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There are a variety of ways to access information on the Internet. Once available almost exclusively on personal computers, people can now also use smartphones and tablet computers to access health information. According to the Pew Research Center (2013a), 87% of U.S. adults use the Internet and 72% of Internet users report that they have searched online for health information. About 50% of these users report searching for information on behalf of someone else. Information on specific diseases or conditions, treatments or procedures, and searching for physicians or other health professionals are the top topics for research on the Internet. Thirty-five percent of U.S. adults have used the Internet for diagnostic purposes, for themselves or for someone they know. People with chronic conditions are more likely than people without chronic conditions to track symptoms, and people with more than one chronic condition (62%) are more likely to do so than people with one (40%).

The Internet has revolutionized the way that consumers access information and communicate with each other. This is important, because it provides APRNs with fundamental information on who uses the Internet, what types of information they are looking for, and what types of devices and methods they use to search for information. Advances in technology have made it faster and easier than ever before to find information. It is a mistake to believe that people rely solely on healthcare providers for information regarding their health or that they will always confirm the accuracy of what they have found on the Internet with their healthcare provider. Although there is a lot of information on the Internet that is valuable and of high quality, some of the information is dubious at best. It is clear that a digital divide exists and that APRNs need to be aware of this disparity. APRNs also need to acquire the skills to improve access to health technology for populations. It is for these reasons that APRNs need to be proactive in talking to patients about their use of the Internet and other new technologies to better serve and manage their healthcare needs. They need to complete their own assessment of the populations to whom they provide care. When researchers investigated the use of Internet and mobile technology by a population of parents using pediatric care centers that serve primarily urban, low-income, African American patients, they found that a large majority (97.0%) reported owning a cell phone and that of those, 91.1% used their phone to text and 78.5% used it to access the Internet. Although these patients used technology primarily for social networking, the researchers determined that most parents were interested in receiving health information or utilizing social networking to learn more about health topics. They concluded that “[m]obile technology and social networks may be an underutilized method of providing health information to underserved minority populations” (Mitchell, Godoy, Shabazz, & Horn, 2014). This example illustrates how important it is for APRNs to assess the populations that they serve to determine how useful technology might be in providing services.

Another report from the Pew Research Center (2011), Peer to Peer Healthcare, describes the results of a survey intended to determine how people use technology to talk to people with similar problems. One of the revealing findings is that one in four Internet users with chronic conditions, such as high blood pressure and cancer, goes online to find people with similar conditions. Only 15% of Internet users who do not have a chronic health condition have sought similar help online. Other people whom the survey identified as going online to share health concerns are those who have suffered a recent medical crisis or who have had a significant change in health status (Pew Research Center, 2011).

There are many studies that illustrate the importance of being vigilant in knowing the patterns of Internet use by consumers. Modave, Shokar, Penaranda, and Nguyen (2014) completed an analysis of Internet sites that provide information on weight loss. Of the 103 websites that were analyzed, none scored the optimal 16 points on the researchers’ scale. Only 5% of the websites scored at least an 8/12 on the section measuring physical activity, behavior, and nutrition content. Although government and university websites scored the highest on the researchers’ evaluation scale, these sites tended to appear on pages 2 or 3 of the search. The researchers noted that the information that was most likely to be accessed by searchers is substandard because quality sites posted further down in the search. Moore and Ayers (2011) completed a systematic review to identify websites related to postnatal mental health for both healthcare professionals and patients. Although they were able to identify a number of useful websites based on an evaluation of the accuracy of information, availability of resources, and overall quality, they found that information on many of the sites was incomplete, difficult to read, and of variable quality.

Chan et al. (2012) searched the Internet using three different Internet search engines for websites that provide health-related information for gastrointestinal cancers. They assessed the websites using a scoring system that ranged from –84 (poor) to 90 (very good). The median score for the websites that they assessed was 53. The highest score was for pancreatic cancer (65) and esophageal cancer (61) sites. Rectal (50), gastric (49), and colon (48) sites scored the lowest. They also found that the best overall sites were charitable websites, which scored a median of 79. The authors noted that gastrointestinal cancers are the most common cancer for which Internet searches are performed.

Ten diabetes-focused social media sites were evaluated for quality of information and privacy protection of users (Weitzman, Cole, Kaci, & Mandl, 2011). The authors noted that only 50% of the sites presented evidence-based information, and inaccurate information about diabetes and ads for unfounded “cures” were found on three sites. In fact, of nine sites with advertising, transparency was missing on five. They also found that privacy protection was poor, “with almost no use of procedures for secure data storage and transmission; only three sites supported member controls over personal information” (p. 5).

