Volume 5 (2003)
Permanent URI for this collectionhttps://hdl.handle.net/1807/4422
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Item Open Access How do Consumers Search for and Appraise Information on Medicines on the Internet? A Qualitative Study Using Focus Groups(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-12-19) Peterson, Geraldine ; Aslani, Parisa ; Williams, Kylie A[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e33/ ] Background: Many consumers use the Internet to find information about their medicines. It is widely acknowledged that health information on the Internet is of variable quality and therefore the search and appraisal skills of consumers are important for selecting and assessing this information. The way consumers choose and evaluate information on medicines on the Internet is important because it has been shown that written information on medicines can influence consumer attitudes to and use of medicines. Objective: To explore consumer experiences in searching for and appraising Internet-based information on medicines. Methods: Six focus groups (N = 46 participants) were conducted in metropolitan Sydney, Australia from March to May 2003 with consumers who had used the Internet for information on medicines. Verbatim transcripts of the group discussions were analyzed using a grounded theory approach. Results: All participants reported using a search engine to find information on medicines. Choice of search engine was determined by factors such as the workplace or educational environments, or suggestions by family or friends. Some participants found information solely by typing the medicine name (drug or brand name) into the search engine, while others searched using broader terms. Search skills ranged widely from more-advanced (using quotation marks and phrases) to less-than-optimal (such as typing in questions and full sentences). Many participants selected information from the first page of search results by looking for keywords and descriptions in the search results, and by looking for the source of the information as apparent in the URL. Opinions on credible sources of information on medicines varied with some participants regarding information by pharmaceutical companies as the "official" information on a medicine, and others preferring what they considered to be impartial sources such as governments, organizations, and educational institutions. It was clear that although most participants were skeptical of trusting information on the Internet, they had not paid conscious attention to how they selected information on medicines. Despite this, it was evident that participants viewed the Internet as an important source for information on medicines. Conclusions: The results showed that there was a range of search and appraisal skills among participants, with many reporting a limited awareness of how they found and evaluated Internet-based information on medicines. Poor interpretation of written information on medicines has been shown to lead to anxiety and poor compliance to therapy. This issue is more important for Internet-based information since it is not subject to quality control and standardization as is written information on medicines. Therefore, there is a need for promoting consumer search and appraisal skills when using this information. Educating consumers in how to find and interpret Internet-based information on medicines may help them use their medicines in a safer and more-effective way.Item Open Access How Adolescents Use Technology for Health Information: Implications for Health Professionals from Focus Group Studies(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-12-18) Skinner, Harvey ; Biscope, Sherry ; Poland, Blake ; Goldberg, Eudice[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e32/ ] Background: Adolescents present many challenges in providing them effective preventive services and health care. Yet, they are typically the early adopters of new technology (eg, the Internet). This creates important opportunities for engaging youths via eHealth. Objective: To describe how adolescents use technology for their health-information needs, identify the challenges they face, and highlight some emerging roles of health professionals regarding eHealth services for adolescents. Methods: Using an inductive qualitative research design, 27 focus groups were conducted in Ontario, Canada. The 210 participants (55% female, 45% male; median age 16 years) were selected to reflect diversity in age, sex, geographic location, cultural identity, and risk. An 8-person team analyzed and coded the data according to major themes. Results: Study participants most-frequently sought or distributed information related to school (89%), interacting with friends (85%), social concerns (85%), specific medical conditions (67%), body image and nutrition (63%), violence and personal safety (59%), and sexual health (56%). Finding personally-relevant, high-quality information was a pivotal challenge that has ramifications on the depth and types of information that adolescents can find to answer their health questions. Privacy in accessing information technology was a second key challenge. Participants reported using technologies that clustered into 4 domains along a continuum from highly-interactive to fixed information sources: (1) personal communication: telephone, cell phone, and pager; (2) social communication: e-mail, instant messaging, chat, and bulletin boards; (3) interactive environments: Web sites, search engines, and computers; and (4) unidirectional sources: television, radio, and print. Three emerging roles for health professionals in eHealth include: (1) providing an interface for adolescents with technology and assisting them in finding pertinent information sources; (2) enhancing connection to youths by extending ways and times when practitioners are available; and (3) fostering critical appraisal skills among youths for evaluating the quality of health information. Conclusions: This study helps illuminate adolescent health-information needs, their use of information technologies, and emerging roles for health professionals. The findings can inform the design and more-effective use of eHealth applications for adolescent populations.Item Open Access Searching for Cancer Information on the Internet: Analyzing Natural Language Search Queries(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-12-11) Bader, Judith L ; Theofanos, Mary Frances[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e31/ ] Background: Searching for health information is one of the most-common tasks performed by Internet users. Many users begin searching on popular search engines rather than on prominent health information sites. We know that many visitors to our (National Cancer Institute) Web site, cancer.gov, arrive via links in search engine result. Objective: To learn more about the specific needs of our general-public users, we wanted to understand what lay users really wanted to know about cancer, how they phrased their questions, and how much detail they used. Methods: The National Cancer Institute partnered with AskJeeves, Inc to develop a methodology to capture, sample, and analyze 3 months of cancer-related queries on the Ask.com Web site, a prominent United States consumer search engine, which receives over 35 million queries per week. Using a benchmark set of 500 terms and word roots supplied by the National Cancer Institute, AskJeeves identified a test sample of cancer queries for 1 week in August 2001. From these 500 terms only 37 appeared ≥ 5 times/day over the trial test week in 17208 queries. Using these 37 terms, 204165 instances of cancer queries were found in the Ask.com query logs for the actual test period of June-August 2001. Of these, 7500 individual user questions were randomly selected for detailed analysis and assigned to appropriate categories. The exact language of sample queries is presented. Results: Considering multiples of the same questions, the sample of 7500 individual user queries represented 76077 queries (37% of the total 3-month pool). Overall 78.37% of sampled Cancer queries asked about 14 specific cancer types. Within each cancer type, queries were sorted into appropriate subcategories including at least the following: General Information, Symptoms, Diagnosis and Testing, Treatment, Statistics, Definition, and Cause/Risk/Link. The most-common specific cancer types mentioned in queries were Digestive/Gastrointestinal/Bowel (15.0%), Breast (11.7%), Skin (11.3%), and Genitourinary (10.5%). Additional subcategories of queries about specific cancer types varied, depending on user input. Queries that were not specific to a cancer type were also tracked and categorized. Conclusions: Natural-language searching affords users the opportunity to fully express their information needs and can aid users naïve to the content and vocabulary. The specific queries analyzed for this study reflect news and research studies reported during the study dates and would surely change with different study dates. Analyzing queries from search engines represents one way of knowing what kinds of content to provide to users of a given Web site. Users ask questions using whole sentences and keywords, often misspelling words. Providing the option for natural-language searching does not obviate the need for good information architecture, usability engineering, and user testing in order to optimize user experience.Item Open Access Design and Testing of a Tool for Evaluating the Quality of Diabetes Consumer-Information Web Sites(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-11-27) Seidman, Joshua J ; Steinwachs, Donald ; Rubin, Haya R[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e30/ ] Background: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality information rather than evaluating actual accuracy and comprehensiveness. Objective: This research sought to develop a new performance-measurement tool for evaluating the quality of Internet health information, test the validity and reliability of the tool, and assess the variability in diabetes Web site quality. Methods: An objective, systematic tool was developed to evaluate Internet diabetes information based on a quality-of-care measurement framework. The principal investigator developed an abstraction tool and trained an external reviewer on its use. The tool included 7 structural measures and 34 performance measures created by using evidence-based practice guidelines and experts' judgments of accuracy and comprehensiveness. Results: Substantial variation existed in all categories, with overall scores following a normal distribution and ranging from 15% to 95% (mean was 50% and median was 51%). Lin's concordance correlation coefficient to assess agreement between raters produced a rho of 0.761 (Pearson's r of 0.769), suggesting moderate to high agreement. The average agreement between raters for the performance measures was 0.80. Conclusions: Diabetes Web site quality varies widely. Alpha testing of this new tool suggests that it could become a reliable and valid method for evaluating the quality of Internet health sites. Such an instrument could help lay people distinguish between beneficial and misleading information.Item Open Access Conceptual Framework for a New Tool for Evaluating the Quality of Diabetes Consumer-Information Web Sites(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-11-27) Seidman, Joshua J ; Steinwachs, Donald ; Rubin, Haya R[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e29/ ] Background: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality of information, rather than evaluating information accuracy and comprehensiveness. Objective: This research sought to build a conceptual framework that could lay the groundwork for a robust performance-measurement system for evaluating the quality of Internet health information. Methods: Application of the quality-of-care measurement paradigm to developing a conceptual framework