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Quality signposting : the role of online information prescription in proviing patient information Liz Brewster & Barbara Sen Information School, University of Sheffiel, Sheffiel, UK Abstract DOI: 10.1111/j.1471-1842.2010.00912.x Backgroun: Information prescriptions (IPs) are part of a Department of Health (DH) initiative to improve patient care. IPs aim to meet health information nees by proviing personalise, high quality patient information about conitions an treatment. Objectives: This paper ientifies current online IP provision an evaluates a sample of IP websites against the original DH aims of IP provision; British Meical Association usability criteria; an information seeking vignettes. Methos: Five UK an one international IP website were ranomly selecte as a sample. Two checklists esigne to appraise the websites were use to review each IP provier. Two patient information seeking vignettes were evelope to enable the websites to be assesse from a patient-centre perspective. Results: Information prescriptions currently vary in content, accessibility an quality. National IP websites score more highly than local IP websites, which are often weak on content for specific conitions an poorly esigne but strong on signposting to local services. Conclusions: Guielines for IP provision nee to be improve to ensure higher quality, more easily accessible information is available. A synthesis of expertise inclue in national an local websites woul improve usability for patients. IP websites shoul conform to stanars of web esign an accessibility. Key Messages Implications for Practice There is a nee to link local an national information prescription (IP) websites to ensure high-quality conition-specific information an accurate, comprehensive local service information are provie. Information management skills, as well as conition-specific expertise, nee to be utilise to ensure high-quality IP provision. Online information proviers nee to ensure that website esign guielines are followe to make IPs accessible. Implications for Policy Information stanars nee wie issemination to ensure best practice in information management. Introuction The concept of information prescription (IP) was first introuce into UK governmental policy in the 2004 paper, Better Information, Better Choices, Better Health: Putting information at the centre of Corresponence: Liz Brewster, Information School, The University of Sheffiel, Regent Court, 211 Portobello Street, Sheffiel, S1 4DP, UK. E-mail: l.brewster@sheffiel.ac.uk health. 1 In this white paper, IPs were efine as a metho of raising the importance of information in consultations where time is often limite. 1 The concept of using high quality information [to] empower people 1 linke with a recognition of the nee for increase patient awareness of treatments to ensure choice. It was also influence by service proviers focus on increase responsibility for patients. 2 59

60 Online information prescription, Liz Brewster & Barbara Sen Better Information, Better Choices, Better Health 1 focuse on the importance of putting information at the centre of health an set out a single national approach to information provision. It followe on from other policy ocuments incluing Creating a Patient-le NHS 2 which escribe the major changes unerway in elivering patient-centre services, incluing patient choice, patient involvement an proviing information for ecision making. Subsequent reviews, incluing High Quality Care for All: NHS next stage review, 3 Choice Matters, 4 an Our Health, Our Care, Our Say 5 have reinforce this focus on information provision as central to healthcare policy. Information prescriptions are esigne to guie people to relevant an reliable sources of information to allow them to be better able to manage their conition an maintain their inepenence. They inclue relevant information about conitions an treatments, care services, benefits an support groups. IPs are preominantly recommene for patients with long-term conitions, like asthma, chronic obstructive pulmonary isease an cancer. They aim to be relevant throughout progress along the care pathway. IPs also contain links or signposts to sources of information. They can be mae available through a wie variety of sources, incluing the online provision on which this paper concentrates. In the UK, an National Health Service (NHS)- base pilot project was unertaken on 20 sites in 2007, examining elivery approaches for IPs. The pilot focuse on information provision for a variety of long-term meical conitions. 