Clearly, people use the Internet to seek out information on health-related matters, and just as clearly, the Internet is used as a source of both good and bad information. Websites are also of inconsistent quality and in constant flux. It is critical that APRNs and the patients to whom they provide care understand how to evaluate websites for current and accurate information as is evidenced by studies that show that most Internet consumers do not confirm the validity of the Internet resources that they use. APRNs have an opportunity to better serve their population by helping consumers use the Internet wisely by guiding them to sites that provide evidence-based information and privacy protection.

The Medical Library Association (MLA), the Health on the Net (HON) Foundation, and the U.S. National Library of Medicine provide guidelines for evaluating online information. Links to these sites can be found in Table 6.1. The NLM has partnered with MedlinePlus to create the tutorial Evaluating Internet Health Information: A Tutorial from the National Library of Medicine, which is accessible through the NLM website. The tutorial is useful for both APRNs and consumers.

There are commonalities present in all of the guidelines. The following questions can be used to evaluate Internet sites for healthcare information.

TABLE 6.1    •    Links for Evaluating Online Information

The HON Foundation is a private organization that has created a code of conduct for medical and health websites (HONcode). It does not rate the quality of information but holds website developers to basic ethical standards in the presentation of information. Both APRNs and patients can look for HONcode certification when searching for reliable websites. Certification is free of charge. All HONcode-certified sites are reviewed annually. In addition to the annual review, the HON Foundation relies on users to report noncompliance with the HONcode and investigates complaints (Health on the Net Foundation, 2010). The HON Foundation code of conduct for medical and health websites can be found at www.hon.ch/HONcode/Webmasters/Conduct.html.

The Internet can be a very helpful tool for APRNs and their patients to use to track and monitor progress or to explore alternative practices for the common goal of improving overall health. But both groups need to be vigilant when using the World Wide Web. APRNs should provide their patients with a list of reliable health websites to visit, and patients should be encouraged to visit more than one site to check information. Patients can be taught to look for the seal of certification from an accrediting organization, such as the HON Foundation, and they need to be warned “to be careful not to believe claims or promises of miraculous cures, wonder drugs, and other extreme statements unless there is proof to these claims” (HON Foundation, 2010, para. 8). It is critical that APRNs encourage patients to discuss anything they learn on the Internet with their healthcare provider and that they confirm that patients know how to evaluate medical and health websites.

Wendel, Brossart, Elliot, McCord, and Diaz (2011) describe a program to increase access to mental health services in a rural Texas community. They cite the many obstacles of rural health, including limited healthcare resources and services and a shortage of healthcare professionals. They also recognized that travel time to medical clinics or hospitals was one barrier to accessing healthcare services for rural residents. Rural settings have significant health disparities compared to urban communities, and one of the contributing factors is limited access to healthcare resources. They designed a program to counteract one such disparity by increasing access to mental health services in a rural community. The researchers used a collaborative effort to improve transportation to services and combined this with a telehealth-based counseling program staffed by doctoral students under the supervision of experienced faculty. Their experience led them to conclude that telehealth is a promising method for providing care to hard-to-reach patients. The authors note that it is imperative that there is a mechanism for secure transmissions and maintaining privacy when technology is used to transmit communications between providers and patients. They also reported that technical difficulties during the study caused some interruption in services. Protecting patient confidentiality and providing reliable services are hallmarks of good care. When planning services using advanced technologies, APRNs need to be aware of both the benefits and the barriers. It is essential that experts in the use of technology are included as team members to help design new interventions that incorporate the use of technology.

Oliver, Wittenberg-Lyles, Demiris, and Oliver (2010) carried out a project to engage residents in long-term care in “virtual” sightseeing. Their study was built on the work of earlier researchers who have demonstrated the positive effects of activity programs in long-term care facilities. The authors tested the feasibility of using live videoconferencing to establish communication between residents in a long-term care facility in Iowa and researchers in Athens, Greece. The overall goal of the study was to “open the world of travel for residents confined in long-term care settings and to engage residents in ‘virtual’ sightseeing of foreign settings” (p. 93). These authors documented that the residents who took part in this feasibility study became clearly engaged in the activity. They noted that through technology, nursing homes can offer residents a way to explore the world outside of their usual environment, and they challenged researchers to build an evidence base to demonstrate the long-term value of this initiative on clinical outcomes for nursing home residents. Other researchers have investigated the use of technology to enrich the environment of people who live in long-term care facilities. Demiris and colleagues (2008) explored the potential of using video phone technology to improve quality of life for long-term care residents and distant family members. The authors propose that technology can redefine the role of distant caregiving for residents and family members in long-term care facilities by increasing opportunities for communication between loved ones. These studies offer tantalizing glimpses into the possibilities of using technology to enrich the lives of people in long-term care.

