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Keywords:

  • Internet;
  • web;
  • online;
  • print;
  • cancer;
  • quality;
  • information;
  • content

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

BACKGROUND

Use of the Internet is common among patients with cancer and their companions. However, little is known about patterns of use of print or telephone-based resources amidst growing Internet utilization, nor is it known whether different types of information are sought from electronic compared with print media. It is not clear as to whether patients and their companions differ in their patterns of content seeking.

METHODS

A survey was developed to evaluate the use of electronic and nonelectronic informational resources by patients and their companions. During a 10-week period, this questionnaire was administered to 443 outpatients and 124 paired companions attending an urban academic cancer center.

RESULTS

In this cohort, 64% of patients and 76% of companions were computer owners, with home Internet access indicated by 58% and 68%, respectively. Use of the Internet to obtain cancer-related information was reported by 44% of patients and 60% of companions. Print resources were used by 79% of patients and 83% of companions, with telephone resources used by 22% and 23%, respectively. The majority of Internet users also read print content (85%), whereas one-half of print users did not access data electronically (52%). Topic areas sought via print and the Internet were similar, with the exception of nutrition-related information, which was more commonly sought in print texts. There was a high rate of concordance between patient and companion use of both electronic and nonelectronic resources.

CONCLUSIONS

Despite recent publicity and scrutiny focusing on the quality of Internet health care content, print products remain the most common source of information sought by patients with cancer. Future investigation should focus on the quality of print products used by patients. Cancer 2004. © 2004 American Cancer Society.

Patients with cancer and their caregivers frequently seek information about disease management, prognosis, and therapeutic alternatives.1–5 Use of the Internet by this group is common, with estimated use by 39–58% of patients in the United States.6–9 Usage rates range from 42% to 49% among patients with breast carcinoma,10–13 from 32% to 45% among patients with prostate carcinoma,14, 15 and from 16% to 18% among patients with lung or head and neck malignancies.16, 17 Clinical oncologists have estimated that approximately 30% of their patients obtain cancer-related information online.18

Amidst increasing rates of Internet searching by patients, there has been limited study of the frequency of use of nonelectronic media resources. We conducted a survey of patients with cancer and their companions to investigate the degree to which Internet use has replaced or supplemented more traditional information resources such as books, pamphlets, and telephone hotlines. Moreover, we examined which types of media are used to gather various categories of information, whether particular patient characteristics are associated with types of media sought, and whether resource use differs between patients and their companions. We hypothesized that although rates of Internet use and online health care seeking are increasing,19–21 patients continue to access nonelectronic resources.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Study Participants

English-speaking adult patients with cancer who reported to the general surgical and gastrointestinal oncology outpatient clinics at Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY) between December 14, 1999, and February 24, 2000, were invited to participate in the current study. After clinic check-in, a single research assistant invited patients to complete a written 15-minute questionnaire regarding their use of cancer information resources. Patients were informed that results would not be linked to individual medical records or made available to clinical staff. Each questionnaire was coded with a unique identification number to ensure confidentiality. Consenting patients accepted and returned the study questionnaire, either directly to the research assistant or to boxes at the clinic check out desk.

Companions accompanying patients to the clinic were invited to complete a similar questionnaire regarding their use of information resources to learn about cancer on behalf of the patient. When more than one person accompanied a patient, a single individual, designated by the patient, completed the companion questionnaire. In the few instances where multiple companions elected to complete questionnaires, their responses were weighted in data analysis. When both patient and companion responded to the questionnaire, their unique identification numbers allowed linkage during analysis.

Questionnaire

The initial questionnaire was developed based on review of the medical literature, targeted Internet browsing, and suggestions made by nurse educators at MSKCC. The majority of the items were constructed specifically for the purposes of the current study based on published guidelines for survey development or were derived from previously validated instruments.22 A pilot version of the survey was administered orally by the research study assistant to 17 patients and 15 companions in the clinic waiting area. Results were used to shorten and revise the instrument to enhance comprehensibility. A second pilot survey was administered by the research assistant to 18 patients and 9 companions; the results of this second pilot trial indicated that the feasibility, willingness of individuals to respond, and survey content were acceptable.