6 It looke at both online an offline solutions, an pilote the use of IP for specific conitions or age groups, aiming to compare the effectiveness of ifferent moels of IP. 7 While the pilot projects ientifie some issues, such as equity of elivery, IP provision was regare overall as a success. 7 An evaluation of the pilot schemes consiere the impact IPs ha on patients, carers an professionals; finings inclue improve confience, an IPs compare well with other methos of information elivery. 7 The pilot evaluation mae recommenations which were taken forwar into a national IP website, NHS Choices. 8 Asie from the pilot project report, 7 there is little current literature on IP. Papers ten to be short, focusing on iniviual examples of project provision, or the benefits an rawbacks of implementing IP provision. Chamberlain, Heaps an Robert foun few examples of literature explicitly concerne with IP in their survey of IP an bibliotherapy. 9 There is thus a gap in the evience base, with comparative stuies of ifferent IP provision neglecte. This stuy examines the accessibility an usability of IP provision, unlike previous literature which has focuse on the organisation or potential importance of IP. Ientifie potential barriers to IP: initial finings from the literature review O Connor examines the use of IP in the context of cancer treatment, noting that there are a number of barriers to accessing IP, incluing literacy skills; accessibility in ifferent languages an in ifferent formats; conitions incluing yslexia which can affect reaing an comprehension an health information literacies. 10 He also comments that sometimes patients may not want to have more information about their conition, citing the nee to return to normal life as influential on information seeking behaviour following iagnosis. Similar barriers are also ientifie by Leisey an Shipman in their work on American IPs, though meical professionals perceptions of these barriers were a key eterminant in the effectiveness of prescription. 11 Corner, again exploring notions of IP from the perspective of cancer care service proviers, offers similar concerns that there nees to be more information about the nature of IP to ensure quality. 12 In her view IPs shoul meet, not only patients clinical information nees, but also their emotional, practical an financial nees. Nevertheless, Corner s preliminary exploration of IP provision for cancer sufferers is supportive of the potential offere by the schemes for patients to access information at any point of nee. This contrasts with Doson, Bisnauth an James work, which note that clinician-irecte IP was more successful than inepenent online provision. IPs in this context were elivere in a variety of formats, but initial access was via a healthcare consultation. 13 One concern raise by stakeholers ientifie in Han, Greenwell et al. s IP evelopment for

Online information prescription, Liz Brewster & Barbara Sen 61 people with Parkinson s isease an their carers was that online information coul vary in accessibility an quality. 14 This le their IP provision to focus on irecte IP provision via telephone, which prove popular for this conition. Their conclusion that it will be essential to engage the support of voluntary organisations where they have quality-assure resources, an ieally, user-le information support systems emphasises the nee to involve all stakeholers in IP provision. This was also reinforce in Wheeler an Nicholson s work. 15 This work also examine the role of traitional information proviers, incluing public libraries, in the aministration of new IP schemes. A recent review of consumer health information provision in the UK note that information proviers neee to face a number of issues relate to health information literacy issues as well as ensuring that new technologies were harnesse to provie information in formats acceptable to patients 16 an this applies in the case of online IP. Objectives The objectives of the research were: To ientify websites from the pilot scheme that are still accessible an being utilise, as well as national an international examples of IP. To assess a sample of online IPs against the five components efine by the Department of Health (DH) as integral to successful IP. To apply information seeking vignettes an usability criteria to an evaluation of a sample of IP sites. Methos A sample of five UK IP sites an one international IP site were ientifie an assesse against a number of guielines. The research utilise a checklist base on the original guielines for IP provision 7 (Appenix A, available online) to evaluate the websites, as well as an inepenent checklist esigne using the British Meical Association (BMA) Patient Information Awar criteria for websites (Appenices B an C, available online). 