An evaluation of telehealth websites for design,literacy,information and content

Introduction

People such as health administrators, health-care providers and patients are increasingly turning to the Internet for information. ^1,2 These are diverse groups and it is important to be aware of the needs and the skills of the users when creating, designing and developing websites. This will allow online resources to be made more accessible and information to be presented in a way that users can understand and can benefit from. Previous studies have examined the quality and content of websites. The majority of these assessments have focused on the design, content and information qualities of health websites generally. ^3–7

In the present study we developed a set of four assessment criteria for telemedicine websites specifically. The aim of developing the evaluation tools was to assist telehealth programmes with their web presence.

Methods

The evaluation tool was based on four assessment instruments. The design assessment instrument evaluated overall design features such as having working and recognizable links, adjustable font sizes, design layout and accessibility from multiple web browsers. The information evaluation instrument assessed if the information presented on a website helped people to determine the credibility of the information presented, for example with a mission statement or the date of the last update. The literacy assessment instrument measured numeracy, readability, information, computer and media literacy, based on items such as frequency of jargon use and definitions (readability); tables, charts and decimal usage (numeracy); applying information from materials on websites (information); helping users to learn computer vocabulary (computer); and helping users realize that not all information on the Internet is correct (media). Finally, the content assessment instrument explored what key telehealth concepts were found on each site, such as sites that encouraged users to ask about telehealth.

A list of websites was generated and evaluated between June and August 2009 from the member list of the American Telemedicine Association and the Office for the Advancement of Telehealth and partner sites, thus excluding Web 2.0 sites. Websites were included if they were currently active and at least three clicks deep, which is the average number of clicks a person will go into a website. ⁸ This selection process produced a total of 62 websites.

The telehealth websites were coded independently by two coders using the four assessment criteria of design, information, literacy and content. The assessment tool questions are listed in Table 1. Reliability was measured as percent agreement between the coders. Coder reliability was established by obtaining agreement above 80% on all variables for at least 10% of the websites.

The websites were evaluated by answering yes, no or not applicable to all questions asked for each of the four evaluation instruments. The responses were entered into a spreadsheet and then tabulated to obtain frequencies for the website themes. The scoring system was created by giving each positive answer the value of one, adding all of those values together, and then dividing that number by the total number of possible positive answers. This provided a percentage of positive attributes that each website had for a given theme. The ‘not applicable’ questions were excluded from the calculation.

Results

The websites evaluated contained an average of 74% of the design tenets. They contained 37% of the telehealth content items, 35% of the information variables and 26% of the literacy variables (see Table 2). Pearson correlations were calculated to determine if any of the four evaluation assessments were correlated with each other. This would indicate that website performance in one theme was related to performance in another. There were significant correlations between the four themes, except that information and literacy were not correlated (see Table 3).

Discussion

The present study evaluated 62 telehealth websites for their design, information, literacy and content using assessment tools based on several literature searches. The websites reviewed contained most of the design variables, although very few of them had interactive or media elements. This is unfortunate because interactive multimedia often serve as the impetus for health-related learning and behaviour change. ^9,10 It is also important to realize that although websites may have strong design features, these may be worthless if the necessary information is not available or provided in a manner that is incomprehensible to the audience.

After design, the websites scored next highest on telehealth content, with the websites containing 37% of the tenets. The majority of telehealth websites promoted awareness of telehealth. Unfortunately, very few provided specific information to patients and providers about how to use or access telehealth, how to overcome barriers, or how to structure a telehealth programme within an organization. This is crucial information for potential audiences who want more information about using telehealth applications.

The websites reviewed contained 35% of the desired information variables. The majority of websites included a copyright statement, but very few displayed the date of last update. Without this information one does not know if information presented on a website is current. The websites were rated lowest in terms of their literacy assessment, with the average website containing approximately one-quarter of the desired tenets. The content provided was above an 8th-grade reading level, and jargon, abbreviations and acronyms were frequently used, and not always defined. Very few websites contained a glossary. Providing links to help users with low literacy levels would probably enhance the audience's awareness and understanding of the subject.

It is important for websites to provide accessible and useful information, especially because the Internet is often an individual's first resource. This is also important for the growth and development of new telehealth programmes and for those seeking telehealth information because research indicates that many factors, including credibility, influence satisfaction with telehealth information, which also has a positive influence on future intent to repeat-search telehealth information online. ¹¹ The Internet provides a potential method of targeting audiences to help them understand telehealth as a concrete application. To ensure their success, creators of telehealth websites must include resources for those who do not have high literacy skills. These include sending a user to another web resource, providing videos or images of staff and patients utilizing telehealth, supplying vivid examples and narratives, and making available additional information in a format that is easy to download or send by email. Also, when information is aimed at patients it is important to be aware of the content readability level.

Another item commonly absent from telehealth websites was information about how to organize and structure telehealth programmes. This is important for individuals who are searching for information on creating a telehealth programme.

A topic for future studies is the evaluation of telehealth websites that utilize social media platforms, such as Facebook, Twitter, YouTube and podcasts, because these new media allow interaction and collaboration between users. Social media platforms are becoming increasingly popular. They have the potential to allow website creators to find out more about their audience and to develop a dynamic relationship with them. This may have interesting effects on how future websites are developed and evaluated.

In summary, the present study identified various matters that should be addressed when developing telehealth websites. The most important may be the recognition that there are different audiences who seek information on telehealth websites, for example health-care professionals, organizations, patients and family members. However, many of the websites did not seem to have a clear focus on their target audience. It is important to present information in a way that makes it easy to read, and also to provide resources that help the different audiences, such as videos about using telehealth, reimbursement information and suggestions for organizational acceptance. Although much of this represents simple common sense in website design, our evaluation demonstrates that there is still much room for improvement.