E-health is a growing field. The Internet can be a very helpful tool for APRNs and their patients to track and monitor progress or to explore alternative practices for the common goal: to improve overall health. Populations are best served when their needs are met using a variety of approaches. There are a number of platforms that can connect APRNs to patients and/or other health providers. Information can be exchanged between health provider and patient via teleconferencing, web casts, podcasting (delivery of audio, text, pictures, and/or video to a computer or mobile device), and Twitter (text-based messages sent through a social networking site), to name just a few. Communication devices range from tabletop home computers and laptops to tablet computers and smartphones. The examples cited in this chapter provide a window into the opportunities open to APRNs to be creative in using technology to improve patient outcomes. Inherent in the fact that this is a relatively new way to provide care, there is a dearth of literature on long-term follow-up and few studies have been replicated. There are also barriers to the use of new technologies such as competency, a poor match between clinical needs and the availability of devices, privacy issues, system downtimes, and disparities among groups related to availability and use patterns. Assessing populations for their patterns of Internet usage and other technologies is an important part of the APRN’s role. Equally important is designing interventions that make use of new technologies and measuring the impact on relevant population outcomes. Further research is needed to fully evaluate the advantages and disadvantages of using technology in populations to improve health while maintaining privacy and sustainability.

U.S. Department of Health and Human Services: www.hhs.gov

The U.S. Department of Health and Human Services (HHS) is the U.S. government’s principal agency for protecting the health of all Americans. It provides essential services (such as Medicare) and administers more grant dollars than all other federal agencies combined. The site has a wealth of information on diseases and conditions. An excellent example is Healthfinder.gov, which provides easy-to-understand information for consumers to stay healthy. The Quick Guide to Healthy Living explains in simple language, recommendations for health screenings and tests. There is even a link for people to help find a physician, health center, or public library. A new addition to the HHS site is StopBullying.gov, which provides information on how children, young adults, parents, and educators can recognize, prevent, or stop bullying. A table provides specific information on how and where to get help for bullying (http://www.stopbullying.gov/). Another recent initiative of the HHS is the National Partnership for Action. This initiative includes a Health Information Disparities Workgroup. The goal of this workgroup is to create projects to combat the digital divide (U.S. Department of Health and Human Services, 2011).

Centers for Disease Control and Prevention: www.cdc.gov

The Centers for Disease Control and Prevention (CDC) is a U.S. government agency. Organizationally, it is under the HHS. Its mission is to “collaborate to create the expertise, information, and tools that people and communities need to protect their health—through health promotion, prevention of disease, injury and disability, and preparedness for new health threats” (Centers for Disease Control and Prevention, 2014, “Mission, Role, and Pledge” section, para 1). The site contains a wealth of information for consumers, health professionals, policy makers, researchers, and educators. The CDC offers a wide variety of helpful resources for these groups, including publications on many health and safety topics, podcasts, and RSS feeds (RSS is the acronym for really simple syndication, which is used to publish recent works, such as blog entries, news headlines, audio, and video, in a standard format and can be sent electronically to subscribers.) The site includes many useful tools, such as photos, a BMI calculator, and slide presentations, that can be used for educational purposes. The CDC also publishes Emerging Infectious Diseases (EID), Morbidity and Mortality Weekly Report (MMWR), and Preventing Chronic Disease (PCD). These publications are free of charge and can be subscribed to on the CDC site. Also available on this site are data on a large range of topics, including FASTSTATS A-Z and trends in U.S. health statistics.

The National Institutes of Health: www.nih.gov

The National Institutes of Health (NIH) is a U.S. government agency. Similar to the CDC, it is under the HSS. Its mission is to “seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability” (National Institutes of Health, 2014, “Mission, Role, and Pledge” section, para 1). Its primary purpose is to support research for improving the health of the nation. It provides a wealth of material for teachers and students alike on science and health topics. It offers everything from brochures to fact sheets and prepared slide presentations on many health and science topics. NIH News provides updated information on U.S. health trends.

FedStats: fedstats.sites.usa.gov

FedStats provides access to a full range of official statistical information produced by the federal government. It links to more than 100 agencies that provide data and trend information on such topics as diseases, demographics, education, healthcare, and crime (FedStats, 2014).