17 The original integral components of an IP were ientifie by the DH 7 are: 1. Information content or the ientification of reliable an relevant sources of information 2. Directories, efine as repositories of information that link to iniviualise IPs 3. Personalise process, ientifie in this instance as whether the patient can fin information that is specific to a conition, place an point on the care pathway 4. Issuing or prescribing, to assess if the patient can access a personalise IP by collecting information to meet their nees 5. Access an outreach or the channels that are use to make information available to users. Two patient information seeking vignettes (Appenix D, available online) were also evise an the website reviewers assesse the IP provision against the nees of these patients. Each website was assesse twice using the IP provision checklist, once focusing on its information provision for epression, an once for ementia. A maximum possible score of 124 was available for each website. The use of vignettes was inspire by Jorm et al. s work, 18 an the checklists an vignettes were written an agree through peer iscussion. The aim of proviing vignettes was to ensure that patient-centre, personalise care was being provie, rather than more general health information. This means that the websites were specifically assesse for the quality of their information on the treatment of epression; local information on support groups for epression; the prognosis for people with ementia; an support groups for people who care for people with ementia. The ages an geners of the patients seeking information an an inication of time since iagnosis were also given in the vignettes. The HONCoe guie for health websites 19 an DISCERN tool 20 were also consiere as guie for checking quality, but it was ecie that the BMA guielines 17 were more appropriate in this instance as they inclue consierations of usability such as the use of language focuse on the use of Plain English interactive features, esign an accessibility in line with current W3C guieline criteria. 21 While the HONCoe an DISCERN tools examine criteria such as authority, confientiality, reliability an transparency, it was felt that there neee to be a greater focus on usability in this stuy. This was consiere important in light of the concentration on patient-centre information provision.

62 Online information prescription, Liz Brewster & Barbara Sen Both reviewers were information professionals, which can be sai to conflict with the typical ientity of an information-seeking patient. However, for the purposes of this review, the provision of the vignettes enable the reviewers to focus on the information nees of specific patients. Professional skills were also appropriate when consiering some aspects of the checklists, such as the application of W3C stanars. 21 As information-seeking practices are highly iniviual, it was consiere appropriate that some aspects of the checklists require subjective jugements, e.g. the navigability of the website. These subjective measures were supplemente with more objective ones, incluing the presence of the last ate of upate. The reviewers score each website inepenently, then scores were assesse for agreement, an iscusse. However, as the reviewers subscribe to Savolainen s recent work on Everyay Life Information Seeking (ELIS), 22 which states that information seeking behaviour information practices epen on socio-cultural contexts, it was not consiere appropriate to revise these scores to provie a consensus. Sampling The characteristics of all 20 pilot sites 6 were note an consiere for inclusion in this project. A full list of the pilots, noting their suitability for inclusion in this stuy, is available online in Appenix E. As the research in this paper focuses on the quality an accessibility of current online provision, IPs coul only be inclue in the stuy if they were available online; covere a number of long-term conitions; were aime specifically at aults (as oppose to subgroups such as the elerly, or young people); an were still operational in August 2009, as some IP sites ha been iscontinue following the pilot. Five of the pilot IP sites met these criteria, an a ranom sample of three of these suitable sites was chosen for manageability for this exploratory stuy. The sample, as presente in Table 1 thus comprises: Three of the online pilot IP websites. One local site evelope after the initial pilot programme, meeting the same sample criteria as