The finalized questionnaire assessed whether patients and companions had used telephone, print, and/or Internet resources to obtain information related to the diagnosis of cancer. For example, participants were asked whether they had used any telephone resource, including the National Cancer Institute (NCI) hotline and the American Cancer Society (ACS) hotline, to obtain cancer-related information. Participants estimated the amount of total time spent using each resource type since their diagnosis and indicated whether they considered each to be not helpful, helpful, or very helpful. Similarly, for print and Internet resources, participants estimated the time dedicated to research in particular content areas such as nutrition, complementary and alternative medicine, physician information, and cancer diagnosis. Internet users were asked to indicate whether they had accessed any of 21 individual websites, selected based on clinician feedback at our institution as well as U.S. usage statistics published by Harris Interactive23 and Jupiter Media Metrix,24 and to estimate the time spent using each particular site. The list of sites included large general medical sites, such as WebMD (available from URL: http://www.webmd.com), as well as cancer-specific sites, such as those of the ACS (available from URL: http://www.cancer.org) and the NCI (available from URL: http://www.cancer.gov). The questionnaire provided blank space for Internet users to identify the three websites that they found to be most helpful, including sites not included in the provided list. Computer ownership and the availability of Internet access at home were also assessed.

To ensure confidentiality, survey responses contained no information that could be linked to an individual's medical record. However, participants did provide basic demographic information, such as age, gender, and level of education, as well as clinical information, including cancer type and date of diagnosis. Companions indicated their relationship to the patient and whether or not they lived in the same household.

Statistical Analysis

Summary statistics were generated based on the results of the questionnaire. Differences between information resource users and nonusers with respect to demographic and clinical characteristics were examined using chi-square or t tests, depending on whether the variable measures were categoric (e.g., highest level of education), dichotomous (e.g., computer owner/nonowner), or continuous (e.g., number of months since diagnosis).

In addition, several hypotheses were tested. Based on available survey data regarding the use of Internet health care information among the general population,19, 20 we expected that younger age, higher education level, and more recent cancer diagnosis would be associated with higher levels of Internet use. We further hypothesized that these variables, as well as computer ownership and the availability of Internet access, would predict Internet use. Variables with significance levels of P < 0.20 on univariate analysis were considered to be candidates for entry into multivariate logistic regression models used to assess correlations with information resource use. The multivariate models yielded adjusted odds ratios and 95% confidence intervals for each variable while controlling for the simultaneous effects of other variables. Variables not contributing substantially to the model were systematically removed in a backward stepwise regression procedure using the likelihood ratio test as the criterion for removal. SAS software (Version 8.0; SAS Institute, Cary, NC), was used to perform all analyses. All P values were two sided.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Participation

Of the 625 individuals approached, 443 (71%; 223 patients and 220 companions) completed and returned questionnaires. From these 443 questionnaires, 124 patient questionnaires were paired with companion questionnaires. No information was available on nonrespondents. Table 1 summarizes the characteristics of patients and companions in the current cohort. On average, companions were 6 years younger than patients. Both groups of respondents were relatively well educated, with the majority of individuals having received college education or more. Furthermore, 64% of patients and 76% of companions were computer owners. Internet access at home was also common, as it was reported by 58% of patients and 68% of companions in the current cohort (Table 1).

Table 1. Characteristics of Survey Respondents
Characteristic% of patients (n = 223)% of companions (n = 220)
  • SD: standard deviation.

  • a

    Patients who had participated in a clinical trial were not asked to respond.

  • b

    Thirty-six patients received both surgical and medical evaluations.

