Faculty Peer Reviewed
There is a stranger in the clinic room, and it is not your patient. This stranger is a multifaceted, opinionated entity with likely conflict-of-interest. This new acquaintance has already spoken to your patient and influenced the direction of this visit in the form of health statistics, symptom explanations, and feared complications. Now your patient wants to know what you think. In an age when patients will often have diagnosed their problem before they walk through a clinic door, the provider may start to feel overwhelmed by a third entrant into the patient-provider dialogue: the elusive online source.
In 2006, 113 million Americans sought health information online, comprising 80% of the online population. These are frequently patients with chronic illnesses needing significant self-directed treatment and education. In one general medicine clinic, more than half of patients stated that they relied on online health information, and 60% of these rated this information as either “the same as” or “better than” information they could obtain from their providers. Additionally, some patients considered online information a substitute for a physician visit, as an online search is more convenient and less expensive. Nationally, patients who report online health information-seeking continue to report significantly greater trust in physicians than in the sources found online. However, these same patients also report that their first source of information for a health question is usually the internet, with some variance based on age. Thus, physicians must be continually ready for dialogue regarding information found online, whether reliable or not.
First, we should ask how patients search for information online. The majority of patients start with a simple search engine and look at two or more websites to answer their question.1 In a set of focus groups in Australia, patients reported mainly using search engines to access information and not looking beyond the first page of results. These patients had a variable definition of validity; some believed that information by pharmaceutical companies was “more official” while others looked for perceived “impartial sources,” such as educational websites and patient message boards. Unfortunately, three quarters of users do not consistently check quality indicators of online health information, such as the source reliability and publication date.1
The second question, then, is how reliable are the data that patients will find from a basic search engine? In one study, the Google search engine was used to answer five common questions in pediatrics, and the top 100 sites found were analyzed based on their ability to answer the question and the accuracy of information they contained, according to evidence-based practice guidelines. Overall, 39% of these sites answered the question correctly; of the others, 49% did not answer the question and 11% were incorrect. In terms of advice offered to patients, governmental sites were always accurate, individual or educational sites 80% of the time, news sites 55% of the time, and sponsored sites never gave accurate information. The accuracy of these sites was somewhat dependent on the question; for example, sites were 51% accurate about breastfeeding in HIV- positive mothers and 100% accurate about the correct sleeping position for a baby. Thus, directing patients to governmental and educational sites and away from news and industry could make a huge difference in the quality of information that they receive.
Another barrier to accurate internet information retrieval may be patient understanding of the sources. In a 2001 study, 34 physicians rated the information brought up by 14 different search engines to answer health-related questions, and analyzed the accessibility and readability of these sites to English- and Spanish-language patients. The great majority of these websites did not fully address the topic, did not contain accurate information, and were at a reading level beyond that of the majority of patients. These findings all suggest great difficulty in patients finding and understanding reliable health information.
To look on the bright side, internet health information fosters greater patient involvement in their care. In one outpatient clinic, 154 patients were surveyed to determine their internet usage and their perceptions of care. The patients who more frequently looked up health information online also reported greater engagement in their healthcare, reassurance about their healthcare, and increased compliance with treatment and behavioral change. Additionally, the majority of users (83%) were comfortable discussing this information with their providers. From this study, it seems that there is a beneficial effect on patient healthcare satisfaction when patients supplement visits with independent research. There is also an openness on the part of providers to involve patient research. Most providers believe that this information is beneficial to patients and encourage their patients to actively seek it out. The only factor independently associated with a decline in the physician-patient relationship is when physicians feel that their authority is threatened.
Thus, the final question we should really be asking ourselves is: how can we communicate effectively with those patients who are motivated to seek information online? One study surveyed 770 patients who had shared internet health information with their providers to discover which strategies were effective in validating patients’ efforts and reducing their overall concern. Not surprisingly, patients showed the lowest level of satisfaction with their care when their provider either directly disagreed with the information that they presented or did not attempt to validate their efforts at independent research. Conversely, providers who appreciated and encouraged their patients’ initiative had significantly more satisfied patients, and these patients reported more comfort with their healthcare providers, whether or not the providers disagreed with their information. A similar study found that patients who are more involved in their health decision-making tend to be more willing to discuss internet findings with their provider. This was equally distributed between patients who were self-reliant and patients who were physician-reliant in their decision making process, which suggests that outside research facilitates patient involvement, no matter how the patient ultimately feels about health-related decisions. Another study found that patients appreciate when physicians supplement in-office education with internet referrals: they may take on responsibility for their own health and look for information to complement what they’ve learned from their providers. Through all of these studies, it is clear that when physicians encourage online health research, patients become more involved in their own care.
From here, it is imperative that physicians find a way to recommend resources for patients motivated to seek further health information. Patient leaflets have been a mainstay of primary care information dispersal, and as electronic medical records make the computer an integral part of the visit, patient-specific handouts linked through internet databases are one way in which providers can educate patients during their visit. Providers may be sure that the information they provide is accurate through various systems of evaluation, such as the Ensuring Quality Information for Patients (EQIP) scale. This validation method has excellent inter-rater reliability and can allow providers to scrutinize their handouts for accuracy and comprehensiveness. Providers may also direct their patients towards online sources in order to facilitate independent research using reliable sites. In one initiative, Internet Rx, providers carry a separate prescription pad on which they write out key search phrases relevant to the patient’s diagnosis or testing, as a way to recommend reliable health information found at medline.gov. Providers using this modality reported improvement in their patients’ understanding and satisfaction as well as more efficient office visits. In turn, patients who were given information prescriptions reported trust in the recommended resource as well as the ability to make more informed health decisions. This is one manner in which providers may encourage patients to select appropriate online information. As electronic medical records expand to allow at-home access and direct online messaging with providers, patients have a greater need to understand personal health information before the office visit occurs. And as provider-patient communication enters the online forum, much to the satisfaction of the majority of patients, providers may be increasingly direct about the online resources that they share. 
The internet is a comprehensive tool for both patient and provider looking for health information. However, it contains a significant amount of false and biased information that could prove dangerous to patient health. It is the provider’s responsibility to direct patients to government-sponsored and educational health information, and to provide specific sites that offer patient-friendly and correct information. With providers encouraging patients to have a selective ear for online information, healthcare is enriched as patients become actively engaged and well informed. Thus, the provider can welcome a third party into the patient’s clinic visit, and view online information as a friend and ally in evolving patient care.
Suzanne MacFarland is a 4th year medical student at NYU School of Medicine
Peer reviewed by Marc Triola, MD, Director, Division of Educational Informatics, NYU School of Medicine, Technical Editor Clinical Correlations
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