for defining and evaluating the quality of diabetes consumer-information Web sites. Results: Performance measures related to accuracy and comprehensiveness of information can be added to structural criteria to provide a more-robust approach to Web site evaluation. Conclusions: The development and implementation of a reliable and valid method for evaluating the quality of Internet health sites could provide lay people with a tool to identify useful content more easily and distinguish between beneficial and misleading information.Item Open Access Improving Web Searches: Case Study of Quit-Smoking Web Sites for Teenagers(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-11-14) Koo, Malcolm ; Skinner, Harvey[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e28/ ] Background: The Web has become an important and influential source of health information. With the vast number of Web sites on the Internet, users often resort to popular search sites when searching for information. However, little is known about the characteristics of Web sites returned by simple Web searches for information about smoking cessation for teenagers. Objective: To determine the characteristics of Web sites retrieved by search engines about smoking cessation for teenagers and how information quality correlates with the search ranking. Methods: The top 30 sites returned by 4 popular search sites in response to the search terms "teen quit smoking" were examined. The information relevance and quality characteristics of these sites were evaluated by 2 raters. Objective site characteristics were obtained using a page-analysis Web site. Results: Only 14 of the 30 Web sites are of direct relevance to smoking cessation for teenagers. The readability of about two-thirds of the 14 sites is below an eighth-grade school level and they ranked significantly higher (Kendall rank correlation, tau = -0.39, P= .05) in search-site results than sites with readability above or equal to that grade level. Sites that ranked higher were significantly associated with the presence of e-mail address for contact (tau = -0.46, P= .01), annotated hyperlinks to external sites (tau = -0.39, P= .04), and the presence of meta description tag (tau = -0.48, P= .002). The median link density (number of external sites that have a link to that site) of the Web pages was 6 and the maximum was 735. A higher link density was significantly associated with a higher rank (tau = -0.58, P= .02). Conclusions: Using simple search terms on popular search sites to look for information on smoking cessation for teenagers resulted in less than half of the sites being of direct relevance. To improve search efficiency, users could supplement results obtained from simple Web searches with human-maintained Web directories and learn to refine their searches with more advanced search syntax.Item Open Access Generic Design of Web-Based Clinical Databases(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-11-04) j, Jacob Anhø[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e27/ ] Background: The complexity and the rapid evolution and expansion of the domain of clinical information make development and maintenance of clinical databases difficult. Whenever new data types are introduced or existing types are modified in a conventional relational database system, the physical design of the database must be changed accordingly. For this reason, it is desirable that a clinical database be flexible and allow for modifications and for addition of new types of data without having to change the physical database schema. The ideal clinical database would therefore implement a highly-detailed logical database schema in a completely-generic physical schema that stores the wide variety of clinical data in a small and constant number of tables. Objective: The objective was to review the medical literature regarding generic design of clinical databases. Methods: A search strategy was devised for PubMed and Google to get the best match of peer-reviewed articles and free Web resources on the subject. Results: Eight peer reviewed articles and a Web tutorial were found. All the resources described the so-called Entity-Attribute-Value (EAV) design as a means of simplifying the physical layout of data tables in a clinical database. In Entity-Attribute-Value design all data can be stored in a single generic table with conceptually 3 columns: 1 for entity (eg, patient identification), 1 for attribute (eg, name), and 1 for value (eg, "Jens Hansen"). To add more descriptive fields to the entity class, all that is necessary is to add attribute values to be stored in the attribute field. The main advantages of the Entity-Attribute-Value design are flexibility and effective entity-centered data retrieval. The main disadvantages are complicated front-end programming needed to display data in a conventional layout that the user understands and less-efficient attribute-centered queries. The Internet offers unique opportunities for database deployment, eliminating problems of user-interface deployment. Furthermore, Web forms may be generated in a completely-generic fashion during run time from metadata describing the semantic structure of clinical information stored in the database. Conclusions: The Entity-Attribute-Value model is useful for generic design of clinical databases. Depending on the specific requirements of the application, more or less complex metadata models may be applied.Item Open Access Reasons for Consulting a Doctor on the Internet: Web Survey of Users of an Ask the Doctor Service(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-10-22) Umefjord, Göran ; Petersson, Göran ; Hamberg, Katarina[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e26/ ] Background: In 1998 the Swedish noncommercial public health service Infomedica opened an Ask the Doctor service on its Internet portal. At no charge, anyone with Internet access can use this service to ask questions about personal health-related and disease-related