Age (yrs)  
 Mean in yrs (SD)59.3 (13.1)52.7 (13.5)
 < 502141
 50–653934
 > 653521
 Unspecified45
Gender  
 Male5737
 Female4160
 Unspecified23
Education  
 High school or less3025
 College3534
 Beyond college3037
 Unspecified43
Computer access  
 Computer ownership6476
 Internet access at home5868
Clinical trial participation  
 Current or previous participation31
 Consideration of participationa13
Malignancy type  
 Colorectal4543
 Pancreatic/biliary812
 Hepatic68
 Gastroesophageal99
 Sarcoma54
 Endocrine53
 Other137
 Unspecified914
Reason for patient visitb  
 Surgical evaluation46
  First opinion19
  Second opinion16
  Follow-up64
  Unspecified2
 Medical evaluation63
  First opinion6
  Second opinion14
  Chemotherapy39
  Follow-up36
  Unspecified5
Time since diagnosis (mos)  
 ≤ 124554
 > 12–242217
 > 243023
 Unspecified37

Internet Use and Characteristics Associated with Use

Among enrollees, 44% of patients and 60% of companions reported use of the Internet to obtain cancer-related information. On multivariate analysis, several factors were found to be significantly associated with increased Internet use among both patients and companions, including younger age (P = 0.03), computer ownership (P < 0.05), Internet access at home (P = 0.002), and higher education level (P < 0.05). Adjusting for these predictors, we identified an interaction between gender and respondent type (Table 2). Female companions were the most likely Internet users, whereas female patients were the least likely users (P = 0.03). A small percentage of patients (7%) who did not specify whether they used Internet resources were treated as having provided negative responses.

Table 2. Respondent Characteristics and Internet Use
Characteristic% reporting Internet use (n = 230)% not reporting Internet use (n = 213)P valuea
  • SD: standard deviation.

  • a

    Univariate analysis.

Respondent type   
 Patient4456 
 Companion60400.001
Gender   
 Male5248 
 Female52480.99
Gender and respondent type   
 Female companion6238 
 Male companion5644 
 Male patient4951 
 Female patient37630.003
Age (yrs)   
 Mean in yrs (SD)52 (12.8)60.5 (13.2)< 0.0001
 < 507129 
 50–655149 
 > 653268< 0.0001
Education   
 High school or less3763 
 College4852 
 Beyond college6733< 0.0001
Time since diagnosis (yrs)   
 ≤ 15941 
 > 145550.008
Computer ownership   
 Yes6832 
 No1684< 0.0001
Internet access at home   
 Yes7129 
 No1981< 0.0001

Comparison of Internet, Print, and Telephone Resource Use

To place Internet usage rates in context, we surveyed respondents regarding their use of noncomputer content. We found that print resources, such as books and pamphlets, were used more often (patients: 79%; companions: 83%) than the Internet. However, telephone resources were used substantially less often (patients: 22%; companions: 23%) than either the Internet or print resources (Table 3).

Table 3. Resource Use Overall and By Topic
Resource type/topic% of patients (n = 223)% of companions (n = 220)
  1. ACS: American Cancer Society.

Internet resources4460
 Websites  
 Diagnosis and Treatment4054
 Nutrition2535
 Cancer physicians2735
 Cancer prevention2132
 Complementary medicine2434
 Patient experiences1620
 Cancer hospitals2636
 Cancer biology1730
 Drugs and side effects2837
 Clinical trials2632
 Medical journals2230
 Pain management1224
 Support networks1214
 Insurance/financial assistance1116
Print resources7983
 Books7173
 Diagnosis and treatment5660
 Nutrition5155
 Cancer physicians4249
 Cancer prevention4047
 Complementary medicine3746
 Patient experiences3740
 Cancer hospitals3640
 Medical textbooks/encyclopedias3445
 Self-help3231
 Cancer biology2330
 Pamphlets6871
 Diagnosis and treatment5866
 Nutrition4956
 Complementary medicine3546
 Patient experiences3337
 Library1930
 Bookstore2429
 ≥ $25 spent on print resources2724
Telephone resources2223
 Hotlines  
  1-800-4CANCER1313
  ACS information line910
  Physician/hospital referral services79

To derive a more complete picture of respondents' information resource use patterns, we assessed their tendencies to rely on more than one resource. We found that 86% of patients and 92% of companions who used the Internet also used print resources. Of the patients and companions who used telephone resources, 100% also used print or both print and Internet resources. Only 14% of patients and 12% of companions denied use of any of the three resource types (Fig. 1).

thumbnail image

Figure 1. Overall resource use. No patient reported use of the Internet only or of telephone hotlines plus the Internet.

