April 2003 Bulletin

What’s new in patient information Web sites

By J. Sybil Biermann, MD

Ever had a patient come in to your office laden with questions from stacks of Internet-derived printouts obtained from Web sites of dubious quality? You’re certainly not alone. According to a recent Harris Poll, at least 70 million Americans are using the Internet for health information. 1 Many orthopaedic patients and families, both in academic practice and in the community, have questions from their Internet searches that they plan to raise with their orthopaedic surgeons at the time of their visit. 2, 3

Unfortunately, patients may not be the best judges of a Web site’s credibility. In a landmark study, Consumer’s Web Watch (the Internet arm of Consumer’s Union, the publishers of Consumer’s Reports) compared how Internet health experts and consumers evaluated credibility of Web sites. 4

Not surprisingly, in deciding whether or not a site was credible, 44 percent of the experts identified the name or reputation of the posting agency as important. The source of the information was next at 26 percent and the company motive at 23 percent. However, the feature rated most frequently as important in determining credibility, with an astonishing 41percent of the 2600 "health consumers," was "site design." "Information focus" and "information design" were the next most important determinates. Only 17 percent listed name/reputation of posting agency as important. Patients are judging information on how it looks.

Additionally, patients can spend hours searching their topic, often becoming frustrated with dead-end search engine results, inaccessible servers, links leading to different parts of the same site and retrieval of items not relevant to their search. In one recent study, in a search of a medical topic, only 74 of 240 search engine-generated Web addresses actually led to unique, useful information postings. 5

What can we do to guide our patients? First and foremost, make sure that the patient knows his or her diagnosis and/or recommended treatment, complete with spelling, so that when and if they do choose to search the Internet they at least are looking for the right information.

If you provide the patient with Web sites (a related collection of Web pages posted together on a topic) or Web pages (a single page on the Internet, readable in its entirety on the screen by scrolling, not clicking) relevant to their problem or interest, you not only ensure that they are viewing reputable material, but you also save yourself time and explanations. The Internet can be a powerful partner in patient education, allowing patients to read information at their own pace, to review it as often as necessary and to share it with relatives and friends.

The Internet is vast–so where to start? Fortunately, you will find just about everything you need by looking on just a few good sites (Table 1). The Academy offers free patient education documents on the patient section of the Web site, "Your Orthopedic Connection," which can be viewed online or downloaded. Hundreds of peer-reviewed documents are available on diagnostic and surgical topics, many in Spanish–and list of topics is growing nearly daily.

If you have established your own Web site through the Academy (OrthoDoc), you can even link these patient education documents to your site, strengthening the impression that these documents are coming from and recommended by you. If your patients are not Internet-savvy, but might benefit from the information, you can print copies of these educational booklets and fact sheets and place them in your office waiting room or exam rooms–free of charge. For members, the Academy also has free "patient education prescription notepads" with the Your Orthopaedic Connection URL (www.orthoinfo.aaos.org) listed.

Government Web sites

There are several U.S. government sites that contain medical information for patients. The National Institute of Health site "Health Topics A to Z" contains some orthopaedic material; the bulk of it relates to arthritis through the efforts of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Medicine Service. What this site lacks in graphics is made up for by the rigorous process by which governmental information is evaluated prior to posting, and the frequent review or updating.

MEDLINEplus is the premier government site for patient medical information. A revamped site rolled out last year, and the depth and breadth are impressive. Much of the information is available in Spanish, and there are some sound/slide shows. Orthopaedic listings are reasonably extensive, although not comprehensive.

The CDC Web site contains some patient information. From an orthopaedic standpoint, the best CDC information is on prevention, including the national bone health campaign and osteoporosis prevention strategies.

Healthfinder is essentially the U.S. government "link page." Although it does access a wealth of information, the system is sometimes slow and poorly navigable.