matters. Objective: To study why individuals choose to consult previously-unknown doctors on the Internet. Methods: Between November 1, 2001, and January 31, 2002 a Web survey of the 3622 Ask the Doctor service users, 1036 men (29%) and 2586 (71%) women, was conducted. We excluded 186 queries from users. The results are based on quantitative and qualitative analysis of the answers to the question "Why did you choose to ask a question at Infomedica's 'Ask the Doctor' service?" Results: 1223 surveys were completed (response rate 34%). Of the participants in the survey 322 (26%) were male and 901 (74%) female. As major reasons for choosing to consult previously-unknown doctors on the Internet participants indicated: convenience (52%), anonymity (36%), "doctors too busy" (21%), difficult to find time to visit a doctor (16%), difficulty to get an appointment (13%), feeling uncomfortable when seeing a doctor (9%), and not being able to afford a doctors' visit (3%). Further motives elicited through a qualitative analysis of free-text answers were: seeking a second opinion, discontent with previous doctors and a wish for a primary evaluation of a medical problem, asking embarrassing or sensitive questions, seeking information on behalf of relatives, preferring written communication, and (from responses by expatriates, travelers, and others) living far away from regular health care. Conclusions: We found that an Internet based Ask the Doctor service is primarily consulted because it is convenient, but it may also be of value for individuals with needs that regular health care services have not been able to meet.Item Open Access Adolescents Searching for Health Information on the Internet: An Observational Study(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-10-17) Hansen, Derek L ; Derry, Holly A ; Resnick, Paul J ; Richardson, Caroline R[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e25/ ] Background: Adolescents' access to health information on the Internet is partly a function of their ability to search for and find answers to their health-related questions. Adolescents may have unique health and computer literacy needs. Although many surveys, interviews, and focus groups have been utilized to understand the information-seeking and information-retrieval behavior of adolescents looking for health information online, we were unable to locate observations of individual adolescents that have been conducted in this context. Objective: This study was designed to understand how adolescents search for health information using the Internet and what implications this may have on access to health information. Methods: A convenience sample of 12 students (age 12-17 years) from 1 middle school and 2 high schools in southeast Michigan were provided with 6 health-related questions and asked to look for answers using the Internet. Researchers recorded 68 specific searches using software that captured screen images as well as synchronized audio recordings. Recordings were reviewed later and specific search techniques and strategies were coded. A qualitative review of the verbal communication was also performed. Results: Out of 68 observed searches, 47 (69%) were successful in that the adolescent found a correct and useful answer to the health question. The majority of sites that students attempted to access were retrieved directly from search engine results (77%) or a search engine's recommended links (10%); only a small percentage were directly accessed (5%) or linked from another site (7%). The majority (83%) of followed links from search engine results came from the first 9 results. Incorrect spelling (30 of 132 search terms), number of pages visited within a site (ranging from 1-15), and overall search strategy (eg, using a search engine versus directly accessing a site), were each important determinants of success. Qualitative analysis revealed that participants used a trial-and-error approach to formulate search strings, scanned pages randomly instead of systematically, and did not consider the source of the content when searching for health information. Conclusions: This study provides a useful snapshot of current adolescent searching patterns. The results have implications for constructing realistic simulations of adolescent search behavior, improving distribution and usefulness of Web sites with health information relevant to adolescents, and enhancing educators' knowledge of what specific pitfalls students are likely to encounter.Item Open Access What Are Patients Seeking When They Turn to the Internet? Qualitative Content Analysis of Questions Asked by Visitors to an Orthopaedics Web Site(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-10-10) Shuyler, Kristen S ; Knight, Kristin M[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/4/e24/ ] Background: More people than ever are turning to the Internet for health-related information, and recent studies indicate that the information patients find online directly affects the decisions they make about their health care. Little is known about the information needs or actual search behavior of people who use the Internet for health information. Objective: This study analyzes what people search for when they use a health-education Web site offering information about arthritis, orthopaedics, and sports-medicine topics. Additionally, it determines who is performing these searches: is it patients, friends or relatives of patients, or neither? Finally, it examines the similarities and differences among questions submitted by Web site visitors from different countries. Methods: Content analysis was performed on 793 free-text search queries submitted to a patient-education Web site owned and operated by the Department of Orthopaedics and Sports Medicine at the University of Washington Medical Center. The 793-query data set was coded into 3 schemes: (1) the purpose of the query, (2) the topic of the query, and (3) the relationship between the asker of the query and the patient. We determined