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Patterns of Use by Topic Area and Specific Source

To evaluate respondents' patterns of information gathering, specific questions were asked regarding the type of information sought from print and Internet resources, as well as the particular sources that were accessed (e.g., websites, bookstores, specific hotlines). Most Internet users sought information on diagnosis and treatment, and many inquired about drugs, treatment side effects, physicians, and hospitals (Table 3). Government-sponsored websites (e.g., the National Institutes of Health [available from URL: http://www.nih.gov] and NCI websites) were more commonly used than were commercial sites (Table 4). The majority of users described the Internet as helpful or very helpful and spent ≥ 1 hour using it (Fig. 2), while 41% spent > 5 hours using it.

Table 4. Specific Websites Visited by Respondents Reporting Internet Use
Website% of patients (n = 99)% of companions (n = 131)
  1. MSKCC: Memorial Sloan-Kettering Cancer Center; NCI: National Cancer Institute; NIH: National Institutes of Health; ACS: American Cancer Society; PDQ: Physician Data Query; ASCO: American Society of Clinical Oncology.

MSKCC (http://www.mskcc.org)6561
 Visited for > 30 min6175
NCI (http://www.cancer.gov)4548
 Visited for > 30 min7171
NIH (http://www.nih.gov)4544
 Visited for > 30 min6281
ACS (http://www.cancer.org)3747
 Visited for > 30 min5960
CancerTrials (http://www.cancertrials.com)3529
 Visited for > 30 min6374
PDQ database (http://www.nci.nih.gov/cancerinfo/pdq/cancerdatabase)2629
 Visited for > 30 min7387
ASCO (http://www.asco.org)1925
 Visited for > 30 min5373
Mayo Clinic (http://www.mayoclinic.org)1922
 Visited for > 30 min4279
CancerHelp (http:/www.cancerhelp.com)1920
 Visited for > 30 min4246
Oncolink (http://www.oncolink.com)1621
 Visited for > 30 min6386
Medicine Online (http://www.medicineonline.com)1621
 Visited for > 30 min6386
M. D. Anderson Cancer Center (http://www.mdanderson.org)1617
 Visited for > 30 min5082
Cancer Support Network (http://www.serve.com/csni/default.htm)1514
 Visited for > 30 min4739
Oncology Online (http://www.asco.org)1419
 Visited for > 30 min5064
WebDoctor (http://www.webdoctor.com)138
 Visited for > 30 min3860
CenterWatch (http://www.centerwatch.com)1318
 Visited for > 30 min6974
WebMD (http://www.webmd.com)129
 Visited for > 30 min5867
PubMed (http://www.ncbi.nlm.nih.gov/PubMed)1012
 Visited for > 30 min6094
Onhealth (www.onhealth.com)1114
 Visited for > 30 min5556
PharmWeb (http://www.pharmweb.net)75
 Visited for > 30 min5786
thumbnail image

Figure 2. Proportion of Internet users designating information resources as helpful or very helpful. *: all friends/relatives; **: friends/relatives in health care profession.

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Print resource users also most commonly sought information on cancer diagnosis and treatment, but these individuals were more likely to research nutrition than were Internet users. Like Internet users, many print resource users investigated physicians, cancer prevention, and complementary/alternative medicine. Use of a library to obtain printed texts was reported by 19% of patients and 30% of companions. Similarly, 24% of patients and 29% of companions indicated use of a bookstore. Only approximately one-fourth of respondents reported spending ≥ $25 on print products (Table 3). Among print resource users, 99% reported ≥ 1 hour of use, with 23% reporting > 5 hours.

