  urlLink JMIR Homepage urlLink Full Text of articles available UPDATE:  Links fixed.  urlLink Using Claims Data to Examine Patients Using Practice- Based Internet Communication:  Is There a Clinical Digital Divide?  Susan H Swartz,
 Timothy M Cowan,  Ida A Batista Background:  Practice- based Internet communication allows patients to obtain health information,  ask questions,  and submit requests through a personalized Web site.
 While such online tools also bring great promise for educating patients with the goal of fostering behavior change,  it is important to examine how individuals currently using such services differ from those who do not.  Objective:  The study used administrative information to characterize a population of patients communicating with a medical practice through the Internet during the end of 1999 and through 2000.  Methods:  Patient claims data generated during clinical encounters from January 1999 through May 2000 were examined to measure the relationship between patient demographics,
 frequency of visits,  specific acute diagnoses,  and specific chronic diagnoses and the use of online communication with the practice.  Results:  Ten percent of patients,  and 13.
2%  of patients 18 years or older,  used the practice Web site.  There were differences in use of the practice Web site by age and insurance status,  but not by gender.  Use of the practice Web site was similar or higher among patients having a diagnosis for a variety of acute and chronic conditions compared to those not having such a diagnosis.
 Patients with more clinic visits were more likely to use the Web- based service.  Conclusions:  Patients using practice- based Internet communication and having significant health risks can be identified through the use of administrative data,  presenting an opportunity to test online educational efforts to improve health.
 KEYWORDS Internet;  ambulatory care;  primary health care;  claims analysis;  outpatients;  ICD codes;
 ICD- 9;  chronic disease;  communication;  patient education urlLink Online Consumer Surveys as a Methodology for Assessing the Quality of the United States Health Care System Christina Bethell,  John Fiorillo,
 David Lansky,  Michael Hendryx,  James Knickman Background:  Interest in monitoring the quality of health care in the United States has increased in recent years.  However,  the policy objectives associated with collecting this information are constrained by the limited availability of timely and relevant data at a reasonable cost.
 Online data- collection technologies hold the promise of gathering data directly and inexpensively from large,  representative samples of patients and consumers.  These new information technologies also permit efficient,  real- time assessment in such areas as health status,
 access to care,  and other aspects of the care experience that impact health outcomes.  Objective:  This study investigates the feasibility,  validity,  and generalizability of consumer online surveys to measure key aspects of health care quality in the United States.
 Methods:  Surveys about the health and health care experiences of a general adult population and of adults with diabetes were administered online and by telephone.  The online survey drew from a sample frame of nearly 1 million consumers and used a single e- mail notification.  The random- digit-
dial methodology included 6 follow- up calls.  Results from the online sample were compared to the telephone sample and to national benchmark data.  Results:  Survey responses about quality of care collected using online and telephone methods were commensurate once they were weighted to represent the demographic distribution of the 2000 United States Census.  Expected variations in health and health care quality across demographic and socioeconomic groups were largely observed,
 as were hypothesized associations among quality indicators and other variables.  Fewer individuals were required to be contacted to achieve target sample sizes using online versus telephone methods.  Neither method yielded representative cohorts of nonwhite individuals.  Conclusions:  Conclusions about the level and variations in health care quality in the United States are similar using data collected in this study compared to data collected using other telephone- based survey methods.
 As is typical for national telephone surveys conducted by the National Center for Health Statistics,  stratified sampling and weighting of survey responses is necessary for results to be generalizable.  Online methods are more appropriate for understanding health care quality than for conducting epidemiologic assessments of health in the United States.  KEYWORDS Quality of health care;  data collection;  Internet;
 health care surveys;  consumers urlLink A Multimedia Interactive Education System for Prostate Cancer Patients:  Development and Preliminary Evaluation Michael A Diefenbach,  Brian P Butz Background:  A cancer diagnosis is highly distressing.  Yet,
 to make informed treatment choices patients have to learn complicated disease and treatment information that is often fraught with medical and statistical terminology.  Thus,  patients need accurate and easy- to- understand information.  Objective:
 To introduce the development and preliminary evaluation through focus groups of a novel highly- interactive multimedia- education software program for patients diagnosed with localized prostate cancer.  Methods:  The prostate interactive education system uses the metaphor of rooms in a virtual health center ( ie,
 reception area,  a library,  physician offices,  group meeting room)  to organize information.  Text information contained in the library is tailored to a person’
s information- seeking preference ( ie,  high versus low information seeker)  We conducted a preliminary evaluation through 5 separate focus groups with prostate cancer survivors ( N =
 18)  and their spouses ( N =  15)  Results:  Focus group results point to the timeliness and high acceptability of the software among the target audience.