above. This was inclue, following ranom selection from a list of other UK IP sites, to examine the impact of the evaluation report in influencing local provision. The national NHS Choices IP site. One American IP website, MelinePlus. The purpose of the inclusion of an international site was to provie a comparison, which coul be utilise for benchmarking UK provision. There is some provision of IPs internationally, with projects in the USA, Australia an New Zealan ientifie in a etaile internet search. However, because of the private sector, insurance-base nature of healthcare provision in the USA, some of these websites were unavailable for evaluation as they provie costbase information. Some IPs were also linke to specific healthcare proviers, an require a passwor log-in to access. This limite the number of international IPs available for evaluation. A further limitation was the restriction to the evaluation of Englishlanguage IP websites only. For this reason, only MelinePlus, an open-access IP scheme aressing a number of long term conitions was inclue. Results As iscusse in the introuction, a number of online IP sites were ientifie from the pilot Table 1 Information prescription (IP) websites evaluate Website Darlington Healthclick 23 Derbyshire IP 24 Isle of Wight Onelink 25 MelinePlus* 26 MyManchester 27 NHS Choices* 28 Focus NHS, National Health Service. *IP websites with a national focus. General long-term conitions IP in pilot scheme Develope after original pilot scheme, covers various long term conitions Dementia an epression IP in pilot scheme, expane to cover further long term conitions in 2008 National American site, inclues a variety of long term conitions General long term conitions IP in pilot scheme, expane to cover further long term conitions in 2008 National UK site inclues a variety of long term conitions

Online information prescription, Liz Brewster & Barbara Sen 63 stuies conucte by the NHS. NHS Choices, NHS Direct Wales an a number of inepenent charities such as the Stroke Association also provie access to online IPs in the UK. Primary Care Trusts not involve in the original pilot project have also ae IP provision to their services, sometimes in association with the local public library. Internationally, as state, many IP sites are linke to local healthcare proviers. There is not scope within this review to iscuss this in more etail. A broa, varie pattern of IP was thus ientifie, an a sample was selecte for evaluation of quality an usability. Initial results show mixe rates of success in elivering all the require components effectively. The overall score for each website is presente in Table 2. The top scoring website, with 102 out of 124, was the NHS Choices website. Both reviewers thought it was very professional an ha a goo range of information an services. It was also very easy to use, an woul be easily navigable for those with limite computer skills. The lowest scoring website was Derbyshire IP, with 40. It ha a limite range of information on very few conitions an no mechanisms for personalisation. Overall, national IP sites score more highly than local ones. Table 2 also presents scores for usability base on BMA criteria. This shows that the American MelinePlus provie the most user-frienly accessible source of IP. Despite not aiming to conform to the original NHS criteria, MelinePlus still score highly when compare to local IP provision in the UK. NHS Choices consistently provie the highest quality information for both conitions in the stuy, meeting the criteria for IP in almost every aspect. Further comments from the reviewers are organise by themes emerging from the analysis in the following sections. Themes Information provision an personalisation As is evient from Table 2, some websites score more highly for one conition than the other. Typically, the information on ementia was foun to be more relevant, useful an high quality than resources for epression. This may relate to the Table 2 Total scores for each IP website Isle of Wight Onelink MelinePlus* MyManchester NHS Choices* Darlington PCT Healthclick Derbyshire IP Scheme assesse Criteria Reviewer 1 2 1 2 1 2 1 2 1 2 1 2 BMA criteria total (out of 22 23 13 13 21 24 28 28 24 16 26 24 34) IP epression criteria total 8 9 1 5 3 9 8 12 11 8 12 14 (out of 14) IP ementia criteria total 3 9 3 5 9 12 8 12 12 10 12 14 (out of 14) Total score (out of 62) 33 41 17 23 33 45 44 52 47 34 50 52 74 40 78 96 81 102 Total score (for both reviewers, out of 124) BMA, British Meical Association; IP, information prescription; NHS, National Health Service. *IP websites with a national focus.