Telephone use was evaluated by hotline type. We found that a majority of telephone users called 1-800-4CANCER and/or the ACS information hotline. A telephone was used for physician and hospital referral services by 32% of patients and 37% of companions (Table 3).

Comparison of Patient and Companion Resource Use

There was a high rate of concordance between patient and companion resource use (Fig. 3). The rate of concordance with respect to Internet use between patients and companions was 0.67 (kappa coefficient = 0.35). Similarly, the concordance rate for printed resource use was 0.75 (kappa coefficient = 0.20), and the concordance rate for telephone resource use was 0.75 (kappa coefficient = 0.31). For each resource type, and for resource use overall, companions whose patient counterparts denied use were more likely to report use than were patients whose companions denied use.

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Figure 3. Correlation between resource use by patients and resource use by companions (124 total pairs).

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DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Use of the Internet to seek health care content is common, particularly among patients with life-threatening or chronic diseases. Surveys suggest that two-thirds of the U.S. population actively uses the Internet,19, 20 whereas > 90 million have sought health information online.21 More than one-third of patients ask clinicians about websites during visits25 and believe that use of the Internet enhances the relationship between patient and physician.26, 27

Multiple surveys reflect the growing prevalence of Internet use by patients with cancer, but little is known about the balance between information gathering on the web and other available resources, such as books, magazines, and telephone hotlines. In the context of increasing concern regarding the quality of Internet health-related content, patient reliance on nonelectronic resources or government-sponsored websites may reassure clinicians.26, 28–35 However, similar concerns regarding quality of content are likely to exist, regardless of the medium of information delivery.

The current study suggests that although the Internet is popular among patients with cancer and their companions as a vehicle for gathering information, print publications remain the most commonly used resources. Furthermore, print products are sought by the majority of Internet users, whereas ≤ 30% of print users do not access the Internet for health-related purposes. These findings suggest a need to focus increased scrutiny on print publications aimed at patients with cancer by broadening recent efforts targeting the quality of Internet-based information.

With the exception of nutrition information, which was gathered more frequently from print resources than from the Internet, topics of inquiry were similar for print and electronic resources. The most common topic area sought by both print and Internet users was the diagnosis and treatment of specific cancer types, including chemotherapy agents. Many also sought information on physicians, prevention, and complementary/alternative medicine. Better data are needed about the specific print resources being used by patients, especially regarding how electronic and print products complement each other. For example, Internet sites can be updated in a more timely manner and may be more useful for tracking information on new therapeutic developments, clinical trial availability, or physician profiles.

Telephone resources were less commonly accessed. However, with the advent of new mobile technologies such as wireless web browsing, short messaging systems, or interactive telephone programs, there may be an opportunity for increased use of telephone-based health care applications in the future.36–42

The majority of respondents had computers with Internet access in their homes. Supplemental print resources were retrieved from both libraries and bookstores. For those who sought information on the web, government-hosted sites were generally preferred over commercial sites. A majority of users found these resources to be satisfactory, describing them as helpful or very helpful, and were willing to devote multiple hours to them.

Very few individuals in either group denied using any of the resource types presented. There was a high rate of concordance with respect to resource use between patients and companions. We confirmed that higher education level was associated with Internet use, which is consistent with other published data.19, 20 Youth was also a factor in Internet use. Less of a factor was the length of time since diagnosis, suggesting that patients and their companions continue to have informational needs over the course of the disease.

The current study has several limitations. The cohort was derived from patients treated at an urban academic cancer center and probably does not represent the general population of individuals with cancer. Nonetheless, although overall rates of resource use may differ in the general population, it is likely that the observed relations between variables would remain unchanged. The generalizability of our results also is limited by the lack of information regarding nonparticipants. Furthermore, patients and companions may have influenced each other's responses, accounting for the high level of response concordance between groups.

