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Rapid Responses: Rapid Responses published:
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Honcode seal presence in the medical web sites.Guarantee of reliableness?
- Moro Quesada Daniel, Díez Jarilla José Luis (12 March 2002)
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prevalence of internet acces and use for medical information
- Andrew J Larner (2 April 2002)
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Popularity of Medical Sites and the Internet as a Scale-Free Network
- Ken A Masters, Lauraine Vivian, Mary-Ann Davies (29 September 2003)
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Please Don't Blame 'The Internet' or Google for 'Pilot Error'
- Trevor G Marshall (30 September 2003)
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Teaching the Pilot the currents
- Ken A Masters, Lauraine Vivian, Mary-Ann Davies (4 December 2003)
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Moro Quesada Daniel, Family Physician Gerencia de Atención Primaria. Area IV, Pumarín, 33011 Oviedo, Asturias, Spain, Díez Jarilla José Luis
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EDITOR- Health on the Net is a non-profit foundation with an eight point code of conduct for sites providing health Information (Honcode)(1). We agree with Meric F. and colleges(2) and with, Shepperd S. and Charnock D.(3). on their affirmations about kitemarks or any other quality seals for medical webs. In fact, we would like to draw your attention about another interesting subject related to the Honcode seal.
In a pilot study (unpublished) on the quality of profesional medical web, we evaluated the compliance with Honcode of the webs carrying the Honcode seal, verifying if every web had their specific codenumber given by Honcode (obtained after clicking the seal), and registering the date of the last revision. We looked for webs containing the words “professional medical web” as well as “Honcode” and then we recorded the presence of the seal, site´s locations, the state of the agreement with Honcode and the date of the last review.
We did this using the FAST ( www.alltheweb.com) searchengine (accessed on January 22, 2002). Initially, it offered 48299 sites but did not facilitate more than 4000. As long as 3744 were repeated, there were only 256 different sites of which 185 showed the seal and 69 did not. From these 185 showing the seal, there were 94 (50.81%) in compliance with Honcode with an average of update (respect 15/02/02) of 693 days. On the other hand, there were 91 webs (49.18%) showing the seal unproperly, without permission or during the evaluation period.
Honcode has for some time been promoting a code of conduct and there have been several overlapping initiatives in the United States(4), but then again, their main drawback is that there is no external verification so the system becomes open to abuse. Indeed, the Honcode seal presence is not enough to guarantee credibleness at medical web sites.
Daniel Moro Quesada , MD, Family Physician, Gerencia de Atención Primaria
, Area IV, Oviedo, 33011 Asturias, Spain
José Luis Díez Jarilla, MD, Professor of Internal Medicine, University
Hospital, 33006 Oviedo, Asturias, Email Competing interests: None declared
1.- Health On the Net Foundation. HON code of conduct (HONcode) for medical and health web sites: principles. www.hon.ch/HONcode/Conduct.html. 2.- Meric F, Bernstam E V, Mirza N Q, Hunt K K, Ames F C, Ross M I, et al. Breast cancer on the world wide web: cross sectional survey of quality of information and popularity of websites. BMJ 2002;324:577- 581[Abstract/Full Text] 3.- Shepperd S. , Charnok D. Against internet exceptionalism. BMJ 2002; 324 : 556-557.[ Full Text] 4.- Rigby M, Forsström J, Roberts R, Wyatt J. Verifying quality and safety in health informatics services. BMJ 2001;323:552-556.[Abstract/Full Text] |
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Andrew J Larner, consultant neurologist walton centre for neurology and neurosurgery, liverpool, L9 7LJ
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EDITOR - Only two articles in your Internet theme issue (9th March) mentioned the prevalence of Internet access and website use to search for medical information amongst “patients” (or “medical endusers”), and then only in passing.1,2 Although the quality of medical information available on the web is crucial, as emphasized in the theme issue, its direct relevance to the practice of medicine depends on how many people use it and whether they access the correct information. Data from the USA suggest 40-54% of patients,1 or 100 million adults regularly go on line for information about health care.2 Are these figures reflective of the situation in the UK? I have informally surveyed consecutive new outpatients in general neurology clinics at two district general hospitals in north-west England (January to March 2001;3 and January to March 2002); and patients and their families and/or carers attending a cognitive function clinic at a regional neurosciences centre (October 2001 to March 2002). Questions were asked about Internet access and use (very rarely was this information spontaneously volunteered).3 The results (Table) suggest fewer UK patients and/or families access website medical information than in the USA. Inappropriate self-diagnosis, a legitimate concern in any form of self-directed information-seeking behaviour, occurred as a consequence of 21% to 33% of Internet searches in the general neurology clinic populations. When asked the hypothetical question whether a website with relevant information would be accessed if this suggestion came directly from the clinic doctor, 82% of patients and families/carers attending the cognitive function clinic answered in the affirmative, a figure comparable with that from an American genetic disorders clinic (92%).4 Asking patients whether they have accessed the Internet, what they have discovered, and being ready to suggest appropriate websites, may be an increasingly important component of the clinical consultation.