64 Online information prescription, Liz Brewster & Barbara Sen nature of the conitions themselves, but there is not scope within this article to iscuss this fining in more etail. In the case of information regaring local groups, this may reflect the provision of such groups in the areas sample. Interactive features to personalise information ensure the relevant an appropriateness of the information. Derbyshire IPs containe no mechanisms to personalise the information. This meant that the information provie was often irrelevant, as the patient information seeking vignettes inclue specific information seeking requirements. Three of the websites allowe the IP service user to specify whether they were a patient, carer or meical professional, which also enable more relevant information to be accesse, especially in terms of support groups. Reviewers thought that this was a positive evelopment, enabling less confient information seekers to ientify appropriate resources without suffering from information overloa. Evience base, attribution an authorship The website reviewers foun few problems with the accuracy of the information available the IP websites. However, there was little evience to emonstrate that this information came from reliable sources. The provenance of the information was not clearly attribute to appropriate meical professionals, though the reviewers chose to assume where there was an association with the NHS that this was the case. NHS Choices provies a link to its eitorial policy, which provies further information on the process through which its content is provie. While IPs are esigne to provie information in a simple, accessible format, there were no references or links to the evience base supporting the information given to enable IP service users to assess the quality of information provie. Accessibility an esign W3C accessibility guielines 21 were use to ensure that international stanars for web content were ahere to. All websites met most, or all, of the guielines. Design varie throughout the websites. Darlington Healthclick utilise a simple free text search box to enable the creation of an IP. Isle of Wight Onelink ha a front page escribe by reviewers as cluttere. MelinePlus an NHS Choices were both consiere to be well esigne. There were some problems loaing Portable Document Formats (PDFs) an pictures in the Derbyshire IP website. Language As the UK is a multicultural society, with many community languages, the website reviewers examine both the provision of information in Plain English, 17 an the opportunity to access information in community languages. All IP proviers score highly on proviing information in Plain English, meeting 6 9 criteria of the Plain English campaign s stanars for meical information. Text on the Isle of Wight OneLink site containe spelling errors. Only MelinePlus provie information in languages other than English. This is because of the large Hispanic population of the USA, which makes up a higher proportion of the community in some areas than comparable Black an Minority Ethnic communities in the UK. Since the initial survey was conucte, NHS Choices now provies translation options incluing Arabic, French, Polish an Uru. Date, coes of conuct an consumer involvement While all of the IP websites provie evience of the ate they ha last been upate, it was not always obvious if this was within the last 6 months, as sites only provie reference to the year. It was ifficult to note if there ha been any evience of service user involvement in service esign, as no IP provier referre to the inclusion of consumers. Only MelinePlus linke to its quality statement, though NHS Choices i provie an eitorial policy statement, performing a similar function. Navigability There were significant issues with navigability of the IP websites. Firstly, much of the IP provision was ifficult to fin within wier website content. Internal website search engines neee to be use

Online information prescription, Liz Brewster & Barbara Sen 65 Table 3 Strengths of national an local information prescription (IP) websites Strengths of national IP websites Well-esigne Goo overall information content Information specific to a point on the care pathway Goo functionality Broa range of topics covere Range of outputs, incluing ifferent languages Goo mechanisms for feeback on appropriateness of information content Clear outline to ai user expectations an signposting to other sites Strengths of local IP websites Goo signposting to local services information Can provie a better range of options for appropriate local services to locate the appropriate page. This means that IPs coul only be locate if the person seeking health information was alreay aware that an IP woul fulfil their nees. Derbyshire IP was note as a particular example of a website with a circular structure, which was ifficult to navigate. It also containe a number of links which i not link to the content liste. One reviewer felt that MyManchester was ifficult to navigate, with a structure base on a large number of rop-own menus. One major concern with navigability was that most links to the home page returne the information seeker to the main website home page, rather than the IP provision home page. Discussion The main problems ientifie with the online IP sites sample were information overloa an a lack of personalisation. Several websites ha better information on one conition than the other. Design was a problem in many cases, often reflecte in the navigability of the website. In general, it was note that goo IPs containe a variety of information, with some local services an some general conition information. These prescriptions also ha a range of outputs, an opportunities for personalisation an selection of information. It was note that there were ifferences between local an national IP websites, presente in Table 3. There are some limitations to the current project. Restricting the health information sites to those available in English meant that both reviewers coul access the content, but this meant that the provision of information in other languages coul be checke, but not assesse. For example, the availability of MelinePlus in Spanish was a significant feature of the website, but for the purposes of this review, the quality of the information coul not be consiere. This also meant that the ientification of the provision of IP websites internationally was limite to the English speaking worl. The use of two inepenent reviewers with ifferent information seeking behaviours, as well as the quantifiable checklists, helpe to prevent a biase account of the quality of the websites. However, both reviewers foun that some categories (e.g. consumer involvement in website esign) were ifficult to ascertain, an so websites tene to have lower scores for these criteria as there was little evience on which to base the rating. The information seeking vignettes also presume a egree of computer literacy on the part of those seeking information. Conclusions The BMA an IP checklists highlighte a number of key themes, important for consierations of the appropriateness of online IP for patients. IPs offer great opportunities to provie patients with helpful information, personalise to their health information nees. Goo IPs contain evience-base information on symptoms, treatments an support, combine with signposting to useful local services. However, there are still some issues, expane below.