Patterns of Internet use among patients with cancer may have changed since the current survey was conducted, and the balance between use of electronic and print resources may have shifted as a result of overall increased Internet use in the United States. However, high levels of home computer and Internet access, consistent with present-day levels of use in the U.S., were observed in the current cohort. Therefore, it is likely that the observed resource use characteristics continue to hold true. Finally, although we have no information regarding any correlation between information use and clinical decision-making or satisfaction with care, this area merits future investigation.

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
  • 1
    Cassileth BR, Zupkis RV, Sutton-Smith K, March V. Information and participation preferences among cancer patients. Ann Intern Med. 1980; 92: 832836.
  • 2
    Champman K, Rush K. Patient and family satisfaction with cancer-related information: a review of the literature. Can Oncol Nurs J. 2003; 13: 107116.
  • 3
    Coulter A. Patient information and shared decision-making in cancer care. Br J Cancer. 2003; 89 Suppl 1: S15S16.
  • 4
    Hardwick C, Lawson N. The information and learning needs of the caregiving family of the adult patient with cancer. Eur J Cancer Care (Engl). 1995; 4: 118121.
  • 5
    Manfredi C, Czaja R, Buis M, Derk D. Patient use of treatment-related information received from the Cancer Information Service. Cancer. 1993; 71: 13261337.
  • 6
    Yakren S, Shi W, Thaler H, et al. Use of the Internet and other information resources among adult cancer patients and their companions [abstract]. Proc Am Soc Clin Oncol. 2001; 20: 398a.
  • 7
    Eysenbach G. The impact of the Internet on cancer outcomes. CA Cancer J Clin. 2003; 53: 356371.
  • 8
    Fleisher L, Bass S, Ruzek SB, McKeown-Conn N. Relationships among Internet health information use, patient behavior and self efficacy in newly diagnosed cancer patients who contact the National Cancer Institute's NCI Atlantic Region Cancer Information Service (CIS). Proc AMIA Symp. 2002; 1: 260264.
  • 9
    Monnier J, Laken M, Carter CL. Patient and caregiver interest in Internet-based cancer services. Cancer Pract. 2002; 10: 305310.
  • 10
    Fogel J, Albert SM, Schnabel F, Ditkoff BA, Neugut AI. Use of the Internet by women with breast cancer. J Med Internet Res. 2002; 4: E9.
  • 11
    Ranson S, Morrow GR, Dakhil S, et al. Internet use among 1020 cancer patients assessed in community practices: a URCC CCPO study [abstract]. Proc Am Soc Clin Oncol. 2003; 22: 534.
  • 12
    Satterlund MJ, McCaul KD, Sandgren AK. Information gathering over time by breast cancer patients. J Med Internet Res. 2003; 5: e15.
  • 13
    Fogel J, Albert SM, Schnabel F, Ditkoff BA, Neugut AI. Internet use and social support in women with breast cancer. Health Psychol. 2002; 21: 398404.
  • 14
    Diefenbach MA, Dorsey J, Uzzo RG, et al. Decision-making strategies for patients with localized prostate cancer. Semin Urol Oncol. 2002; 20: 5562.
  • 15
    Smith RP, Devine P, Jones H, DeNittis A, Whittington R, Metz JM. Internet use by patients with prostate cancer undergoing radiotherapy. Urology. 2003; 62: 273277.
  • 16
    Metz JM, Devine P, DeNittis A, et al. A multi-institutional study of Internet utilization by radiation oncology patients. Int J Radiat Oncol Biol Phys. 2003; 56: 12011205.
  • 17
    Peterson MW, Fretz PC. Patient use of the Internet for information in a lung cancer clinic. Chest. 2003; 123: 452457.
  • 18
    Helft PR, Hlubocky F, Daugherty CK. American oncologists' views of Internet use by cancer patients: a mail survey of American Society of Clinical Oncology members. J Clin Oncol. 2003; 21: 942947.
  • 19
    Diaz JA, Griffith RA, Ng JJ, Reinert SE, Friedmann PD, Moulton AW. Patients' use of the Internet for medical information. J Gen Intern Med. 2002; 17: 180185.