 Results also underscore the importance of a guide or tutor who assists in navigating the program and who responds to queries to facilitate information retrieval.  Conclusions:  Focus groups have established the validity of our approach and point to new directions to further enhance the user interface.  KEYWORDS Multimedia software;  multimedia;  software;
 prostate cancer;  patient education;  treatment decision making;  treatment;  decision making urlLink DietPal:  A Web-
Based Dietary Menu- Generating and Management System Shahrul A Noah,  Siti Norulhuda Abdullah,  Suzana Shahar,  Helmi Abdul- Hamid,
 Nurkahirizan Khairudin,  Mohamed Yusoff,  Rafidah Ghazali,  Nooraini Mohd- Yusoff,  Nik Shanita Shafii,
 Zaharah Abdul- Manaf Background:  Attempts in current health care practice to make health care more accessible,  effective,  and efficient through the use of information technology could include implementation of computer- based dietary menu generation.
 While several of such systems already exist,  their focus is mainly to assist healthy individuals calculate their calorie intake and to help monitor the selection of menus based upon a prespecified calorie value.  Although these prove to be helpful in some ways,  they are not suitable for monitoring,  planning,  and managing patients’
 dietary needs and requirements.  This paper presents a Web- based application that simulates the process of menu suggestions according to a standard practice employed by dietitians.  Objective:  To model the workflow of dietitians and to develop,  based on this workflow,
 a Web- based system for dietary menu generation and management.  The system is aimed to be used by dietitians or by medical professionals of health centers in rural areas where there are no designated qualified dietitians.  Methods:  First,  a user-
needs study was conducted among dietitians in Malaysia.  The first survey of 93 dietitians ( with 52 responding)  was an assessment of information needed for dietary management and evaluation of compliance towards a dietary regime.  The second study consisted of ethnographic observation and semi- structured interviews with 14 dietitians in order to identify the workflow of a menu-
suggestion process.  We subsequently designed and developed a Web- based dietary menu generation and management system called DietPal.  DietPal has the capability of automatically calculating the nutrient and calorie intake of each patient based on the dietary recall as well as generating suitable diet and menu plans according to the calorie and nutrient requirement of the patient,  calculated from anthropometric measurements.  The system also allows reusing stored or predefined menus for other patients with similar health and nutrient requirements.
 Results:  We modeled the workflow of menu- suggestion activity currently adhered to by dietitians in Malaysia.  Based on this workflow,  a Web- based system was developed.
 Initial post evaluation among 10 dietitians indicates that they are comfortable with the organization of the modules and information.  Conclusions:  The system has the potential of enhancing the quality of services with the provision of standard and healthy menu plans and at the same time increasing outreach,  particularly to rural areas.  With its potential capability of optimizing the time spent by dietitians to plan suitable menus,  more quality time could be spent delivering nutrition education to the patients.
