Website labels are analogous to food labels

EDITOR—We disagree with several of the ideas expressed by Delamothe in his editorial—for example, that we cope without the help of kitemarks and gateways in the real world. 1 2 Book reviews, television programmes, even the BMJ are all counterparts of “infomediaries.” There is also consensus that any gateway, kitemark, or trustmark cannot and does not intend to guarantee the “accuracy” or completeness of information,3 as implied by the editorial. Instead, they should be seen and used as tools to increase transparency.

The European Union project MedCERTAIN (MedPICS Certification and Rating of Trustworthy and Assessed Health Information on the Net) will use the concept of a third generation of trustmark, which must be discriminated from traditional kitemarks. The approach can best be explained by drawing an analogy to food labels. In order to direct consumers to a healthy diet we are not telling them which products to eat specifically; instead we educate consumers about healthy constituents of a diet, encourage food providers to use clear labels telling consumers important facts—for example, how much fat and sodium the food contains—and regulate how these labels are displayed, and what they must contain. Together, these measures empower and encourage consumers to make informed choices. We hope that the MedCERTAIN trustmark will play a similar part on the world wide web, by educating users and encouraging information providers to label their services, but also by monitoring and evaluating these labels to prevent misuse and by making transparent what others say about the service. Information providers certified by MedCERTAIN will display electronic labels using a standardised vocabulary (MedPICS), containing all relevant information allowing consumers to judge the quality of an information provider themselves and to select information that is relevant and appropriate for their individual needs. Moreover, users may set their own preferences by using a special browser add on to get automatic alerts and advice if a site does not meet their individual requirements. This concept of “downstream filtering” is different from attempts of upstream filtering such as the dot.health proposal of the World Health Organization.4 Our decentralised system depends on building a network of developers, users, information providers, and evaluators, much as the Cochrane Collaboration built a network in its field. The Heidelberg Collaboration for Critical Appraisal of Health Information hopes to be an initiative to help lay people, patients, and professionals to identify health information useful to them—for example, by developing and sharing methods with an international network of colleagues.5

NHS Direct Online has important role

EDITOR— Our experience with NHS Direct Online (www.nhsdirect.nhs.uk) over the past year has shown that kitemarking information on the web1 is of equal interest to healthcare professionals, patient groups, and commercial companies.

Government policy has been the driving force behind the kitemarking agenda. The Department of Health promised access to accredited information both for professionals (through the National Electronic Library for Health) and for patients (through NHS Direct).2 Subsequent policies have continued the theme, including the NHS plan.

Worthy statements in policy documents often display an ignorance of the complexities involved in retrospective evaluation of health information. Although there is some agreement on broad quality criteria, the consensus often breaks down when we try to codify these criteria and establish objective measurements. The situation is complicated further by the numerous groups seeking to establish their own ethical codes and quality rating schemes, often with laudable intentions but little systematic development or evaluation. NHS Direct Online has experimented with the DISCERN instrument for rating written patient information.3 Although not designed for web based information, DISCERN has been subject to tests of its reliability and validity.4 Even so, it does have serious limitations and could not be used as the basis of a more comprehensive kitemarking scheme without substantial additional work.

Implementing kitemarking schemes also means we have to deal with economic realities: Is kitemarking cost effective? Establishing and running a comprehensive kitemarking system of British health websites would involve tens if not hundreds of people including subject experts, information professionals, designers, etc. The costs could run into millions of pounds and involve untold bureaucracy. Is this a sensible and appropriate way to spend taxpayers' money? What measurable benefits might it have for patient care?

I believe that NHS Direct Online has a legitimate part to play in helping citizens to access some of the better resources for health information that are available and providing them with up to date information about the NHS. But ultimately, we are just as likely to be judged on the reputation we establish and the integrity we display as an organisation than by the logos, kitemarks, and attendant paraphernalia that we chose to decorate our site with.