the country from which each query was submitted by analyzing the Internet Protocol addresses associated with the queries. Results: The 5 most frequent reasons visitors searched the Web site were to seek: (1) information about a condition, (2) information about treatment, (3) information about symptoms, (4) advice about symptoms, and (5) advice about treatment. We were able to determine the relationship between the person submitting the query and the patient in question for 178 queries. Of these, the asker was the patient in 140 cases, and the asker was a friend or relative of the patient in 38 cases. The queries were submitted from 34 nations, with most coming from the United States, Australia, the United Kingdom, and Canada. When comparing questions submitted from the United States versus those from all other countries, the 3 most frequent types of questions were the same for both groups (and were the top 3 question types listed above). Conclusions: These results provide the University of Washington Department of Orthopaedics and Sports Medicine, as well as other organizations that provide health-information Web sites, with data about what people around the world are seeking when they turn to the Internet for health information. If Web site managers can adapt their health-information Web sites in response to these findings, patients may be able to find and use Internet-based health information more successfully, enabling them to participate more actively in their health care.Item Open Access A Web-Based Screening Instrument for Depression and Anxiety Disorders in Primary Care(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-09-29) Farvolden, Peter ; McBride, Carolina ; Bagby, R Michael ; Ravitz, Paula[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e23/ ] Background: Major depressive disorder (MDD) and anxiety disorders are common and result in considerable suffering and economic loss. People suffering from major depressive disorder and/or anxiety disorders are commonly encountered in the primary care setting. Unfortunately, most people with these disorders remain either untreated or inadequately treated; current data suggest that general practitioners fail to diagnose up to half of cases of major depressive disorder or anxiety. There is a need for screening tools that will help physicians and other professionals in primary care recognize and adequately treat major depressive disorder and anxiety disorders. While the currently-available self-report screening instruments have been demonstrated to be reliable and valid, there remain considerable barriers to their widespread use in primary care. Objective: The purpose of the present study is to report preliminary validation data for a freely-available, brief, Web-based, self-report screener for major depressive disorder and anxiety disorders. Methods: The Web-Based Depression and Anxiety Test (WB-DAT) was administered to 193 subjects who presented for assessment and/or treatment in ongoing research projects being conducted at the Mood and Anxiety Program and Clinical Research Department at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Subjects completed the Web-based screening instrument and were subsequently interviewed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis I Disorders (SCID-I/P). The diagnostic data from the screening instrument were then compared with the data from the individual's SCID-I/P interview. Diagnostic concordance between SCID-I/P diagnoses and the Web-Based Depression and Anxiety Test were assessed using Cohen's kappa, sensitivity, specificity, positive predictive value, negative predictive value, and efficiency. Results: Agreement ranged from acceptable to good (0.57-0.70) for major depressive disorder, panic disorder with and without agoraphobia (PD+/-AG), social phobia/social anxiety disorder, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), and post traumatic stress disorder (PTSD). With the exception of generalized anxiety disorder, the sensitivity (0.71-0.95) and specificity (0.87-0.97) for the major diagnostic categories assessed by the Web-Based Depression and Anxiety Test were good. The sensitivity for generalized anxiety disorder was somewhat lower (0.63) but acceptable. Positive predictive values were good (0.60-0.75) for major depressive disorder, obsessive compulsive disorder, generalized anxiety disorder, and post traumatic stress disorder, and acceptable for panic disorder with and without agoraphobia and for social phobia/social anxiety disorder. Conclusions: These preliminary data suggest that the Web-Based Depression and Anxiety Test is reliable for identifying patients with and without major depressive disorder and the anxiety disorders of panic disorder with and without agoraphobia, social phobia/social anxiety disorder, obsessive compulsive disorder, and post traumatic stress disorder. Further research is required in a larger sample in primary care.Item Open Access Use and Utility of Web-Based Residency Program Information: A Survey of Residency Applicants(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-09-25) Embi, Peter J ; Desai, Sima ; Cooney, Thomas G[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e22/ ] Background: The Internet has become essential to the residency application process. In recent years, applicants and residency programs have used the Internet-based tools of the National Residency Matching Program (NRMP, the Match) and the Electronic Residency Application Service (ERAS) to process and manage application and Match information. In addition, many residency programs have moved their recruitment information from printed brochures to Web sites. Despite this change, little is known about how applicants use residency program Web sites and what constitutes optimal residency Web site content, information that is critical to developing and maintaining such sites. Objective: To study the use and perceived utility of Web-based residency program information by surveying applicants to an