Agency for Healthcare Research and Quality: www.ahrq.gov

The mission of the Agency for Healthcare Research and Quality (AHRQ) “is to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable” (Agency for Healthcare Research and Quality, Mission & Budget section, para 1, 2014). The AHRQ provides information on health so that consumers and healthcare providers can make informed decisions and provide quality healthcare. The information is designed to be useful to consumers, policy makers, healthcare providers, and employers. The site includes extensive information and resources such as information on funding opportunities for research, databases, research findings, and a health information technology (IT) information tool.

The National Guideline Clearinghouse: www.guideline.gov

The National Guideline Clearinghouse (NGC) is a public resource for evidence-based practice guidelines and is housed within the AHRQ. Healthcare providers can search the NGC site to obtain up-to-date guidelines for the provision of evidence-based care.

Let’s Move!: www.letsmove.gov

Obesity is a national issue and there are online sites related to obesity springing up all over the Internet. One excellent resource for consumers and APRNs alike is Let’s Move, the online site related to First Lady Michelle Obama’s campaign against obesity. Readers can learn how to prevent childhood obesity, find nutritional facts, get ideas for being active, and learn how you can help schools and communities make healthier foods available to children. Let’s Move is on Facebook, where individuals can share stories and ideas. There are also connections to Twitter and Meetup (a social networking site that facilitates group meetings among people with common interests and goals).

Educational Sites

Nongovernmental websites are also a source of excellent information for healthcare providers and consumers. Sites with .edu in the address are owned by educational institutions. Many universities, particularly those that offer health-related degrees, have extensive resources available for people who are looking for information on health-related topics.

The Nursing Archives, Boston University: hgar-srv3.bu.edu/collections/nursing

A fascinating glimpse into the history of nursing is provided by the Nursing Archives, which is part of the Howard Gotlieb Archival Research Center at Boston University. The Nursing Archives includes a collection of personal and professional papers of many nursing leaders, including 250 of Florence Nightingale’s letters. There are also records of schools of nursing, public health and professional nursing organizations, histories of various American and foreign schools of nursing, and early textbooks (Boston University, 2014). These materials provide a fascinating look at the early years of nursing and public health.

Institute of Medicine: www.iom.edu

The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of the government to provide “unbiased and authoritative advice to decision makers and the public” (Institute of Medicine, 2014, “About the IOM” section, para 1). It is an arm of the National Academy of Sciences. It undertakes specific mandates from Congress, federal agencies, and independent organizations. The site makes available a complete list of its reports published after 1998. One such report is “The Future of Nursing: Leading Change, Advancing Health,” commissioned by the Robert Wood Johnson Foundation and published in 2010.

Professional Organizations

Professional membership organizations are usually run as not-for-profits and work to further the interests of a profession and to protect the public. They are generally a rich source of information on the healthcare professions. They generally have .org in the address. APRNs should search their specialty organizations for resources and information.

American Nurses Association: www.nursingworld.org

The ANA (American Nurses Association; 2014a) is the professional organization for registered nurses in the United States. It has 54 constituent member nurses associations and is affiliated with 35 specialty nursing and workforce advocacy affiliate organizations. It publishes standards of nursing practice for general RN nursing and nursing subspecialty practices. The ANA also lobbies Congress and regulatory agencies on healthcare issues affecting nurses and consumers. The ANA publishes American Nurse Today and the Online Journal of Issues in Nursing (OJIN). The OJIN is a peer-reviewed, online publication. Only members have access to current issues, but archived issues are available to anyone. The ANA also distributes the RSS, ANA SmartBrief.

The ANA, teamed with seven other organizations, launched an online resource for consumers in 2011. The site HealthCareandYou.org (www.healthcareandyou.org) outlines the provisions in the Affordable Care Act and breaks down the act’s benefits by state. Healthcare providers can use the site to obtain information that will be useful for explaining the key points of the Affordable Care Act to patients, and the language and format are kept clear and simple for easy use by consumers (ANA, 2014b).

The American Nurses Credentialing Center (ANCC) is a subsidiary of the ANA. It sets the standards for professional certification, accredits continuing nursing education, and created and oversees the Magnet Recognition Program. Standards for certification and accreditation are published on the group’s website (www.nursecredentialing.org/default.aspx).

American Public Health Association: www.apha.org

Founded in 1872, the American Public Health Association (APHA) is a diverse membership organization of public health professionals. Its mission is to “Improve the health of the public and achieve equity in health status” (American Public Health Association [APHA], 2015, “Our Mission” section, sentence 1). Among its goals are to increase access to healthcare, protect funding for core public health services, and eliminate health disparities. It publishes the American Journal of Public Health and The Nation’s Health. These publications are available free to members and to nonmembers by subscription (APHA, 2014).