 KEYWORDS Dietary services;  menu planning;  health;  information systems;  health information system;  Web-
based services;  Internet urlLink Sex Differences in Youth- Reported Depressive Symptomatology and Unwanted Internet Sexual Solicitation Michele L Ybarra,  Philip J Leaf,  Marie Diener- West Background:
 As the number of youths using the Internet regularly increase,  so too does the number of youths potentially vulnerable to negative experiences online.  Clinicians,  policy makers,  and parents need to better understand the Internet and factors related to positive and negative experiences online.  Objective:
 Primarily to investigate the association between youth- reported depressive symptomatology and unwanted Internet sexual solicitation and secondarily to identify sex differences in related characteristics of affected youth.  Methods:  Data from the Youth Internet Safety Survey were analyzed to investigate the association between reported depressive symptomatology and unwanted Internet sexual solicitation.  The Youth Internet Safety Survey was a nationally- representative,
 cross- sectional telephone survey.  Youth participants ( N =  1501)  were English speakers between the ages of 10 and 17 years who had accessed the Internet at least 6 times in the previous 6 months and had resided in the household for at least 2 weeks in the previous year.
 Eighty- two percent of contacted households agreed to participate. Each participant was asked to indicate whether any of the 9 symptoms of major depression defined by the Diagnostic and Statistical Manual of Mental Disorders,  Fourth Edition ( DSM- IV)
 had been present within the previous month.  Logistic regression was used to estimate the odds of reporting an unwanted sexual solicitation online for youths with mild or major depressive symptomatology versus no symptomatology.  A parsimonious,  multivariate model of significant youth characteristics was identified separately for males and females.  Results:  Youths who report major depressive-
like symptoms were 3. 5 times more likely ( odds ratio,  3. 54;  95%
 confidence interval,  2. 19- 5. 71)  to also report an unwanted sexual solicitation online compared to youths with mild/
no symptomatology.  After adjusting for significant Internet and psychosocial characteristics,  male Internet users who report major depressive- like symptomatology were 2. 5 times more likely to also indicate an unwanted Internet solicitation ( adjusted odds ratio,
 2. 72;  95%  CI,  1. 15-
6. 40)  significant differences were not observed among otherwise- similar females.  Further,  among youths reporting an Internet solicitation (
N =  283)  youths with major depressive- like symptomatology were twice as likely to report feeling emotionally distressed by the incident compared to youths with mild/ no symptomatology ( odds ratio,
 2. 27;  95%  CI,  1. 03-
5. 02)  Conclusions:  While the majority of youths report positive experiences online,  some youths may be more vulnerable to negative experiences.  Cross-
sectional results indicate that the report of depressive symptomatology is significantly related to the concurrent report of an unwanted Internet sexual solicitation,  especially for young males.  Future research should focus on parsing out the temporality of events and identifying additional populations of vulnerable youths online.  KEYWORDS Youth;  Internet;  depression;
 sexual solicitation;  mental health urlLink Can Clinical Trials Requiring Frequent Participant Contact Be Conducted Over the Internet?  Results From an Online Randomized Controlled Trial Evaluating a Topical Ointment for Herpes Labialis Margaret Formica,  Karim Kabbara,  Rachael Clark,  Tim McAlindon Background:
 The Internet has tremendous appeal for conducting randomized clinical trials and may be especially applicable to trials requiring frequent participant contact.  Trials of cold sore remedies,  for example,  often require daily clinic visits during outbreaks,  imposing substantial burden on participants.  An Internet-
based randomized clinical trial design may reduce this burden,  permitting frequent symptom reports with considerably less effort.  Objective:  To evaluate the feasibility of a Web- based randomized clinical trial requiring frequent participant interaction,  using a 6-
month,  double- blind,  randomized,  placebo- controlled pilot trial of a topical ointment containing dioctyl sodium sulfosuccinate (
DSS)  ( Zilex;  Meditech Pharmaceuticals,  Inc,  Scottsdale,
 Arizona,  USA)  intended for treatment of recurrent herpes labialis.  A secondary objective was to obtain preliminary data on effectiveness outcomes,  to assist in planning a fully- powered trial of DSS.
