Assessing, Controlling, and Assuring the Quality
of Medical Information on the Internet
Caveant Lector et Viewor\p=m-\Letthe Reader and Viewer Beware
Health care professionals and patients alike should view with In fact, effective use of technology can be an important
equal parts delight and concern the exponential growth of the indicator of quality—and especially utility—in communicat¬
Internet (the Net), and especially its graphical, user-friendly ing medical information on the Net. The best digital desti¬
subset, the World Wide Web (the Web), as a medical infor- nations will employ designs and tools that facilitate naviga¬
mation delivery tool.1,2 Delight because the Internet hosts a tion through large quantities of information, provide
large number of high-quality medical resources and poses appropriate mechanisms for feedback and interactivity, moni¬
seemingly endless opportunities to inform, teach, and connect tor and maintain the links they've chosen to provide to other
professionals and patients alike. Concern because the fulfill- sites, and generally commit the resources needed to maintain
ment of that promise remains discouragingly distant. Tech- a useful presence in an increasingly crowded electronic land¬
nical glitches aside, when it comes to medical information, the scape.
Internet too often resembles a cocktail conversation rather But the bedrock on which these technical tools rest is
than a tool for effective health care communication and de- content. And in this regard, the basic issues involved in pre¬
cision making. senting information on the Internet have changed little since
Gutenberg first pulled the lever on his printing press. In the
case of traditional print publishing, of course, the rules of
See also p 1258.
engagement have been worked out over 5 centuries. There
are standards by which to judge the quality of editorial con¬
The problem is not too little information but too much, vast tent, to differentiate author from shill, editorial from adver¬
chunks of it incomplete, misleading, or inaccurate, and not tising, education from promotion, evidence from opinion, sci¬
only in the medical arena.3,4 The Net\p=m-\andespecially the ence from hype. Those who follow these conventions develop
Web\p=m-\hasthe potential to become the world's largest vanity a respected brand identity, establish a level of trust with their
press. It is a medium in which anyone with a computer can readers, and serve as a forum for the kind of informed, in¬
serve simultaneously as author, editor, and publisher and can telligent discourse that advances the scientific process and
fill any or all of these roles anonymously if he or she so benefits the public health.6
chooses. In such an environment, novices and savvy Internet Not everyone in the print world plays by these well-es¬
users alike can have trouble distinguishing the wheat from tablished rules. More than a few presses produce little more
the chaff, the useful from the harmful. than empty pages. Nor are the rules under which even the
This should not be terribly surprising. After all, the In¬ best-known and most-trusted purveyors of medical informa¬
ternet is a new and exciting communications medium and, tion function by any means final or foolproof. But at least they
therefore, highly attractive to those whose agendas range provide a base, tested by lengthy experience, on which to
from the sublime to the ridiculous.5 At first glance, science operate.
and snake oil may not always look all that different on the The same set of quality moorings that helps users of medi¬
Net. Those seeking to promote informed, intelligent discus¬ cal information navigate in print should apply in the digital
sion often sit byte by byte with those whose sole purpose is world. We believe the time has come to discuss vigorously
to advance a political point of view or make a fast buck. And how such a set of basic quality standards can be developed
naive viewers may be lulled by technological brilliance into and applied in an electronic context. Such standards are built
placing more value on the content than it deserves, simply on the foundation of accountability—that an identifiable per¬
because they get it from the Net. son or group of people stands behind what is being "pub¬
lished" on the Web and in Internet discussion forums. These
principles amount to a framework for critical thinking, al¬
Mr Silberg is Editorial Director, New Media Office, Scientific Information and Mul- lowing consumers and professionals alike to reasonably judge
timedia Group (e-mail: Bill_Silberg@ama-assn.org); Dr Lundberg is Editor, JAMA whether what they are reading is credible, reasonable, or
(e-mail: George_Lundberg@ama-assn.org); and Dr Musacchio is Vice President of useful and to make measured, informed decisions about how
Information Resources and Chief Information Officer (e-mail: Robert_Musacchio
@ama-assn.org), American Medical Association, Chicago, III. to apply this information in the real world.
Downloaded From: http://jama.jamanetwork.com/ by a Michigan State University User on 09/11/2013
The core standards that can help to achieve these goals are Industry groups have begun discussing ways to craft vol¬
not complicated: untary guidelines, believing self-restraint could head off more
•
Authorship: Authors and contributors, their affiliations, stringent government regulation (John Mack, president, Vir-
and relevant credentials should be provided. Sci Corp, Levittown, Pa, written communication, March 7,
• Attribution: References and sources for all content should 1997). Some health information technology groups also
care
be listed clearly, and all relevant copyright information noted. are looking to draft
guidelines with input from major pro¬
• Disclosure: Web site
"ownership" should be prominently fessional organizations (Helga Rippen, MD, PhD, MPH, di¬
and fully disclosed, as should any sponsorship, advertising, rector, Health Information Technology Institute, Mitretek
underwriting, commercial funding arrangements or support, Systems Ine, oral communication, January 24, 1997). In ad¬
or potential conflicts of interest. This includes arrangements dition, Web site index and review services increasingly offer
in which links to other sites are posted as a result of financial evaluations of sites by topic area (examples of such sites
considerations. Similar standards should hold in discussion include Medical Matrix [http://www.slackinc.com/matrix/], Six
forums. Senses [http://www.echo-strategies.com/sixsenses/]; and Phy¬
•
Currency: Dates that content was posted and updated sicians Choice [http://www.mdchoice.com/]). We suggest that
should be indicated. criteria similar to those that we propose for Web sites be
Web sites and other Internet-based sources of medical applied to Web site reviewers as well and are pleased to see
information that fail to meet at least these basic standards that some already apply such standards.