Institutional Web sites

Several academic or institutional sites have extensive orthopaedic listings. Virtual Hospital, the University of Iowa site, has some of the best graphic orthopaedic information, with good depth and breadth in listings. The Mayo clinic site is one of the more popular institutional sites, likely in part to the reputation of the posting institution. Although there is a good database of information, the material is text heavy and the searching capability is only fair. The continuous ads and header are distracting and cumbersome as the new material occupies a relatively smaller space on the screen. The University of Michigan patient education site has excellent search features and a broad listing of topics, especially in sports; information is nearly all text.

The National Arthritis Foundation, a national nonprofit organization, is notable for what are arguably some of the best on-line surgical demonstrations with graphics and video.

Link pages can be particularly helpful because someone else has done the work of culling good sites by topic from a broad base in the Internet. New York Access to On-line Heath (NOAH) was started and maintained by medical librarians in New York; although the links are not as extensive as some, there are some real "pearls," especially to national resources and material you might not normally find. Orthopaedic Web Links, initiated and maintained by an orthopaedic surgeon, Myles Clough MD, has links to numerous patient education sites, many with graphics.

All these sites and information can be overwhelming, not just for the patients, but for us as well! The good news is that with a relatively small investment of time, you can become familiar with these sites and start making them work for you.

To get the best use of the Internet for your particular practice, review some of the listed sites (or others you may know about) and identify those that most closely reflect the information you would like your patients to have. The easiest way is to use the electronic version of this article, available under the "Library and Archives" section of the AAOS Web site (www.aaos.org).

You can then link to these sites without all the cumbersome typing! Then, create a list of four or five sites to give to your patients. They will be happy to have it and will recognize that not only are you not threatened by their forays into broadening their education, but also that you embrace new technology and are eager to work with them for their best possible education. If you have a specialized practice and treat only a few conditions, you may wish to identify a few specific documents (Web pages) rather than entire sites to customize your information recommendations.

Use of the Internet and volume of Internet material is growing. Working with it, rather than against it, we can deploy the Internet as a powerful champion to be mobilized in the arsenal of patient education.

Table 1




American Academy of Orthopaedic Surgeons


National, nonprofit

National Institutes of Health


National, government




National, government

Center for Disease Control and Prevention


National, government



National, link page

University of Iowa (Virtual Hospital)



Mayo Clinic



University of Michigan

http://www.med.umich. edu


New York Access to On-line Heath

http://www.noah-health.org/ index.html

Link page

National Arthritis Foundation


National, nonprofit

Orthopaedic Web Links

http://www.orthopaedic weblinks.com/

Link page


  1. Harris Interactive Health Care Research, "Patient/physician online communication: Many patients want it, would pay for it, and it would influence their choice of doctors and health plans," 2002. http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2002Vol2_Iss08.pdf. Accessed 3-6-2003
  2. Beall, M., Beall, S., Greenfield, M.L.V.H., Biermann, J.S.,"Patient Usage of the Internet in an Outpatient Community Setting," Iowa Orthopaedic Journal 22:100-104, 2002.
  3. Beall, M., Greenfield, M.L.V.H., Golladay, G., Hensinger, R.N., Biermann, J.S.: "Utilization of Internet Resources by an Outpatient Pediatric Orthopaedic Population" Journal of Pediatric Orthopaedics: Vol. 22, No. 2: 261-264, Mar/April, 2002.
  4. Stanford, J., Tauber, E.R., Fogg, B.J.. Marable, L.: "Experts vs. Online Consumers: A comparative credibility study of health and finance Web sites," 2002. http://www.consumerwebwatch.org/news/report3_credibilityresearch/slicedbread_abstract.htm. Accessed 3-6-2003
  5. Bichakjian, C.K., Wang, T.S., Hall, J.M., Schwartz, J.L., Johnson, T., Biermann, J. S.: "Melanoma Information on the Internet: Often Incomplete. A Public Health Opportunity?" Journal of Clinical Oncology, 20(1): 134-141, January 2002.

Sybil Biermann, MD, is a member of the Internet Communications Committee. She is Associate Professor in the Department of Orthopaedic Surgery at the University of Michigan in Ann Arbor, Mich. She can be reached via e-mail at biermann@umich.edu.

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