 Methods:  Adults with physician- confirmed herpes labialis were recruited to apply to the trial.  Eligible applicants were randomized to DSS or placebo,  mailed to them upon enrolment with instructions to apply topically every 2 hours for the duration of every cold sore outbreak.  Participants were instructed to complete online questionnaires at 2-
week intervals and,  at the initiation of a cold sore,  daily " outbreak questionnaires"  until outbreak termination.  Feasibility outcome measures included trial participant characteristics,
 frequency of cold sores,  participant retention and adherence ( to study medication)  and data completeness.  Treatment effectiveness outcome measures included outbreak duration,  days to crust formation,
 and pain.  Results:  Of the 292 individuals applying,  182 screened eligible;  32 participants with confirmed herpes labialis enrolled in the trial.  16 were randomized into the verum group and 16 into the placebo group.
 29 ( 91%  participants completed the trial.  During the trial,  34 outbreaks were reported among 23 ( 72%
 participants,  resulting in a cold sore incidence rate of 19. 8 per 100 person- months of observation.  Online data were available for 32 outbreaks;  the absence of a resolution date made it impossible to accurately calculate the duration of 12 (
38%  outbreaks.  Although the DSS treatment group had a shorter mean outbreak duration ( 6. 6 vs 7. 7 days,
 P =  . 2)  and fewer mean days to crust formation ( 3. 5 vs 4.
9,  P =  . 1)  these differences did not reach statistical significance.  The DSS group has statistically significant lower mean pain scores (
3. 1 vs 7. 6,  P =  . 04)
 but participants in this group also consumed more acetaminophen tablets than the placebo group ( 1. 1 versus 0. 5,  P= 55)
 Adherence to medication was similar in both groups:  7 ( 50%  of the verum group reported using the cream as directed compared to 6 ( 46. 2%
 in the placebo group;  ( P =  . 8)  Conclusions:
 We efficiently recruited participants and achieved high overall retention rates.  However,  participant adherence to the daily outbreak visit schedules was low and only 7 ( 50%  participants used the cream as directed.  These limitations could be addressed in future Internet-
based studies by using Personal Digital Assistants ( PDAs)  using reminder devices,  and providing incentives.  By enhancing participant adherence,  clinical trials requiring frequent participant contact may be feasible over the Internet.
 KEYWORDS Internet;  randomized controlled trial;  clinical trial;  herpes labialis;  dioctyl sodium sulfosuccinate urlLink Online Pediatric Information Seeking Among Mothers of Young Children:  Results From a Qualitative Study Using Focus Groups Jay Bernhardt,
 Elizabeth Felter Background:  Pre- natal and post- natal periods are times when many women actively seek health information from multiple sources,  including the Internet.  However,
 little is known about how pregnant women and mothers of young children seek and process online pediatric health information.  Objective:  To explore why and where mothers of young children look for online health information and how they determine if the information they receive is trustworthy.  Methods:  Focus groups were conducted in a Southeastern US city to provide an in- depth exploration of web-
related behaviors and beliefs among mothers who work inside and outside of the home.  Data from the focus groups were coded using deductive and inductive coding schemes and content was analyzed for the existence of themes.  Results:  Twenty mothers of young children participated in four focus groups.  Most participants sought information on the Internet during pregnancy and nearly all sought online information after their child was born,  primarily to diagnose or treat pediatric conditions and to seek advice on parenting and development.
 Participants mainly used commercial information websites for health information and many expressed disdain for commercial product websites.  Many also expressed concerns about the reliability of health information on the web and described strategies for determining how much they trust each website.  Conclusions:  Women appear to be high information seekers during pregnancy and the first few years following delivery,  and this period represents an important window of time for providing online health information.  Participants suggested that online information sources and motives for providing online information should be clear in order to increase perceptions of trust.
 Participants expressed preference for online clinical health information that is presented by clinical professionals,  and online parenting advice that is presented from other parents.  KEYWORDS Internet;  Pediatrics;  Focus Groups;  Mothers;
 Health Education urlLink The Internet as a Vehicle to Communicate Health Information During a Public Health Emergency:  A Survey Analysis Involving the Anthrax Scare of 2001 Anne F Kittler,  John Hobbs,  Lynn A Volk,  Gary L Kreps,  David W Bates Background:
 The recent public health risks arising from bioterrorist threats and outbreaks of infectious diseases like SARS ( Severe Acute Respiratory Syndrome)  highlight the challenges of effectively communicating accurate health information to an alarmed public.  Objective:  To evaluate use of the Internet in accessing information related to the anthrax scare in the United States in late 2001,  and to strategize about the most effective use of this technology as a communication vehicle during times of public health crises.