Not-for-Profit Organizations

A nonprofit organization uses its earnings to pursue its goals and has controlling members or boards instead of owners. Some examples are the American Heart Association (AHA), the American Cancer Society (ACS), and the Asthma and Allergy Foundation of America (AAFA). Many of these sites have an impressive amount of information and resources that they make available to the public. Most of these groups have .org in their URLs.

American Heart Association: www.heart.org/HEARTORG

The AHA has an extensive and eclectic library of information and resources for educators at all levels, consumers, and healthcare professionals. The site includes downloadable lesson plans, risk-assessment tools, and free application software (apps) such as the Walking Path Mobile app. The AHA develops guidelines and course materials for first aid, basic life support, and advanced life support courses.

American Cancer Society: www.cancer.org

Similar to the AHA, the ACS provides extensive information and resources to both consumers and healthcare professionals. Its site includes information on the latest research in cancer prevention and treatment, information and resources for specific cancer topics, information on side effects of different treatments for cancer, and information on funding and paying for treatment.

Asthma and Allergy Foundation of America: www.aafa.org

The mission of the AAFA is to improve the quality of life for people with asthma and allergic diseases through education, advocacy, and research (Asthma and Allergy Foundation of America, 2011). Examples of its extensive online resources are an online “allergy forecast tool,” information on its asthma and allergy certification program, an “ask the allergist” online tool, and extensive educational resources on allergies and asthma.

The Pew Research Center: www.pewresearch.org

The Pew Research Center is a subsidiary of the Pew Charitable Trusts. It is a think tank that informs the public about the issues, attitudes, and trends shaping America and the world. It conducts public opinion polling, demographic research, media content analysis, and other empirical social science research (Pew Research Center, 2014).

International Organizations

There are many international organizations described throughout this book. Perhaps one of the most powerful and influential is the World Health Organization (WHO).

World Health Organization: www.who.int

WHO (2014) is an arm of the United Nations. It provides leadership on global health matters and technical support to countries, and monitors and assesses health trends. Its website includes a multilingual page with publications and resources in many languages and on various health topics, and another page with evidence-based guidelines. There is also current information on disease outbreaks and world health trends. WHO publishes the World Health Report, World Health Statistics Report, and information for international travelers. The multimedia site includes podcasts and videos on various health topics. WHO news can be accessed on Twitter and via RSS.

Commercial Sites

Although only one is listed here, there are many commercial sites that provide balanced and transparent information. Do not dismiss websites because .com is in the address. Use the information provided in this chapter to evaluate all websites.

Medscape: www.medscape.com

Medscape (2014) is an online, peer-reviewed resource for health professionals. It features peer-reviewed original articles and provides both continuing medical education (CME) and continuing nursing education contact hours (CH). It also offers a customized version of the NLM’s MEDLINE database, a drug interaction checker, and a drug reference, and has free downloadable apps for health professionals. All content in Medscape is available free of charge for professionals and consumers alike, but registration is required. Review the website for information on copyright restrictions and privacy protection.

Analytic Software on the Internet

Epi Info: www.cdc.gov/epiinfo/

Epi Info is a collection of software tools that are available for free download through the CDC website. It can be used to create questionnaires and download data, and allows the user to perform advanced statistical analyses and geographic information system (GIS) mapping. GIS is a technological tool that allows users to map trends in disease or outcomes of interest using such markers as zip codes or city boundaries, and to integrate data into a geographic map that summarizes data to assist users in identifying trends based on geographic location. In healthcare, mapping can be used to show the geographical distribution of specific factors such as obesity or cancer types. By mapping these factors, patterns of occurrence can be identified and specific areas can be targeted for intervention.

The Visual Statistics System: www.uv.es/visualstats/Book

The Visual Statistics System (ViSta) is a free, downloadable statistical system. ViSta can be used for both descriptive and inferential analytic analyses. It performs both univariate and multivariate analyses. Go to the website to learn how to use the program, but be sure to review the copyright restrictions prior to usage.

The Not-So-Hidden Dangers of Social Media in Healthcare

Many professional organizations have written guidelines for the use of social media. It is critical that APRNs remember at all times that patient confidentiality is both a legal and an ethical responsibility. Complaints to state boards of nursing against nurses who use social media usually fall within the following areas (Spector & Kappel, 2012):

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