internal medicine program. Methods: Our sample population was the applicants to the Oregon Health & Science University Internal Medicine Residency Program who were invited for an interview. We solicited participation using the group e-mail feature available through the Electronic Residency Application Service Post-Office application. To minimize the possibility for biased responses, the study was confined to the period between submission of National Residency Matching Program rank-order lists and release of Match results. Applicants could respond using an anonymous Web-based form or by reply to the e-mail solicitation. We tabulated responses, calculated percentages for each, and performed a qualitative analysis of comments. Results: Of the 431 potential participants, 218 responded (51%) during the study period. Ninety-nine percent reported comfort browsing the Web; 52% accessed the Web primarily from home. Sixty-nine percent learned about residency Web sites primarily from residency-specific directories while 19% relied on general directories. Eighty percent found these sites helpful when deciding where to apply, 69% when deciding where to interview, and 36% when deciding how to rank order programs for the Match. Forty-nine percent found sites most useful in deciding where to apply, while 40% found them most useful while preparing for their interviews. Seventy-two percent felt that a "complete" Web site could substitute for a mailed printed brochure. Qualitative analysis identified additional important information needs. Conclusions: Applicants are turning to residency Web sites for information during critical phases of the application process. Though usually helpful, many of these sites are felt to be incomplete and may not be meeting important applicant information needs. These findings should be useful to those involved in residency recruitment efforts and in counseling applicants.Item Open Access Trusted Online Sources of Health Information: Differences in Demographics, Health Beliefs, and Health-Information Orientation(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-09-25) Dutta-Bergman, Mohan[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e21/ ] Background: The recent surge in online health information and consumer use of such information has led to expert speculations and prescriptions about the credibility of health information on the World Wide Web. In spite of the growing concern over online health information sources, existing research reveals a lacuna in the realm of consumer evaluations of trustworthiness of different health information sources on the Internet. Objective: This study examines consumer evaluation of sources of health information on the World Wide Web, comparing the demographic, attitudinal, and cognitive differences between individuals that most trust a particular source of information and individuals that do not trust the specific source of health information. Comparisons are made across a variety of sources. Methods: The Porter Novelli HealthStyles database, collected annually since 1995, is based on the results of nationally-representative postal-mail surveys. In 1999, 2636 respondents provided usable data for the HealthStyles database. Independent sample t tests were conducted to compare the respondents in the realm of demographic, attitudinal, and cognitive variables. Results: The most trusted sources of online health information included the personal doctor, medical university, and federal government. The results demonstrated significant differences in demographic and health-oriented variables when respondents who trusted a particular online source were compared with respondents that did not trust the source, suggesting the need for a segmented approach to research and application. Individuals trusting the local doctor were younger ( t 2634= 4.02, P< .001) and held stronger health beliefs (F 1= 5.65, P= .018); individuals trusting the local hospital were less educated ( t 2634= 3.83, P< .001), low health information oriented (F 1= 6.41, P= .011), and held weaker health beliefs (F 1= 5.56, P= .018). Respondents with greater trust in health insurance companies as online health information sources were less educated ( t 2634= 1.90, P= .05) and less health information oriented (F 1= 4.30, P= .04). Trust in medical universities was positively associated with education ( t 2634= 11.83, P< .001), income ( t 2634= 10.19, P< .001), and health information orientation (F 1= 10.32, P<.001). Similar results were observed in the realm of federal information credibility, with individuals with greater trust in federal sources being more educated ( t 2634= 7.45, P< .001) and health information oriented (F 1= 4.45, P= .04) than their counterparts. Conclusions: The results suggest systematic differences in the consumer segment based on the different sources of health information trusted by the consumer. While certain sources such as the local hospital and the health insurance company might serve as credible sources of health information for the lower socioeconomic and less health-oriented consumer segment, sources such as medical universities and federal Web sites might serve as trustworthy sources for the higher socioeconomic and more health-oriented groups.Item Open Access Designing Tailored Web-Based Instruction to Improve Practicing Physicians' Preventive Practices(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-09-24) Casebeer, Linda L ; Strasser, Sheryl M ; Spettell, Claire M ; Wall, Terry C ; Weissman, Norman ; Ray, Midge N ; Allison, Jeroan J[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e20/ ] Background: The World Wide Web has led to the rapid growth of medical information and continuing medical educational offerings. Ease of access and availability at any time are advantages of the World Wide Web. Existing physician-education sites have often been designed and developed without systematic application of evidence and cognitive-educational theories; little rigorous evaluation has been