 Methods:  A paper- based survey to assess how individuals obtained health information relating to bioterrorism and anthrax during late 2001. We surveyed 500 randomly selected patients from two ambulatory primary care clinics affiliated with the Brigham and Women's Hospital in Boston,  Massachusetts.  Results:
 The response rate was 42%  While traditional media provided the primary source of information on anthrax and bioterrorism,  21%  ( 95%  CI,
 15%  -  27%  of respondents reported searching the Internet for this information during late 2001.  Respondents reported trusting information from physicians the most,  and information from health websites slightly more than information from any traditional media source.
 Over half of those searching the Internet reported changing their behavior as a result of information found online.  Conclusions:  Many people already look to the Internet for information during a public health crisis,  and information found online can positively influence behavioral responses to such crises.  However,  the potential of the Internet to convey accurate health information and advice has not yet been realized.
 In order to enhance the effectiveness of public- health communication,  physician practices could use this technology to pro- actively e- mail their patients validated information.  Still,
 unless Internet access becomes more broadly available,  its benefits will not accrue to disadvantaged populations.  KEYWORDS bioterrorism;  public health;  communication;  electronic mail;
 inequality;  behavior urlLink Swiss Community Pharmacies' on the Web and Pharmacists' Experiences with E- commerce:  Longitudinal study and Internet- based Questionnaire Survey Simon Zehnder,  Rudolf Bruppacher,
 Hans Ruppanner,  Kurt E Hersberger Background:  There are multiple ways in which community pharmacies can present themselves on the Internet,  e. g.  as a platform for drug information or as an advertising platform for their services.
 Objective:  To estimate the number of Swiss community pharmacies on the Internet over the period of 32 months ( 2000- 2003)  to describe their current e- commerce services,
 and to explore the experiences and plans these pharmacies have with regard to their Internet presence.  Methods:  A longitudinal study was performed to determine the number of Swiss German pharmacies on the Internet by conducting Internet searches in 2000,  2001,  and 2003.  In April 2002,
 a cross- sectional Internet- based survey was administered to explore the pharmacies' experiences and plans regarding their Web sites.  Results:  As of April 2003,  373 (
44%  of 852 community pharmacies from the German speaking part of Switzerland were on the Internet.  One hundred eighty four listed an e- mail address and were asked to complete a questionnaire.  Of the 107 pharmacies answering the survey questions ( 58%
 response rate)  46%  had been on the Internet for 1 to 2 years;  33%  of the Web sites are part of a pharmacy group's Web portal;  31%
 of the pharmacies plan to expand their Internet appearance in the future;  74%  provide e- commerce services,  with 81%  of those pharmacies filling five or less orders per month;
 and 12%  plan on expanding their e- commerce services in the future.  Conclusions:  The number of community pharmacies offering Internet services steadily increased over 32 months.  Given the importance of the Internet as a tool for information,
 communication,  and advertising for pharmacy products and services,  it can be expected that the increase will continue.  Pharmacy- group portals are important promoters of pharmacies on the Internet.  For many community pharmacies,
 Internet portals that provide an Internet presence for the pharmacies and provide regularly- updated content ( e. g.  health news,  tips,
 drug information)  seem to be the most effective solutions.  Even though 40%  of the pharmacies already offer e- commerce services,  these services are still of minor importance.