TABLE
Clinic General General Cognitive
(Jan-March 2001)(Jan-March 2002) (Oct 2001-March 2002)
n 198 211 104
Internet access:
33% 38% 52%
AJ Larner 1. Meric F, Bernstam EV, Mirza NQ et al. Breast cancer on the world wide web: cross sectional survey of quality of information and popularity of websites. BMJ 2002; 324: 577-81 (9th March). 2. Wilson P. How to find the good and avoid the bad or ugly: a short guide to tools for rating quality of health information on the internet. BMJ 2002; 324: 598-602 (9th March). 3. Larner AJ. Use of Internet medical websites and of NHS Direct by neurology outpatients prior to consultation. Int J Clin Pract 2002; 56: (in press). 4. Taylor MRG, Alman A, Manchester DK. Use of the Internet by patients and their families to obtain genetics-related information. Mayo Clin Proc 2001; 76: 772-6. |
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Ken A Masters, Director: IT (Education), Faculty of Health Sciences University of Cape Town, Observatory, 7925, Lauraine Vivian, Mary-Ann Davies
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The value of popularity in the results in the paper by Merc, Bernsram and Mirrza et al ([1]), is indicative of deeper mechanisms and broader problems of search engine results on medical and other sites. Although Google indeed measures the number of links to a page, it is not simply the number of direct links that determine the value. Google's PageRank system applies a weighting factor to each page, and that weighting factor is carried over to any further pages [2,3]. This means that, in order to measure "popularity" based on links, not only should the number of linking pages be counted; for each of those linking pages, their popularity is also determined by the number of linking pages, and should also be counted. Further, recent studies into the structure of the Internet reveal it as a scale-free network, defined loosely as a network in which a large number of nodes have a minimum number of connections, and a small number of nodes have a large number of connections (or links) ([4,5,6]). The importance of this is that not only does Google read this scale-free structure, but actually contributes to it by increasing access to the very "popular" sites [7]. (The fact that other search engines are also used, does not detract from this, as, in many cases, these are powered by Google). In a recent study we asked South African undergraduate medical students to search for sites related to a case of a child with rheumatic heart disease in South Africa. The overwhelming use of Google and Google-powered search engines led to a significant favouring of a few, mainly US sites, with very little reference to local sites [7]. This has several implications, for new sites and for sites outside the US. An added problem, morevoer, is verifiability. When a researcher finds a "strange" fact in a journal, a common method of verification is to look for other supporting literature. Because the Internet has limited enforceable controls regarding copying, material has often been copied from one site to another by web page authors who have not identified errors. The very fact of copying, however, serves to duplicate the error. The unsuspecting researcher, finding these "supporting" references, perceives the error to be validated. This is of grave concern to medical practitoners and educators whose students use the Internet for research.
Competing interests: None declared |
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Trevor G Marshall, Managing Editor JOIMR.org California 91360
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Click here to perform a search of google for "child with rheumatic heart disease in South Africa". I fail to see any "significant favoring of a few, mainly US sites", unless PubMed is regarded as a "US site"? The Internet is indeed presenting major problems for traditional medical
publishing. Where one might have, in the past,
been able to cite an obscure reference with little expectation that anybody
would actually go and try to locate it,
the Internet researcher expects such key citations to be supplied as links,
and to be verifiable and accurate. Competing interests: None declared |
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Ken A Masters, Director: IT (Education), Faculty of Health Sciences University of Cape Town, Observatory, 7925, Lauraine Vivian, Mary-Ann Davies
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One of the issues raised in our previous correspondence concerned the number of US sites found by South African medical students when researching a topic. This was raised in the context of discussing the mechanism of PageRank and the structure of the Internet. Dr Marshall is quite correct when he points out that the Internet and Google should not be blamed for "pilot error" - we don't wish them to be blamed; we wish them to be understood so that they can be used appropriately by patients and students. For that reason, we should have written "The overwhelming or undiscerning use of Google…" rather than "The overwhelming use of Google…" In the link supplied, Dr Marshall demonstrates very effectively that adding the country to the search phrase immediately reduces the number of non-South African sites. The problem is that when students (and possibly patients) wish to investigate a medical condition, there is a tendency to enter only the name of the condition as the search phrase, as our students did in the study we mentioned. Under these circumstances, the nature of the Internet and Google is to deliver mostly US sites. Patients and students need to be aware of why these are not necessarily the most appropriate sites (they're not even necessarily the most appropriate sites in the US); rather, these are the sites delivered based on the search phrase, Google's PageRank, and the nature of the Internet. PageRank is not necessarily either bad or good; it is merely a particular system. Once it is understood, patients and students have a greater chance of understanding the nature and implications of the search result, and are in a better position to utilise the power of the Internet. They are also less likely to be duped by those sites that exploit the nature of PageRank and the Internet in order to increase ranking (such as the use of "link farms" and paid reciprocal linking). The first, and most sensible approach, as given by Dr Marshall, is to include the region or country in the search phrase. But even that should be used in conjunction with rather than in place of searches that exclude the country or region. In our example, to search for only South African sites would run the risk of ignoring a wealth of foreign experience and research. In addition, the listing resulting from such a search in Google reduces the scope, but still lists them according to PageRank's criteria - again students and patients need to realise that these might not necessarily be the most appropriate SA sites. A second step should be to attempt to gauge the date of the site, for PageRank sometimes allows old sites (because of the number of links to them) to rate unexpectedly highly. This occurs not only in the medical field. A current search on "most commonly used search engines" using Google yielded a document in #2 position at http://www.ariadne.ac.uk/issue6/survey/ that did not mention Google. The reason is probably because the document was last updated in 1996, but this does not affect its high ranking. The implications for medical sites is that older sites will receive a ranking, based, not on their accuracy, but on their age. While they may be valuable for historical reasons, there is little to warn to the visitor that the medical information may now be questionable because of subsequent research. Other steps include using a variety of search engines, using local search engines, and searching subject-specific databases. All this, however, takes effort, and can only be justified if the reason is clear. The reason, of course, is the one first raised in the original article by Meric et al (that the popularity of sites is not related to their quality), expanded upon in our responses (that an understanding of the nature of the Internet and Google is required) and dealt with in Dr Marshall's letter (that "pilot error" is a major contributing factor to inappropriate search results).
Competing interests: None declared |
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