conducted to determine which design factors are most effective in facilitating improvements in physician performance and patient-health outcomes that might occur as a result of physician participation in Web-based education. Theory and evidence-based Web design principles include the use of: needs assessment, multimodal strategies, interactivity, clinical cases, tailoring, credible evidence-based content, audit and feedback, and patient-education materials. Ease of use and design to support the lowest common technology denominator are also important. Objective: Using these principles, design and develop a Web site including multimodal strategies for improving chlamydial-screening rates among primary care physicians. Methods: We used office-practice data in needs assessment and as an audit/feedback tool. In the intervention introduced in 4 phases over 11 months, we provided a series of interactive, tailored, case vignettes with feedback on peer answers. We included a quality-improvement toolbox including clinical practice guidelines and printable patient education materials. Results: In the formative evaluation of the first 2 chlamydia modules, data regarding the recruitment, enrollment, participation, and reminders have been examined. Preliminary evaluation data from a randomized, controlled trial has tested the effectiveness of this intervention in improving chlamydia screening rates with a significant increase in intervention physicians' chlamydia knowledge, attitude, and skills compared to those of a control group. Conclusions: The application of theory in the development and evaluation of a Web-based continuing medical education intervention offers valuable insight into World Wide Web technology's influence on physician performance and the quality of medical care.Item Open Access Multimedia Formats for Patient Education and Health Communication: Does User Preference Matter?(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-08-29) Wiljer, David ; Catton, PamItem Open Access Just-in-time Database-Driven Web Applications(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-08-29) Ong, Kenneth R[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e18/ ] : "Just-in-time" database-driven Web applications are inexpensive, quickly-developed software that can be put to many uses within a health care organization. Database-driven Web applications garnered 73873 hits on our system-wide intranet in 2002. They enabled collaboration and communication via user-friendly Web browser-based interfaces for both mission-critical and patient-care-critical functions. Nineteen database-driven Web applications were developed. The application categories that comprised 80% of the hits were results reporting (27%), graduate medical education (26%), research (20%), and bed availability (8%). The mean number of hits per application was 3888 (SD = 5598; range, 14-19879). A model is described for just-in-time database-driven Web application development and an example given with a popular HTML editor and database program.Item Open Access The Impact of Health Information on the Internet on Health Care and the Physician-Patient Relationship: National U.S. Survey among 1.050 U.S. Physicians(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-08-29) Murray, Elizabeth ; Lo, Bernard ; Pollack, Lance ; Donelan, Karen ; Catania, Joe ; Lee, Ken ; Zapert, Kinga ; Turner, Rachel[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e17/ ] Background: Public use of the Internet for health information is increasing but its effect on health care is unclear. We studied physicians' experience of patients looking for health information on the Internet and their perceptions of the impact of this information on the physician-patient relationship, health care, and workload. Methods: Cross-sectional survey of a nationally-representative sample of United States physicians (1050 respondents; response rate 53%). Results: Eighty-five percent of respondents had experienced a patient bringing Internet information to a visit. The quality of information was important: accurate, relevant information benefited, while inaccurate or irrelevant information harmed health care, health outcomes, and the physician-patient relationship. However, the physician's feeling that the patient was challenging his or her authority was the most consistent predictor of a perceived deterioration in the physician-patient relationship (OR = 14.9; 95% CI, 5.5-40.5), in the quality of health care (OR = 3.4; 95% CI, 1.1-10.9), or health outcomes (OR = 5.6; 95% CI, 1.7-18.7). Thirty-eight percent of physicians believed that the patient bringing in information made the visit less time efficient, particularly if the patient wanted something inappropriate (OR = 2.5; 95% CI, 1.5-4.4), or the physician felt challenged (OR = 3.6; 95% CI, 1.8-7.2). Conclusions: The quality of information on the Internet is paramount: accurate relevant information is beneficial, while inaccurate information is harmful. Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so. A minority of physicians feels challenged by patients bringing health information to the visit; reasons for this require further research.Item Open Access Evaluation of New Multimedia Formats for Cancer Communications(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-08-29) Bader, Judith L ; Strickman-Stein, Nancy[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e16/ ] Background: Providing quality, current cancer information to cancer patients and their families is a key function of the National Cancer Institute (NCI) Web site. This information is now provided in predominantly-text format, but could be provided in formats using multimedia, including animation and sound. Since users have many choices about where to get their information, it is important to provide the information in a format that is helpful and that they prefer. Objective: To pilot and evaluate multimedia strategies for future cancer-information program formats for lay users, the National