on the internet is being studied asrelevance was in the past. In health science, where information qualitycan mean the difference between an effective treatment and a potentiallydangerous and/or harmful outcome, criteria for information quality havebeen developed to act as a gold standard to which all health sites areencouraged to subscribe. Quality of information on the internet: a library and informationscience perspective When online information was only available via discrete databasesof records, usually in a defined subject area, information retrieval information retrievalRecovery of information, especially in a database stored in a computer. Two main approaches are matching words in the query against the database index (keyword searching) and traversing the database using hypertext or hypermedia links. researchers sought to identify the meaning of relevance to users and howsystems could best meet users' requirements, this being one aspectof quality. Relevance is associated with recall and precision, andcalculations rested on the approximate number of items in a databasebeing searched and the number of relevant items in any database inrelation to a specific search (Mizzaro, 1997). Clearly, calculations ofthis nature are not applicable when searching the internet. Furthermore,while the relevance of traditional online information derived from knownsources has always been subject to variation according to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. individualneeds, even greater variation will be seen in the assessment ofinformation retrieved from the internet. Online information has movedout of the academy and the specialised context into the public domain. Quality is a concept considered by Thomas Allen in the 1960s whenhe explored the information behaviour of research scientists andengineers (Klobas, 1995, p96). Klobas identified four components fromthese and other studies. They are: information quality; technicalquality; relevance; and participants' interpretation of quality.The first of these, information quality, is the nearest equivalent tothe way in which quality is viewed in terms of health information. Itincludes the attributes of accuracy; currency; authority; and noveltyThe second component, technical quality, is included as a criterion forsome health information assessment tools and relates to factors such asease of navigating a web site and the use and deployment of graphics. Quality was also a component in a number of studies conducted inthe 1990s exploring users' relevance judgements (Park, 1993; Wang& Soergel, 1998; Wang & Soergel, 1999). However, it is a recentstudy by Rieh (2002) that brings much of this work together to focus ontwo factors: information quality and cognitive authority (a term firstused by Wilson in 1983 to describe the judgments humans make regardingthe credibility and believability be��liev��a��ble?adj.Capable of eliciting belief or trust. See Synonyms at plausible.be��lieva��bil of a source of information). Riehfound there were five facets of information quality: goodness; accuracy;currency; usefulness; and importance. Rieh's facets of cognitiveauthority are: trustworthiness; credibility; reliability; scholarliness;how official it is; and authority These facets are similar to many ofthe criteria included in quality assessment tools for health informationon the internet. As noted above, many of the papers about quality of healthinformation on the internet tend to be research-oriented: however, thereis a notable exception that indicates how librarianship can contributeto the broader discussion. The DISCERN Handbook, published with fundingfrom the British Library British Library,national library of Great Britain, located in London. Long a part of the British Museum, the library collection originated in 1753 when the government purchased the Harleian Library, the library of Sir Robert Bruce Cotton, and groups of manuscripts. , was designed to be used with printed healthinformation rather than information on the internet. The purpose of thehandbook is to assist users of health information to judge 'thequality of written consumer health information on treatmentchoices' (Charnock, 1997). But many of DISCERN's qualitycriteria are relevant to both printed and electronic formats and thehandbook is widely cited in health science literature. Quality of information on the internet: a health scienceperspective Much of the literature about the quality of information in healthscience publications has a research focus, but quality is increasinglyan issue brought to the attention of all health professionals and healthconsumers. (See, for example, the BMJ issue referred to