 For many pharmacists,  the current legal regulations seem to be unclear.  Most pharmacies want to maintain their Internet services.  KEYWORDS Web site;  community pharmacies;  professional-
patient relations;  quality of health care;  e- commerce;  e- pharmacies;
 Switzerland urlLink Pharmacist Computer Skills and Needs Assessment Survey Robert M Balen,  Peter J Jewesson Background:  To use technology effectively for the advancement of patient care,  pharmacists must possess a variety of computer skills.  We recently introduced a novel applied informatics program in this Canadian hospital clinical service unit to enhance the informatics skills of our members.  Objective:
 This study was conducted to gain a better understanding of the baseline computer skills and needs of our hospital pharmacists immediately prior to the implementation of an applied informatics program.  Methods:  In May 2001,  an 84- question written survey was distributed by mail to 106 practicing hospital pharmacists in our multi- site,
 1500- bed,  acute- adult- tertiary care Canadian teaching hospital in Vancouver,  British Columbia.
 Results:  Fifty- eight surveys ( 55%  of total)  were returned within the two-
week study period.  The survey responses reflected the opinions of licensed BSc and PharmD hospital pharmacists with a broad range of pharmacy practice experience.  Most respondents had home access to personal computers,  and regularly used computers in the work environment for drug distribution,  information management,  and communication purposes.
 Few respondents reported experience with handheld computers.  Software use experience varied according to application.  Although patient- care information software and e- mail were commonly used,  experience with spreadsheet,
 statistical,  and presentation software was negligible.  The respondents were familiar with Internet search engines,  and these were reported to be the most common method of seeking clinical information online.  Although many respondents rated themselves as being generally computer literate and not particularly anxious about using computers,  the majority believed they required more training to reach their desired level of computer literacy.
 Lack of familiarity with computer- related terms was prevalent.  Self- reported basic computer skill was typically at a moderate level,  and varied depending on the task.  Specifically,
 respondents rated their ability to manipulate files,  use software help features,  and install software as low,  but rated their ability to access and navigate the Internet as high.  Respondents were generally aware of what online resources were available to them and Clinical Pharmacology was the most commonly employed reference.  In terms of anticipated needs,
 most pharmacists believed they needed to upgrade their computer skills.  Medical database and Internet searching skills were identified as those in greatest need of improvement.  Conclusions:  Most pharmacists believed they needed to upgrade their computer skills.  Medical database and Internet searching skills were identified as those in greatest need of improvement for the purposes of improving practice effectiveness.  KEYWORDS Computer literacy;
 pharmacy;  clinical informatics;  needs assessment;  pharmacists;  survey urlLink Experience and Attitudes towards Information Technology among First- Year Medical Students in Denmark:
 Longitudinal Questionnaire Survey Jens Doerup Background:  As more and more information technology ( IT)  resources become available both for support of campus-  based medical education and for Web- based learning,
 it becomes increasingly interesting to map the information technology resources available to medical students and the attitudes students have towards their use.  Objective:  To determine how extensively and effectively information handling skills are being taught in the medical curriculum,  the study investigated Internet and computer availability and usage,  and attitudes towards information technology among first- year medical students in Aarhus,
 Denmark,  during a five- year period.  Methods:  In the period from 1998 to 2002,  students beginning the first semester of medical school were given courses on effective use of IT in their studies.
 As a part of the tutorials,  the students were asked to complete a web- based questionnaire which included questions related to IT readiness and attitudes towards using IT in studies.  Results:  A total of 1159 students ( 78%
 responded.  Overall,  71. 7%  of the respondents indicating they had access to a computer at home,  a number that did not change significantly during the study period.
 Over time,  the power of students' computers and the use of e- mail and Internet did increase significantly.  By fall 2002,  approximately 90%  of students used e-
mail regularly,  80 %  used the Internet regularly,  and 60 %  had access to the Internet from home.  Significantly more males than females had access to a computer at home,
 and males had a more positive attitude towards the use of computers in their medical studies.  A fairly constant number of students ( 3- 7 %  stated that they would prefer not to have to use computers in their studies.  Conclusions:
 Taken together with our experience from classroom teaching,  these results indicate optional teaching of basic information technology still needs to be integrated into medical studies,  and that this need does not seem likely to disappear in the near future.  KEYWORDS Information technology;  Internet;  e-
mail;  students,  medical;  education,  medical 