  • 20
    Taylor H. Those with Internet access continue to grow but at a slower rate [monograph online]. Available from URL: http://www.harrisinteractive.com/harris_poll/index.asp?PID=356 [accessed March 8, 2004].
  • 21
    Fox S, Fallows D. Internet health resources: health searches and email have become more commonplace, but there is room for improvement in searches and overall Internet access. Washington, DC: Pew Charitable Trust, 2003.
  • 22
    Streiner DL. Health measurement scales: a practical guide to their development. New York: Oxford Medical Publications, 1989.
  • 23
    Harris Interactive. Internet utlization statistics, December 1999–February 2000. Available from URL: http://www.harrisinteractive.com [accessed February 27, 2000].
  • 24
    Media Metrix. Online media usage. Available from URL: http://www.comscore.com/metrix [accessed December 14, 1999].
  • 25
    Ferguson T. Digital doctoring—opportunities and challenges in electronic patient-physician communication. JAMA. 1998; 280: 13611362.
  • 26
    Murray E, Lo B, Pollack L, et al. The impact of health information on the Internet on health care and the physician-patient relationship: national U.S. survey among 1,050 U.S. physicians. J Med Internet Res. 2003; 5: e17.
  • 27
    Murray E, Lo B, Pollack L, et al. The impact of health information on the Internet on the physician-patient relationship: patient perceptions. Arch Intern Med. 2003; 163: 17271734.
  • 28
    Adelhard K, Obst O. Evaluation of medical Internet sites. Methods Inf Med. 1999; 38: 7579.
  • 29
    Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA. 2001; 285: 26122621.
  • 30
    DeWoskin RS. Information resources on quality available on the Internet. Qual Assur. 2003; 10: 2935.
  • 31
    Karp S, Monroe AF. Quality of healthcare information on the Internet: caveat emptor still rules. Manag Care Q. 2002; 10: 38.
  • 32
    Purcell GP, Wilson P, Delamothe T. The quality of health information on the Internet. BMJ. 2002; 324: 557558.
  • 33
    Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: caveant lector et viewor–let the reader and viewer beware. JAMA. 1997; 277: 12441245.
  • 34
    Stavri PZ, Freeman DJ, Burroughs CM. Perception of quality and trustworthiness of Internet resources by personal health information seekers. Proc AMIA Symp. 2003: 629633.
  • 35
    Fogel J, Albert SM, Schnabel F, Ditkoff BA, Neugut AI. Quality of health information on the Internet. JAMA. 2001; 286: 20932094.
  • 36
    Friedman RH, Stollerman J, Rozenblyum L, et al. A telecommunications system to manage patients with chronic disease. Medinfo. 1998; 9 Pt 2: 13301334.
  • 37
    Glanz K, Shigaki D, Farzanfar R, Pinto B, Kaplan B, Friedman RH. Participant reactions to a computerized telephone system for nutrition and exercise counseling. Patient Educ Couns. 2003; 49: 157163.
  • 38
    Kaplan B, Farzanfar R, Friedman RH. Personal relationships with an intelligent interactive telephone health behavior advisor system: a multimethod study using surveys and ethnographic interviews. Int J Med Inf. 2003; 71: 3341.
  • 39
    Kruger DF, White K, Galpern A, et al. Effect of modem transmission of blood glucose data on telephone consultation time, clinic work flow, and patient satisfaction for patients with gestational diabetes mellitus. J Am Acad Nurse Pract. 2003; 15: 371375.
  • 40
    Larner AJ. Use of the Internet and of the NHS Direct telephone helpline for medical information by a cognitive function clinic population. Int J Geriatr Psychiatry. 2003; 18: 118122.
  • 41
    Mair F, Whitten P, May C, Doolittle GC. Patients' perceptions of a telemedicine specialty clinic. J Telemed Telecare. 2000; 6: 3640.
  • 42
    Mooney KH, Beck SL, Friedman RH, Farzanfar R. Telephone-linked care for cancer symptom monitoring: a pilot study. Cancer Pract. 2002; 10: 147154.