above and aNovember 2002 issue of the Weekend Australian newspaper which publisheda half-page article in the Health section about online healthinformation (Gaffney, 2002)). There is nothing new in the suggestionthat some health information available in the public sphere The public sphere is a concept in continental philosophy and critical theory that contrasts with the private sphere, and is the part of life in which one is interacting with others and with society at large. is notaccurate, is produced by people who do not have appropriate expertise,and is potentially dangerous. Previously, though, health information wasnot available in the quantities and with the easy access that exists nowwith the internet. A number of studies have been carried out to assessinformation about specific health topics located on the internet and allarrive at similar conclusions, epitomised by the following statement:'there is an urgent need to check public-oriented healthcareinformation on the internet for accuracy, completeness, andconsistency' (Impicciatore, Pandolfini, Casella, & Bonati,1997). Accuracy is particularly difficult for health informationconsumers to assess because they usually have no benchmark with which tomeasure it. In addition to concerns about accuracy, completeness, andconsistency of health information, other issues are raised, such ascurrency and an absence of accountability (Bower, 1996; Eysenbach et al,1998; Silberg, Lundberg, & Musacchio, 1997; Van Der Weyden, 1997;Wyatt, 1997). In relation to accountability, Bower (1996) noted thatproduct advertisements on the internet can and do carry information thatis in many cases based on unsubstantiated claims about treatments andcures. Moreover, the products being advertised and available throughonline purchase are not bound by the regulations that would apply toover-the-counter products in the purchaser's country. Silberg,Lindberg and Musacchio (1997) wrote, 'at first glance, science andsnake oil A product that has been proven to not live up to the vendor's marketing hype. The term comes from the 1800s in which elixirs and potions of all kinds, even ones that supposedly included the oils from snakes, were sold as a cure for everything that ailed a person. may not always look all that different on the net'. Theseauthors suggested that technology has the potential to dazzle daz��zle?v. daz��zled, daz��zling, daz��zlesv.tr.1. To dim the vision of, especially to blind with intense light.2. users sothat they fail to apply critical faculties they might employ in otherinformation environments. A further aspect of accountability, notrestricted to information on the internet, is an apparent reluctance ofauthors of health science information to declare conflict of interest,such as drug company support for their work (Tonks Tonks may refer to: Henry Tonks, artist Lewi Tonks, American quantum physicist especially known for the discovery of the Tonks-Girardeau gas Nymphadora Tonks, a fictional character in J. K. , 2002). Eysenbach (1998) noted that the context in which health informationappears on the internet is also important because context provides userswith clues to the purpose, intended audience, and credibility of theinformation. Using the term 'context deficit', Eysenbachlisted a number of ways that internet users could be misled byinformation found on or missing from web pages. One example is the lackof traditional publishing 'markers' that printed forms ofinformation usually carry. These can indicate to readers that theinformation was created for a particular audience and alert them to thelevel of subject-specific knowledge required to fully comprehend theinformation. Another example of 'context deficit', noted byEysenbach, occurs when a search engines takes a user directly to a webpage without first accessing introductory information, such as a titlepage which may carry 'disclaimers and warnings'. Tools to assess the quality of health information A variety of assessment tools set out criteria which take accountof the concerns discussed above. These range from simple checklists tosophisticated software programs that filter information found in aninternet search (BIOME Special Advisory Group on Evaluation, 2001;Charnock, 1997; Eysenbach et al, 1998; Health On the Net Foundation Health On the Net Foundation (HON) is a not-for-profit organization founded in 1995 and based in Switzerland. The stated mission of the foundation is to help both laypersons and medical practitioners find useful and reliable medical and health information online. ,2000; Health Summit Working Group, 1997; Pealer & Dorman, 1997).Wilson (2002) provides an excellent discussion about the