Cancer Institute created new multimedia versions of existing text programs. We sought to evaluate user performance and preference on these 3 new formats and on the 2 existing text formats. Methods: The National Cancer Institute's "What You Need to Know About Lung Cancer" program was the test vehicle. There were 5 testing sessions, 1 dedicated to each format. Each session lasted about 1 hour, with 9 participants per session and 45 users overall. Users were exposed to the assigned cancer program from beginning to end in 1 of 5 formats: text paperback booklet, paperback booklet formatted in HTML on the Web, spoken audio alone, spoken audio synchronized with a text Web page, and Flash multimedia (animation, spoken audio, and text). Immediately thereafter, the features and design of the 4 alternative formats were demonstrated in detail. A multiple-choice pre-test and post-test quiz on the cancer content was used to assess user learning (performance) before and after experiencing the assigned program. The quiz was administered using an Authorware software interface writing to an Access database. Users were asked to rank from 1 to 5 their preference for the 5 program formats, and provide structured and open-ended comments about usability of the 5 formats. Results: Significant improvement in scores from pre-test to post-test was seen for the total study population. Average scores for users in each of the 5 format groups improved significantly. Increments in improvement, however, were not statistically different between any of the format groups. Significant improvements in quiz scores were seen irrespective of age group or education level. Of the users, 71.1% ranked the Flash program first among the 5 formats, and 84.4% rated Flash as their first or second choice. Audio was the least-preferred format, ranking fifth among 46.7% of users and first among none. Flash was ranked first among users regardless of education level, age group, or format group to which the user was assigned. Conclusions: Under the pilot study conditions, users overwhelmingly preferred the Flash format to the other 4 formats. Learning occurred equally in all formats. Use of multimedia should be considered as communication strategies are developed for updating cancer content and attracting new users.Item Open Access Information Gathering Over Time by Breast Cancer Patients(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-08-27) Satterlund, Melisa J ; McCaul, Kevin D ; Sandgren, Ann K[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/3/e15/ ] Background: Unlike many patients of the past, today's health-care users want to become more informed about their illnesses, and they want the most current information. The Internet has become a popular way to access current information, and since its introduction more people are turning to it to find medical information. Studies report that anywhere from 36% to 55% of the American population that use the Internet is using the Internet to research medical information, and these percentages have been rising. Cancer is 1 of the top 2 diseases about which people seek information on the Internet. Some studies have specifically asked whether breast cancer patients access the Internet for medical information; estimates range from 10% to 43% of breast cancer patients who use the Internet, with higher usage being associated with more education, greater income, and younger age. Objective: To identify where breast cancer patients find medical information about their illness and to track changes over time, from active treatment to survivorship status. Methods: Participants were 224 women who had been recently diagnosed with Stage I, Stage II, or Stage III breast cancer. Each woman was contacted approximately 8 months and 16 months after diagnosis and was asked about 10 different information sources they could have used to obtain information or support about their breast cancer. Results: Eight months after diagnosis, the top 3 information sources used by women were books (64%), the Internet (49%), and videos (41%). However, at follow-up (16 months after diagnosis), the most frequently cited information source was the Internet (40%), followed by books (33%), and the American Cancer Society (17%). We found that women continued to use the Internet as a means of gathering information even after their treatment ended. Significant unique predictors of Internet use were more years of formal education and younger ages. Cancer stage was not a significant predictor of Internet use. Conclusions: Previous research has been mixed about the percentage of cancer patients who use the Internet to gather information about their illnesses. The results of the present study corroborate 2 other data sets of breast cancer patients, as just over 44% of the women reported using the Internet after diagnosis. Sixteen months after diagnosis, the percentage of women using the Internet dropped slightly, but other chief sources dropped sharply at that time. The Internet continues to play an important role for cancer survivors after medical treatment has ended, and health professionals can use this knowledge to provide their patients with Internet advice.Item Open Access Doctors Who Are Using E-mail With Their Patients: a Qualitative Exploration(Gunther Eysenbach; Centre for Global eHealth Innovation, Toronto, Canada, 2003-05-15) Patt, Madhavi R ; Houston, Thomas K ; Jenckes, Mollie W ; Sands, Daniel Z ; Ford, Daniel E[This item is a preserved copy and is not necessarily the most recent version. To view the current item, visit http://www.jmir.org/2003/2/e9/ ] Background: Despite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted. Objective: To survey physicians currently using e-mail with their patients daily to understand their experiences. Methods: In-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus. Results: Almost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear. Conclusions: These physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices.