The Pharmaceutical Journal
Vol 268 No 7188 p324
9 March 2002

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Six-point plan helps assess quality of internet health information

By Mark Duman, Antony D'Emanuele and D. K. Theo Raynor

As with medicines and other health care interventions, potent instruments like the internet have risks as well as benefits. Ease of publication on the internet has undoubtedly resulted in many poor quality health-related websites, which can lead to harm. However, the current drive to develop rating and accreditation systems to protect the public is misguided, in terms of both its desirability and likely effectiveness.

Delamothe first questioned whether quality rating of websites was the right approach¹ and the resultant debate has produced cogent arguments on both sides. We have concluded that he is right, basing our arguments on issues of philosophy, practicalities and resources.

First is the issue of whether such systems of control are desirable. The internet has evolved as a medium for people to communicate and share information freely. Are we challenging this philosophy by attempting to "police" the internet? Many governments and organisations are strongly encouraging consumer empowerment. Yet imposing accreditation systems could affect how people access and choose information to help them make their own decisions. These schemes directly oppose the developing philosophy of patient empowerment. Health information has long been available via many other sources and in most cases, consumers appear to be able to separate the wheat from the chaff.

The motives may be in part the status and potential financial benefits associated with a global accreditation scheme. Many such schemes have been proposed, some with an impressive pedigree, such as Health on the Net Foundation and MedCERTAIN. This variety is potentially confusing for both the health professional and the consumer. But who is driving the process? Regulators, with best intentions, rarely represent the wishes of their constituents. It is also unclear how well informed the public are of these initiatives, and whether accreditation bodies have sought any feedback and involvement from the "consumer". Who sits on these bodies? What evidence do they have that consumers want, and more importantly will actually use, such schemes? A US survey by California Health Care Foundation, found that more than 50 per cent said that "seals of approval" would have no impact on them.

Conceptually they appear to offer grand solutions, but in reality there is often little detail on how this mammoth task will be undertaken. Eysenbach described the Med-CERTAIN system as analogous to a food label² and different from the conventional idea of a kitemark (allowing the consumer to judge the quality of the information provider themselves). Unfortunately, this "trustmark" would have many if not all of the disadvantages of its competitor marks in terms of practicality and resource.

Most instruments appear incomplete and many use different evaluation criteria (many do not state their criteria), and provide limited guidance to their usage. A review of 29 rating tools by Kim et al³ suggested that a consensus was developing of critical criteria for evaluating web-based health information and suggested that a clear set of consensus criteria be developed that the public can understand. It is not clear how so many competing organisations would be able to work together to achieve this goal and the subsequent tripartite "eHealth Code of Ethics" is acknowledged as only being an "aspirational framework".⁴

Organisations endeavouring to certify or develop quality standards face a colossal, perhaps unrealistic task. It has been estimated that there are presently at least 100,000 medically related sites and Jordan⁵ concluded that establishing and running a comprehensive kite-marking system in the UK would involve tens if not hundreds of people, including subject experts, information professionals and designers. It would probably cost many millions of pounds and involve untold bureaucracy, and state funding is unlikely. Is this a cost-effective and appropriate way to spend tax-payers' money? Who would do this and how is unclear. There are many unanswered questions, eg, is a Western reviewing body qualified to accredit a Chinese medicine information site?

Given the resources likely to be required for these accreditation schemes, will organisations that are accredited become the elite (ie, those who can afford to pay to have their sites reviewed)? It is not feasible to provide accreditation as a free service, thus many excellent sites would simply be excluded. A more practical, feasible and acceptable approach involves self-accreditation of health information by the public, in partnership with their health care professional(s). Existing guidelines could be applied⁶ to educate users to review:

• Authorship — who are the authors of the site, are they qualified to provide the information, and what are their affiliations?

• Attribution — is the information reliable, is it referenced?

• Currency — is the information up to date?

• Disclosure — who owns/sponsors the site, do they have a vested interest?

• Audience — states intended recipients and targets information accordingly

• Double check — use more than one source, and where possible in co-operation with health professionals

Health professionals have a key role to play in helping patients to evaluate information on the internet. Professionals should be readily accessible and themselves familiar with applying the above principles. A physician in California delivers workshops aimed at educating the public on health information assessment via the internet. It is clear that consumers could drive health professionals to improve their knowledge of the internet. A key driver could be the World Health Organization in promulgating the above six points to consumers and professionals.

The internet is transforming health care, and we are witnessing a communications revolution where large amounts of information can be shared among people. Accreditation systems are an admirable concept, but they may not be desirable, or achievable. Delamothe concluded that legislators should await evidence that interventions would improve human health.1 In the meantime, a more practical approach would be to support the public in self-accrediting information. Doing so, in co-operation with health professionals, supports the philosophies of quality improvement, concordance and improves communication.

Mark Duman is head of health care markets, Hutchison 3G UK Ltd. Antony D'Emanuele is senior lecturer at Manchester University school of pharmacy. Theo Raynor is professor of pharmacy practice, medicines and their users at the University of Leeds