different typesof quality assessment tools developed and a number of these are listedat the end of this article. The assessment tool of the Health Summit Working Group falls intoWilson's 'codes of conduct' category. Codes of conductrecommend standards that creators of websites can employ as a guide inthe development phase and which consumers can use to assess the qualityof the information on them (Wilson, 2002). For example, when credibilityof a website is being assessed, the user is encouraged to examine thesource, context, currency, relevance and/or utility, and editorialreview process of the information. This process was used in a smallstudy examining the quality of information about caring for a feverish feverish/fe��ver��ish/ (fe��ver-ish) febrile. fe��ver��ishadj.1. Having a fever.2. Relating to or resembling a fever.3. Causing or tending to cause a fever. child. This study is illustrative of many others in this context. An example of health information quality on the internet A total of twenty-two websites found using popular search engines(Google, AltaVista, and Yahoo!) and simple terms (child and fever), wereassessed and each site was evaluated against the criteria: accuracy;currency; source; original source; and disclosure. Accuracy wasdetermined by the extent of agreement with the findings of a systematicreview conducted in 2001 which gathered evidence about the mosteffective treatment for a child with fever (Watts, Robertson, &Thomas, 2001). In terms of health information, systematic reviews areregarded as providing the best possible evidence about a topic. Afurther criterion, completeness, was applied to determine whetherwebsites carried warnings against potentially dangerous treatments. At best, 14 websites (sixty-four per cent) carried accurateinformation about how to care for a feverish child. At worst, only onewebsite noted that sustained use of paracetamol paracetamolsee acetaminophen.acetaminophen, paracetamolan analgesic and antipyretic drug in dogs. It is contraindicated for cats because of serious side-effects which include intravascular hemolysis, methemoglobinemia and hepatic necrosis. is not advised--animportant issue that has gained public exposure through the mass mediain recent months (see for example The West Australian West Australian commonly refers to people or things from Western Australia.Specific things to which it may refer include: the newspaper The West Australian; , Saturday 10August 2002 and ABC television's 7.30 Report on 5 November 2002).The majority of websites were current, but nine (forty per cent) had nocreation date. Source information was included in nearly all thewebsites, however, only half the websites carried disclosure informationrelating to relating torelate prep → concernantrelating torelate prep → bez��glich +gen, mit Bezug auf +accthe purpose and intended use of the information. Warningsabout potentially dangerous treatments for a child with fever were notgiven by between seven to ten (thirty-two to forty-five per cent) of thewebsites. Overall, only three (fourteen per cent) of the twenty-twocould be classed as carrying quality information based on all criteriaincluded in the study. These findings are supported by numerous otherstudies (Abbott, 2000; Bidwell, 2000; Eysenbach & Kohler, 2002;Impicciatore et al., 1997; Kunst, Groot, Latthe, Latthe, & Khan,2002; Pandolfini & Bonati, 2002). Implications for library practitioners and information managers The issues discussed above illustrate the challenges facinglibrarians and information service managers in their provision of healthinformation to their users. Clearly, it is not enough to offer generaldirections to information on the internet as this can vary widely,unlike printed resources on the shelves that are more likely to havebeen selected within a known framework of quality judgments. Theseissues are particularly important for public libraries, which may be theprimary source of information for some users. There are a number of strategies that might be considered bylibrarians to ensure their users gain access to health information ofquality. * Reputable consumer health sites can be listed on a library'sweb page, providing direction for users with little prior experience. * A short guide to criteria with which to assess the quality ofinformation could be compiled and either given to users or left nearcomputer terminals with internet access See how to access the Internet. . * Short information sessions about quality could be incorporatedinto general internet training sessions or included when users ask foradvice when searching the internet. The first list below is a collection of health information sitescreated by reputable organisations specifically for health consumers. Arecent initiative by the Federal Government has provided all Australianinternet users with free access to the Cochrane Collaboration The Cochrane Collaboration was developed in response to Archie Cochrane's call for up-to-date, systematic reviews of all relevant randomized controlled trials of health care. Library,an important international source of high quality health information.Although much of the information in the Cochrane Library The Cochrane Library is a collection of databases in medicine and other healthcare specialties provided by the Cochrane Collaboration. At its core is a database of systematic reviews and meta-analyses which summarise and interpret the results of high-quality medical research. website is notwritten for consumers, the summaries available on the Cochrane websiteand included in the Medibank Private Medibank Private is an Australian government-owned private health insurer, established under the Fraser government in 1976 through the Health Insurance Commission (now known as Medicare Australia). website are written for the healthconsumer audience. It should be noted that health information on theinternet should not be regarded as a substitute for consulting a healthprofessional. Manuscript received November 2002 This is a refereed article Reputable websites for health consumers: ABC Health Matters: Australian Broadcasting Corporation http://www.abc.net.au/health/ Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality,n.pr formerly known as the Agency for Health Care Policy and Research, this agency researches the quality of medical care and health services. http://www.ahcpr.gov/consumer/ Better Health Channel: Government of Victoria, Australiahttp://www.betterhealth.vic.gov.au/bhcv2/hcsite.nsf?Open Choice: Australian Consumers' Associationhttp://www.choice.com.au/articles/a100481p1.htm Cochrane Consumer Network http://www.cochraneconsumer.com healthfinder: US Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979Health and Human Services, HHS http://www.healthfinder.gov HealthInsite: Australian Commonwealth Department of Health andAging http://www.healthinsite.gov.au Health Topics A-Z: World Health Organisation--information inEnglish, Spanish and French http://www.who.int/home-page/ Medibank Private--includes Cochrane Consumer Network informationhttp://www.medibank.com.au/index.asp NHS Direct NHS Direct is the name of a 24 hour, confidential telephone, online and interactive digital TV health advice and information service provided by the National Health Service in England and Wales. The service is provided by the NHS Direct Trust. : National Health Service in the United Kingdomhttp://www.nhsdirect.nhs.uk/ Below is a list of websites for a range of quality assessment toolsdeveloped to evaluate health information on the internet. While theyhave been developed for health information, many of the criteria arerelevant to all types of information on the internet. American Medical Association: Guidelines for American MedicalAssociation websites http://www.ama_assn.org/ama/pub/category/1905.html Discern: Quality Criteria for Consumer Health Information--aquestionnaire to judge the quality of health informationhttp://www.discern.org.uk/ eEurope: Good Practice Guidelines--developed as part of the EUInformation Society program http://europa.eu.int/information_society/eeurope/ehealth/quality/index_en.htm Health on the Net (HON): Code of Conduct--ethical standards andlogo for website developers http://www.hon.ch/ Health Summit Working Party: Assessing the Quality of internetHealth Information--a list of criteria for assessment of internetinformation http://hitiweb.mitretek.org/hswg/default.asp HiEthics: Health internet Ethics--ethical principles for web sitedevelopers http://www.hiethics.com/Principles/index.asp Internet Healthcare Coalition: eHealth Code of Ethics--a code ofethics for health care sites on the internethttp://www.ihealthcoalition.org/ethics/ehcode.html MedCertain: An International Trustmark for Health Information--aself- and third-party rating system for identification of trust-worthyhealth information http://www.medcertain.org/ Net Scoring: Criteria to Assess the Quality of Health internetInformation --quality based on points awarded--to maximum 312 pointshttp://www.churouen.fr/netscoring/netscoringeng.html Quick: The Quality Information Checklist--designed for children andyoung adults http://quick.org.uk/ URAC URAC Utilization Review Accreditation Commission (health care accreditation & certification)URAC University Recreation & Aquatic Centre Ltd (Australia)URAC Union Regional de Apoyo Campesino : Health Web Site Accreditation--the logo indicates a websitehas been reviewed for quality http://www.urac.org/ References Abbott, V P (2000). 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Unpublished DoctoralThesis, University of Western Australia Western Australia,state (1991 pop. 1,409,965), 975,920 sq mi (2,527,633 sq km), Australia, comprising the entire western part of the continent. It is bounded on the N, W, and S by the Indian Ocean. Perth is the capital. , Perth, Western Australia This article is about the metropolitan area of Perth, Western Australia. For the local government area, see City of Perth. Perth is the capital of the Australian state of Western Australia. . Health On the Net Foundation. (2000, November 20, 2000). HON'sInitiatives and Services: MARVIN MARVIN - U Dortmund, 1984. Applicative language based on Modula-2, enhanced by signatures (grammars) terms (trees) and attribute couplings (functions on trees). Used for specification of language translators. [WWW page]. HON. Retrieved 8 February2002, from the World Wide Web:http://www.hon.ch/Project/Marvin_project.html Health Summit Working Group. (1997). 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It also drills, bores, polishes, grinds, makes threads, and performs other operations. , P M, Latthe, M, & Khan, K. S.(2002). 'Accuracy of information on apparently credible websites:survey of five common health topics'. British Medical Journal, 324(9 March), 581-582. Mizzaro, S (1997). 'Relevance: the whole history'.Journal of the American Society for Information Science, 48 (9),810-832. Pandolfini, C, & Bonati, M (2002). 'Follow-up of qualityof public oriented health information on the world wide web: systematicre-evaluation.' British Medical Journal, 324 (9 March), 582-583. Park, T K (1993). 'The nature of relevance in informationretrieval: an empirical study.' Library Quarterly, 63 (3), 318-351. Pealer, L N, & Dorman, S M (1997). 'Evaluatinghealth-related web sites.' Journal of School Health, 67 (6),232-235. Rieh, S Y (2002). 'Judgment of information quality andcognitive authority in the web.' Journal of the American Societyfor Information Science and Technology, 53 (2), 145-161. Silberg, W M, Lundberg, G D, & Musacchio, R A (1997).'Assessing, controlling and assuring the quality of medicalinformation on the internet: caveat lector et viewer--let the reader andviewer beware.' JAMA, The Journal of the American MedicalAssociation JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world. , 277 (15), 1244-1246. Tonks, A (2002). 'Authors of guidelines have strong links withdrugs industry.' British Medical Journal, 324 (16 February), 383. Van Der Weyden, M B (1997). 'Medical information and the WorldWide Web.' MJA MJA Medical Journal of AustraliaMJA Methanococcus JannaschiiMJA Marsden Jacob Associates (Australia)MJA Modern Jesus ArmyMJA Microjet Array , 167, 571-572. Wang, P, & Soergel, D (1998). 'A cognitive model The term cognitive model can have basically two meanings. In cognitive psychology, a model is a simplified representation of reality. The essential quality of such a model is to help deciding the appropriate actions, i.e. ofdocument use during a research project. Study I. Documentselection.' Journal of the American Society for InformationScience, 49 (2), 115-133. Wang, P, & Soergel, D (1999). 'A cognitive model ofdocument use during a research project. Study II. Decision at thereading and citing stages.' Journal of the American Society forInformation Science, 50 (2), 98-114. Watson, R (2002). 'European Commission to publish a code ofpractice for websites.' British Medical Journal, 324 (9 March),567. Watts, R, Robertson, J, & Thomas, G (2001). The nursingmanagement of fever in children (Vol 14). Adelaide: The Joanna BriggsInstitute for Evidence-Based Nursing and Midwifery midwifery(mĭd`wī'fərē), art of assisting at childbirth. The term midwife for centuries referred to a woman who was an overseer during the process of delivery. In ancient Greece and Rome, these women had some formal training. . Wilson, P (2002). 'How to find the good and avoid the bad orugly: A short guide to tools for rating quality of health information onthe internet.' British Medical Journal, 324 (9 March), 598-600. Wyatt, J C (1997). 'Commentary: measuring quality and impactof the world wide web.' British Medical Journal, 314 (7098), 1879. The author is currently working as a Research Project Officer forthe WA Centre for Evidence-based Nursing and Midwifery, a collaboratingcentre of the Joanna Briggs Institute. Her background is inlibrarianship, with a special interest in the relationship betweenresearch and practice. G.Haddow@curtin.edu.au