66 Online information prescription, Liz Brewster & Barbara Sen Variations in quality of website esign While NHS Choices an MelinePlus were well esigne an easy to navigate, local IP sites were often ifficult to navigate. This meant that reviewers ha concerns about accessing the IPs if health information literacy was low. IP proviers nee to ensure that IPs are simple to use, with a clear layout, instructions for use an a facility for reporting problems to service proviers. Variation in quality of information content Improvements nee to be mae in the organisation an selection of patient information. Options for personalisation also neee to be improve to ensure that the search for information provie relevant results. There were ifferences between local websites, which provie high quality information about local services, an national sites, which supplie high quality, conition-specific information. While this conition-specific content was useful for patients, it was clear that there was a nee for skille information management professionals to ensure that this content was organise in an accessible manner. Lack of evience of use of information stanars Information prescription websites i not contain evience of aherence to information stanars. However, in the UK, this may change with the introuction of the DH s Information Stanar initiative, following pilot testing in Summer 2009. 29 It is the intention of the DH that ultimately, all sources of information on IPs will be quality assure through the information accreitation scheme. 30 Consierations of a patient-centre approach As previously state, there was no evience of patient involvement in IP esign. An introuction of patient review for these sites, or application of patient information seeking vignettes like the ones utilise in this stuy woul ai IP proviers in ientifying weaknesses in their IPs. While the information is usually accessible, the personalisation process often require a higher egree of accuracy. Allowing patients to specify age, gener an length of time since iagnosis woul ensure information was accurately targete to the patient. Recommenations for practice an future research There is an argument for linking national an local IPs as both have strengths. There shoul be some support an guiance for local IP websites on content preferably from patients noting information seeking preferences an on esign from IT professionals, as accessibility issues were particularly ba on some local IP sites. Sites woul also benefit from the introuction of some guielines about what patients can expect from an IP, an the best way to utilise them. Improvements mae to local IP sites coul inclue the introuction of information in community languages. In terms of further research, it woul be appropriate to repeat this evaluation when the new DH Information Stanar criteria have been finalise, see if the websites meet the stanars or assess changes require to ensure that these stanars are met. There shoul be an evaluation of any future partnerships between local an national schemes, to ascertain if this improve services as theorise. Conflict of interest No conflicts of interest have been eclare. Source of funing This stuy has been fune as part of the work of the Centre for Health Information Management Research (CHIMR) at the University of Sheffiel. Acknowlegements Initial research presente in this paper was presente as a poster at the 14th International Symposium for Health Information Management Research, Kalmar, Sween, October 2009. Supporting Information Aitional Supporting Information may be foun in the online version of this article:

Online information prescription, Liz Brewster & Barbara Sen 67 Appenix A. Scoring checklist for Information Prescription base on DH guielines. Appenix B. BMA checklist criteria. Appenix C. Scoring checklist for information prescriptions base on BMA criteria. Appenix D. Patient information vignettes. Appenix E. NHS information prescription pilot projects, iscussing reasons for inclusion in current evaluation. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplie by the authors. Any queries (other than missing material) shoul be irecte to the corresponing author for the article. References 1 Department of Health. Better Information, Better Choices, Better Health: Putting information at the centre of health. Lonon: Department of Health, 2004. 2 Department of Health. Creating a Patient-le NHS Delivering the NHS Improvement Plan. Lonon: Department of Health, 2005. 3 Darzi, A. High Quality Care For All: NHS Next Stage Review Final Report. Lonon: Department of Health, 2008. 4 Department of Health. Choice Matters. Lonon: Department of Health, 2007. 5 Department of Health. Our Health, Our Care, Our Say. Lonon: Department of Health, 2006. 6 NHS. Information Prescription: About the Pilot Sites. Lonon: NHS, 2007. Accessible at: http://www.information prescription.info/pilots.html 7 Department of Health. Information Prescriptions Evaluation: Final Report Recommenations an DH Responses. Lonon: Department of Health, 2008. 8 National Health Service. NHS Choices. Lonon: National Health Service, 2010. Accessible at: http://www.nhs.uk/ Pages/HomePage.aspx 9 Chamberlain, D., Heaps, D. & Robert, I. Bibliotherapy an information prescriptions: a summary of the publishe evience-base an recommenations from past an ongoing Books on Prescription projects. Journal of Psychiatric an Mental Health Nursing 2008, 15, 24 36. 10 O Connor, S. J. Eitorial. European Journal of Cancer Care 2007, 16, 207. 11 Leisey, M. R. & Shipman, J. P. Information prescriptions: a barrier to fulfilment. JAMA 2007, 95, 435 438. 12 Corner, J. For your information. Nursing Management 2008, 15, 12 13. 13 Doson, L., Bisnauth, R. & James, N. Information is power. Nursing Management 2008, 15, 14 19. 14 Han, A., Greenwell, K., Corbett, S., Walker, R. & Kirrane, H. Developing an information prescription service. Nursing Times 2008, 104, 34 37. 15 Wheeler, A. & Nicholson, S. Information on prescription. Public Library Journal 2008, 23, 24 26; 31. 16 Smith, S. & Duman, M. The state of consumer health information: an overview. Health Information an Libraries Journal 2009, 26, 260 278. 17 British Meical Association Patient Information Awar. 2009. Accessible at: http://www.bma.org.uk/whats_on/ offers_an_competitions/ LIBBMAPatientInformationAwar.jsp 18 Jorm, A., Korten, A. E., Rogers, B., Pollitt, P., Jacomb, P. A., Christensen, H. & Jiao, Z. Belief systems of the general public concerning the appropriate treatments for mental isorers. Social Psychiatry an Psychiatric Epiemiology 1997, 32, 468 473. 19 HONcoe principles. 2008. Accessible at: http:// www.hon.ch/honcoe/patients/conuct.html 20 DISCERN. Accessible at: http://www.iscern.org.uk/ iscern_instrument.php 21 W3C. Web Content Accessibility Guielines 1.0, 1999. Accessible at: http://www.w3.org/tr/wcag10/ 22 Savolainen, R. Everyay Information Practices. Plymouth: Scarecrow Publishing, 2008. 23 Darlington Healthclick. 2007. Accessible at: http:// www.healthclick.nhs.uk/ 24 Derbyshire Information Prescriptions. 2009. Accessible at http://www.erbyshirecountypct.nhs.uk/informationprescriptions.asp: 25 Isle of Wight OneLink. 2009. Accessible at: http:// www.iwight.com/onelink/ 26 MelinePlus. 2010. Accessible at: http://melineplus.gov/ 27 MyManchester. 2010. Accessible at: http:// www.mgeomatics.co.uk/mymanchesterservices/ (S(p3s1rq45oyptqn452i1qpa45))/Default.aspx 28 NHS. NHS Choices Information Prescriptions. 2010. Accessible at: http://www.nhs.uk/yourhealth/pages/ informationprescriptions.aspx 29 Department of Health. The Information Stanar, 2010. Accessible at: http://www.h.gov.uk/en/healthcare/ PatientChoice/BetterInformationChoicesHealth/ Informationstanar/inex.htm 30 Department of Health. Information Prescriptions. 2010. Accessible at: http://www.h.gov.uk/en/healthcare/ PatientChoice/BetterInformationChoicesHealth/ Informationprescriptions/inex.htm Receive 1 February 2010; Accepte 6 August 2010