should be considered suspect. The best will be those where We applaud the current discussions about quality and hope
such quality protocols are part of a broader, well-established that they will lead quickly to widespread agreement on a set
editorial process. We encourage content providers to outline of core standards that information producers can choose to
and post that process for all users to see (listing the factors follow. We are not, however, calling for a single or centralized
by which they produce or select content) and to identify staff, review process, institution, or agency, except to any extent
reviewers, and advisory boards. that appropriate laws or regulations might require. We be¬
The benchmarks we propose certainly are no guarantee of lieve such an approach is neither desirable or realistic, since
quality in and of themselves. Nor is the only valuable infor¬ the Internet is a decentralized, global medium. Nor are we
mation to be found on the Internet produced by "traditional" calling for punitive action against those who do not follow
sources, such as journals, professional societies, universities, such standards. Professionals and the public alike are hungry
libraries, and government agencies. Medically oriented com¬ for quality information, will over time recognize efforts to
munities ofinterest—both professional and nonprofessional— provide it, and will show their appreciation by pointing their
thrive in the digital world. There is much to be gleaned and Web browsers to sites that do so.
likely gained from these sources.7 We also hope our proposal will not be taken as an exercise
But all who surf the Net also must be wary in evaluating in arrogance or an attempt to protect traditional publishing's
such information, applying the same stringent criteria of "turf in the new digital world order. Web "publishers" of all
context, relevance, and utility as we hope they would in stripes—ourselves included—should be free to post what¬
weighing any other resource. And, needless to say, it should ever they like and live with the consequences. Let a thousand
to be made clear to users that the information presented in flowers bloom. We just want those cruising the information
a Net discussion group or on any medically oriented Web site superhighway to be able to tell them from the weeds.
is designed to be part of—not substitute for—the relationship William M. Silberg
between patient and professional that is central to the health George D. Lundberg, MD
care decision-making process. The Net should facilitate, not Robert A. Musacchio, PhD
serve as a barrier to, care of high quality.8
1. Lundberg GD, for the JAMA Review Group. One multimedia medical world.
Efforts to better assess the quality of medical information JAMA. 1995;274:655.
on the Net are under way in several quarters. For example, 2. Kassirer J. The next transformation in the delivery of health care. N Engl J Med.
the Geneva-based Health on the Net Foundation has estab¬ 1995;332:52-54.
3. Achenbach J. Reality check: you can't believe everything you read, but you'd bet-
lished a 6-point code of conduct for sites providing health ter believe this. Washington Post. December 4, 1996:C1.
4. Medical help on the Internet. Consumer Rep. 1997;62:27-31.
information.9 The US Food and Drug Administration, which 5. Lundberg GD. Providing reliable medical information to the public\p=m-\caveat lec-
now regulates pharmaceutical advertising and promotion in tor. JAMA. 1989;262:945-946.
6. Guarding the guardians: research on editorial peer review: selected proceedings
the traditional print and broadcast media, is now looking at from the First International Congress on Peer Review in Biomedical Publication.
JAMA. 1990;263:1317-1441.
how (or whether) to apply such regulations on the Internet.10 7. Ferguson T. Health Online. Reading, Mass: Addison-Wesley Publishing Co;
The US Department of Health and Human Services, mean¬ 1996:201-236.
8. Widman L, Tong D. Requests for medical advice from patients and families to
while, is looking at how to best promote quality in consumer health care providers who publish on the World Wide Web. Arch Intern Med. 1997;
health information networks (Mary Jo Deering, PhD, direc¬ 157:209-212.
9. Health on the Net Foundation, http://www.hon.ch. Accessed March 20, 1997.
tor, Health Communication and Telehealth, US Department 10. Public hearings, Food and Drug Administration and the Internet, Advertising
of Health and Human Services, Washington, DC, oral com¬ and Promotion of Medical Products; October 16-17,1996; Silver Spring, Md. Hearing
transcript available (http://www.fda.gov/opacom/morechoices/transcript1096/
munication, March 12, 1997). fdainet.html). Accessed March 18, 1997.
Downloaded From: http://jama.jamanetwork.com/ by a Michigan State University User on 09/11/2013
