Medical information and the World Wide Web

Separating the signal from the noise

MJA 1997; 167: 571-572

Ideally, the practice of medicine in Australia should combine the best of scientific medicine and the traditions of Sir William Osler, the pre-eminent physician of the turn of the century. The art of Osler's medical practice was to foster a personal relationship based on trust and confidence and make this relationship intrinsic to the therapeutic process.1 Before the explosion of biomedical knowledge and technology, the communication of clinical information was not central to this patient-doctor relationship. The generation whose expectations were shaped by the Depression and World War II tended to respect the medical system and to follow doctors' orders without actively pursuing or questioning health matters.2 In stark contrast is the unquenchable thirst of the "baby boomers" for medical information. Their assertive consumerism and aggressive pursuit of information and choice2 has been accompanied by an explosion of mass media medical information. With this societal paradigm shift, the provision of clinical information is now integral to building trust and confidence in the patient-doctor relationship; in fact, the Consumer Health Forum of Australia recently reported that "consumers want communication by medical and hospital staff to enable patients, patients' families and carers to be better informed", and that "up to date information is essential to ensure that informed decision making processes are in place".3 Thus, the provision of reliable and relevant information has become a primary component of quality health care.4 There is no doubt that the Internet, particularly the World Wide Web (WWW), represents one of the most powerful vehicles yet created for disseminating such information.5 The opportunities for rapid communication and education are clear, and access to health care information on the Web should be of major benefit to both consumers and providers of health care. In June of this year, the United States National Library of Medicine, part of the National Institutes of Health (Bethesda, Maryland), inaugurated a program of free access for all Americans to MEDLINE -- the world's most extensive collection of published medical information -- on the Web.6 Announcing the service, the United States Secretary for Health and Human Services, Donna Shalala, said: "American citizens now have at their fingertips both the scientific information gathered by the National Library of Medicine as represented by MEDLINE and the extensive consumer information on Healthfinder.7 We are committed to using the new technology including the WWW and the Internet to provide health information to the public."8 However, the Web, despite its promise to deliver medical information and the presence of high quality medical resources (including medical journals such as The Medical Journal of Australia 9 ), is ruled by anarchy and information bedlam prevails. Anybody with a computer and Internet connection can be an author, editor and publisher rolled into one, and can do so anonymously. There is no accountability for the quality and safety of information. Impicciatore et al. recently surveyed the accuracy of medical advice management of fever in children on the Web.10 The keywords "fever management", "child" and "parent information" retrieved 41 Web pages, 32 produced by commercial ventures and nine by individual practitioners, clinics, academic institutions or other educational organisations. Only four of these pages adhered closely to the main recommendations of conventionally published guidelines. The authors of the report suggested there was an urgent need to check public-oriented health care information on the Internet for accuracy, completeness and consistency.10 This should not be terribly surprising. After all, those with medicopolitical or commercial agendas have the same access to the Web as those seeking to publish science. The activities of the former are illustrated by the unreferenced claims and rhetoric of pressure groups11 as well as the growing number of dubious or even preposterous health claims on the Web (e.g., shark cartilage has been "shown to be effective in inhibiting tumour growth and cancer; helpful in the treatment of arthritic conditions, macular degeneration, psoriasis and cartilage support"; and melatonin "strengthens the immune system, and reduces free radicals in the body"12 ). The simple search words "alternative medicine" open a virtual bazaar in the US, offering a wide variety of substances to treat any ailment.12 Despite the glitter and buzz of the technology, publishing medical information on the Web still relies on content; Silberg and colleagues argued recently that the quality criteria applied to medical information in print should be applied equally in the electronic world.13 The International Committee of Medical Journal Editors has agreed on a minimum set of benchmarks for medical information posted on the Internet (Box). Others have outlined criteria useful for evaluating Web pages and ways of measuring their impact.13,15 Criteria include: Credibility and conflict of interest (owner or sponsor of site; author credentials); and Structure and content of site (reference to sources; scope, accuracy and currency of content; readability; quality of links to other sites; media used to communicate material; function and impact of site). There is no reason that medical information on the Web should not receive the same scrutiny for its impact on clinical outcome and cost effectiveness as other methods of delivering the same information. Efforts to assess the quality of medical information are under way. For example, the Geneva-based Health on the Net Foundation has established a six-point code of conduct for sites providing medical information.16 In the United Kingdom, the Organising Medical Network Information initiative is attempting to provide a gateway to high quality biomedical information for the higher education and research communities.17 These initiatives to ensure quality of medical information on the Web are not attempts to stifle or censor information. Patients and medical practitioners are faced with an enormous quantity of information of variable quality, and the calls for rigorous adherence to quality are attempts to separate the wheat from the chaff, the useful from the harmful.11 The time has come for active regulation or accreditation of health care Web sites. After all, the health of the people of our global village is at stake. Martin B Van Der Weyden Editor, The Medical Journal of Australia Wheeler HB. Shotkick Lecture: healing and heroism. N Engl J Med 1990; 322: 1540-1548. Moloney TW, Paul B. Rebuilding public trust and confidence. In: Gertius M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patient's eyes. San Francisco: Jossey-Bass Publishers, 1993: 280-298. Consumer Health Forum of Australia Inc. Consultations on a health service standard report. A report to the Department of Health and Family Services on consumer community consultations. Lyons, ACT. Consumer Health Forum of Australia Inc, 1996. Daley J. Understanding and promoting patient centre care. In: Gertius M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patient's eyes. San Francisco: Jossey-Bass Publishers, 1993: 72-95. Coiera E. Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall, 1997: 275-292. PubMed: URL: http://www.ncbi.nlm.nih.gov/PubMed URL: http://www.healthfinder.gov National Institutes of Health. National Library of Medicine press release. 26 June 1997. URL: http://www.mja.com.au Impicciatore P, Pandolfini C, Casella N, Bonati M. Reliability of health information on the world wide web: systematic survey of advice on managing fever in children at home. BMJ 1997; 314: 1875-1879. Australian Vaccination Network: http://www.ozemail.com.au/~shotinfo/ Bower H. Internet sees growth of unverified health claims. BMJ 1996; 313: 381. Silberg WM, Lundberg GD, Musacchio RA. Assessing controlling and asuring quality of medical information on the Internet. JAMA 1997; 277: 1244-1245. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. JAMA 1997; 277: 927-934. Wyatt JC. Commentary: measuring quality and impact on the world wide web. BMJ 1997; 314: 1879-1881. Health on the Net Foundation. http://www.hon.ch Coiera E. The Internet's challenge to health care provision. BMJ 1996; 312: 3-4.

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