- Email: [email protected]
burn centers in Germany, Austria and Switzerland
burns 38 (2012) 444–449
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Evaluation of the online-presence (homepage) of burn units/ burn centers in Germany, Austria and Switzerland H.F. Selig a, D.B. Lumenta b, C. Ko¨nig a, H. Andel c, L.P. Kamolz a,b,* a
Section of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, State Hospital Wiener Neustadt, Austria Vienna Burn Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria c Department of Anaesthesia and Intensive Care, Medical University of Vienna, Austria b
article info
abstract
Article history:
Purpose: A successful online presence is an important key factor in the competition among
Accepted 20 September 2011
hospitals today. However, little is known about the internet presence and the quality of websites of burn units on the World Wide Web. The aim was to assess the online presence of
Keywords:
hospitals provided by specialized burn units in German speaking countries with a focus on
Burn center
the rate and the performance of actively run websites.
Internet
Methods: A multicenter, observational, cross-sectional study was performed over a period of
Website
1.5 month (October–December 2010). Forty-four burn units were assessed by using a
Information
previously generated criteria list. The list included 36 criteria with following topics: ‘‘re-
World Wide Web
search and teaching’’; ‘‘patient care’’; ‘‘clinical emphases’’, ‘‘general information’’; ‘‘information brokerage’’. Results: Overall, the websites examined offered a good overview about their different online services with many multimedia-based elements included. All websites consisted of hyperlinks, general multimedia-based elements and information on means of communication with the hospital, respectively. In contrast, the quality of specific information for burn patients was relatively poor. With regard to the need of elderly people, the usability and the layout, the different websites offer a lot of options for future improvements. Conclusion: Burn centers in Germany, Austria and Switzerland already consider the World Wide Web as an important tool for self-promotion and communication. The potential of burn center websites to function as a knowledge base for first aid as well as preventive measurements should be considered and realized in future web site designs. # 2011 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
In the course of the past decades the internet has gone through considerable and fast-paced changes. In the 21st century, the World Wide Web has finally become a vital part of our lives. An increasing number of letters is gradually being replaced by emails and very often the internet is used as a source of information rather than newspapers.
In 2008, more than half (56%) of the 500 million of citizens in the EU used the internet regularly [1]. Due to the increasing number of households having access to the internet (up from 33% in 2004 to 80% in 2008) [1] and the large number of virtual information sources, it is inevitable to offer high-quality websites in the medical field. Having an online presence is also very important for hospitals [2]. Since using the internet has become a part of our daily lives and access to the internet has become fast and easy, a majority
* Corresponding author at: Section of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, State Hospital Wiener Neustadt, Corvinusring 3-5, A-2700 Wiener Neustadt, Austria. E-mail address: [email protected] (L.P. Kamolz). 0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.09.018
445
burns 38 (2012) 444–449
of people searches for information on diseases, treatment methods and prognoses on their own on the net. Some of them simply look up medical information because they are interested in it. A survey of the European Union in 2003 indicated that approximately one quarter of the Europeans look up information on medical issues on the internet [3]. The particular problem in the relation between medicine and the internet is that on one hand, the large number of information sources have a positive aspect, on the other hand, the potentially negative aspects resulting of inappropriate handling of the information provided on the websites (by patients as well as by professionals) has to be taken into account [4]. Thus, it is important, in particular in the medical field, to operate high-quality websites that provide correct information and are easy to use for the patients [5]. That is the only way how the danger of misinformation or incomplete information can be faced. The competition among the hospitals is fierce. A successful online presence is an important key factor for the hospitals in that competition. The internet is an additional source of information for numerous interested individuals. That is the reason why communication and external presentation have become so important today [6]. However, websites are not extensively evaluated today. Overall, it appears to be difficult to find standardized evaluation criteria for medical websites. According to Urban [6] and the ‘‘Initiative Medizin Online’’ (imedOn) [7] several factors are important to achieve a successful web presence. Websites should provide the newest information and keep featured events up-to-date. Names and the respective addresses should also be kept up-to-date. Texts need to be written clearly and straight-forward, the content on the pages needs to be well organized and if possible, loading times should be kept low [7]. Another useful feature for online users is a route description [6]. Internal links (e.g., to another department) or external links to other websites (e.g., to partner hospitals) are also very helpful. These are called ‘‘hyperlinks’’ and provide cross-references from a certain keyword to further information; short name: link. According to imedOn; it is extremely important that all (hyper-) links are up-to-date and working. An online survey of German TV channels ARD and ZDF [8] indicates that also elderly and old individuals, who have only little experience in the field of information research, are increasingly using the internet to find information. In most cases the eyesight of these people is poor. Thus, the fonts on the websites need to be well readable and adjustable in terms of size. The internet should be well accessible also for handicapped individuals [9]. With regard to the online presence of hospitals and its website quality, several studies from diagnostic radiology units [10], surgical [11], orthopaedic and traumatology departments [12] exist, indicating substantial failures in their online performance. However, information of the internet presence of burn units is scarce. Therefore, we aimed to perform a study about the online presence of hospitals with burn units in German speaking countries, namely in Germany, Austria and Switzerland. We focused on the rate and the performance of actively run websites of hospitals provided by specialized burn units.
2.
Methods
This study was a descriptive, quantitative, multicentre observational cross-sectional study to evaluate the internet/ websites of German-speaking hospitals provided by burn centers in Germany, Austria and Switzerland. Overall, 45 hospitals provided by specialized burn units exist in Germany (n = 37), Austria (n = 5) and Switzerland (n = 3) summarized in Table 1. Over a period of 1.5 months (October–December 2010) the websites of hospitals with burn units were assessed by using a previously generated list of criteria. Collective search was based on the online website list of burn centers available from the German Association of Burn Medicine (DGV) and the Federal Association for burn patients [13,14].
2.1.
Criteria list for evaluation
Previously published criteria to assess online performance were used [10] and adjusted for the field of surgical burn care. The generated list included in total 36 criteria and consisted of the following topics: ‘‘general information’’, ‘‘research and teaching’’, ‘‘patient care’’, ‘‘clinical emphases (burning)’’, and ‘‘information brokerage’’ (Table 2). Closed-ended questions (yes–no) were used in 31 criteria, whereas multiple answers were allowed in five criteria (including language, introduction of staff member, availability of multimedia-based resources in general and with regard to burn injuries, staff member contact information). Each question was followed by point allocation (negative answer: 0 point; positive answer: 1 point); in case of multiple answer possibilities, 2 points were allocated. The total maximum score of each website was equivalent to 41 points.
2.2.
Burn center’s quality record
After primary evaluation of online performance of selected hospitals, each website was searched for the availability of detail quality records with regard to structure and performance data of hospitals, as well as quality control and management. The available quality records were assessed for following information: ‘‘total number of treated patients’’; ‘‘information on treatment possibilities’’; ‘‘technical equipment’’; ‘‘total number of beds available for burn patients’’; ‘‘introduction of burn ward’’.
2.3.
Statistical analysis
Descriptive statistics were used for data analysis by using ExcelTM (Microsoft, Seattle, WA, USA). Numbers are given as
Table 1 – Number of hospitals providing specialized burn care in Germany, Austria and Switzerland. Pediatric
Adults
Pediatric + adults
Total
Germany Austria Switzerland
19 1 1
17 3 1
1 1 1
37 5 3
Total
21
21
3
45
446
burns 38 (2012) 444–449
Table 2 – List of criteria for website evaluation (in total: n = 36). Topics
Description of each criteria
General information Status quo of the website (e.g., availability, under construction) Linkage to other hospitals or universities Linkage to bibliography Information of glossary, medical terms, dictionary, learning programs Information of supporting groups for burn victims Language selection (German, English, others) Introduction of staff members (physicians and nursing staff) Contact references of staff members Introduction of the ward General information of the hospital (e.g., history, information on the city) Information on visiting hours Information brokerage Integration of multimedia-based elements with regard to burn injuries Integration of multimedia-based elements for patients in general Hyperlinks Means of communication (e.g., email, telephone, chat) Search aid Possibility to define the text size of the website Research Key scientific aspects in Burn Surgery Publication or scientific projects in Burn Surgery Teaching Information on current courses Introduction on lecturers Information on clinical clerkships or rotations for students Information on meetings (e.g., congress, course) Patient care Site plan ‘‘How to reach the hospital’’ Site plan ‘‘How to reach the burn unit’’ Information on the preparation for medical examination Information on possible waiting times Information on first aid measurements for burn injuries Background information on burn wound depth Background information on burn severity Information for patients and relatives (e.g., staff members, social counselling, spiritual guidance Total number of burn patients annually treated Emergency number(s) Key aspects of clinical treatment Information on primary care, skin grafting, post-operative treatment or scar revision procedures Information on technical and diagnostic equipment Total available number of ICU beds for burn victims
means (SD) for normally distributed continuous variables or fractions for nominal and ordinal data.
3.
Results
multimedia-based. Not any website contained details with regard to possibly existing waiting times. While the majority of websites (86.3%) achieved a total score between 18 and 35 points, not one website scored 9 points or lower.
3.1. Forty-four websites, of whom all were present on the World Wide Web, were examined for further evaluation. One French website of a Swiss hospital was excluded. An online quality record was available on 32 websites. Overall, 39 (88.6%) of the websites were fully available to the users during the time of research; 6 website or parts of those were found to be under construction. In total, 4 out of 36 criteria (11.1%) were available on each evaluated website, including support for patients or relatives, information on means of communication with the hospital, hyperlinks availability and integration of general
General information
Twenty-three websites (52.3%) provided only one language selection. Websites in German or English were available in 31.8% (n = 14), in German or Russian in 2.3% (n = 1) and in German, English or any other language selection in 18.2% (n = 8). Forty-one websites (93.2%) contained links to different hospitals or universities and 34 (77.3%) provided linkage to supporting groups for burn-related victims. The majority of websites (95.5%, n = 42) consisted of staff member introduction and provided their contact references (93.2%, n = 41). Information on visiting hours was available in 95.5% (n = 42).
burns 38 (2012) 444–449
447
information on current courses and lectures. Overall, 75% (n = 33) of all assessed websites were found to offer clinical clerkships or rotations for students. The evaluation revealed the tendency of university hospitals providing more information on research activities than hospitals without any university affiliation.
3.4.
Fig. 1 – Example for a multimedia element in terms of an audio-podcast available from Hannover Medical SchoolMHH (http://www.mhhannover.de/ index.php?id=17180&L=1). English translation: The burn center of Hannover Medical School-MHH. Severe burns are among one of the worst injuries that can happen. Victims are often in a critical condition and they have to cope with the subsequent scars. Burn centers guarantee an ideal patient care for burn victims. The MHH accounts for one of the most efficient burn center in Germany.
3.2.
Information brokerage
All websites (n = 44) consisted of hyperlinks, general multimedia-based elements (Fig. 1) and information on means of communication with the hospital, respectively. Forty-one websites (93.2%) contained the function of using a search aid. The possibility to define the size of the text on the website was found in 34.1% (n = 15).
3.3.
Research and teaching (Fig. 2)
Scientific projects and publications were found in 45.5% (n = 20) of all websites. Twenty-one websites (47.7%) provided
75,0
Clinical rotations 50,0
Scientific focus
47,7
Lectures Current projects
45,5
Publications
45,5 0
20
40
60
80
Frequency in % Fig. 2 – Frequency distribution of criteria found with regard to research and teaching. While the majority of all assessed websites were found to offer clinical clerkships or rotations for students, information on lectures, publications, current projects and the scientific focus were available in only up to 50% of all websites.
Patient care
Fig. 3 demonstrates the rate of available information with regard to patient care. While 43 websites (97.7%) comprised information on direction to the hospital, 29 (65.9%) provided a detailed position plan of the burn center and 8 (18.2%) offered information on first aid measurements for burn injuries. Background information on possible depth and degree of burn injuries were available in 18.2% (n = 8). Emergency numbers were present in 75% (n = 33), of whom 63.3% (n = 21) were found to be accessible on the start page. All websites (100%) offered information or support for patients and relatives in terms of social counselling or spiritual guidance.
3.5.
Key aspects of clinical treatment
Overall, 81.8% (n = 36) of all websites consisted of information on primary care, skin grafting, post-operative treatment or revision operation. Thirty-four (77.3%) burn centers provided information on technical or diagnostic equipment, whereas 26 burn centers (59.1%) listed the total available number of ICU beds for burn victims.
4.
Discussion
In recent years, the World Wide Web has been evolving as an essential source for patients and laypersons gaining health related information or details of health facilities and its key aspects of treatment possibilities [15]. Therefore, the online presence of hospitals and its quality information seem to be crucial today [2]. Because only limited data have been available about the online presence of burn centers and its website performance, we aimed to describe these variables from a cross-sectional study. To guarantee a representative evaluation, we performed a multicenter website evaluation of all burn centers from German-speaking European countries, albeit with a predominance of burn centers in Germany. Because scarce information exist about a standard procedure for medical website evaluation, our criteria list was mainly based on criteria from another study in the field of radiology performed in Germany [11]. Whether these criteria satisfied considerations of validity were not found to be clearly stated. Additional resources were gained from the imedonhomepage that gave recommendations how to assess usability and layout [8]. Based on these criteria were have adjusted our survey for the field of surgical burn care. Overall, the websites examined offered a good overview about their different online services with many multimediabased elements included. While the online-presence of burn centers was found to be sufficient, the quality of specific information about burn injuries, even on first aid measures for laypersons, was relatively poor. With regard to the need of
448
burns 38 (2012) 444–449
Direction to the hospital
97,7
Treatment
81,8
Equipment
77,3
Emergency number(s)
75.0
Social counseling, spiritual guidance
65,9
Site plan
65,9
ICU beds
59,1
Burn depth
18,2
First aid
18,2
Preparation
11,4
Waiting time
0 0
10
20
30
40
50
60
70
80
90 100
Frequency in %
Fig. 3 – Frequency distribution of criteria found on the websites with regard to patient care and key aspects of treatment.
elderly people, the usability and the layout, the different websites offered a lot of options for future improvements. Substantial differences in web performance were not found between Austria, Germany and Switzerland, maybe due to the fact that the health care systems are quite similar. In addition, the quality of burn center websites was found to be independent of its hospital size. Only a well-designed general homepage of the analyzed hospitals revealed the tendency of a better website performance of its affiliated burn centers. The comprehensive presence of burn centers on the World Wide Web in our analysis underlined the value for introduction, self-promotion and communication of that specific subarea of plastic surgery. However, the transmission of valuable and detail information for patients to overlook the main aspects of burn injuries were found to be insufficient. Even information on first aid measurements was lacking. Previously, burn-related first aid information on the Internet has been reported to be inaccurate and of poor quality [16]. This issue may have to be addressed by burn centers that can provide quality information for lay- or interested persons. In addition, there is evidence that the main topics of burn patients, their relatives and their friends who search on the internet include skin grafting, scar management and rehabilitation [17]. However, commercial websites with regard to burn scar management have been reported to be of poor information quality, even if academic and organizational websites were found to be better rated [18]. Therefore, these topics may have to be emphasized at burn center websites in the future. Our study revealed that only up to half of all websites offered information of key aspects in research, current projects or provided papers of lecture for students. This may be based on the circumstance that our sample included but were not limited to university hospitals which give different emphases on these topics compared to nonuniversity hospitals. However, information on research and teaching are considered to be a substantial quality criteria of hospital websites [10] that should not be omitted. Only in about half of all assessed websites, relevant information was possible to be translated into another language than German. Apparently, most burn centers consider their online-presence only for the German-speaking population to be sufficient. Despite the fact that translation
service may incur additional charges [10], hospital websites with at least English as additional language seem to be of substantial necessity in the age of globalization. Nevertheless, Singh and colleagues reported that Internet users preference the local language, rather than English, to obtain healthrelated information [19]. Overall, only one out of three websites provided the possibility to define the text size, indicating a great need for improvement in terms of user-friendly online service. For elderly and visually impaired users, this has been considered as an important quality criteria of websites [7]. In addition, improvements are demanded because of the German Disability Discrimination Act (BGG) that gives the legal bases for the access to online-media without obstacles for disabled people [20]. Unfortunately, not any website provided information of possible occurring waiting times, limiting the ability for patients to schedule in advance. A possible explanation may be that the information of actually existing longer waiting times is withheld. Notwithstanding, this information could be particularly useful for employed persons. The internet is also increasingly used for educational purposes. A study on future gynaecologists tested if the kind of education (clinically standardized electronic learning course versus traditional lectures) has any effect on knowledge expansion [21]. The study indicated that both means of learning were equally effective and that the e-learning course was well accepted (independent studying, documentation easy to update). With regard to this result and the fact that elearning is the least expensive method, it might be worth considering integrating an e-learning course into the postgraduate curricula particularly.
5.
Conclusion
Burn centers in Germany, Austria and Switzerland already consider the World Wide Web as an important tool for selfpromotion and communication. Improvements may be required in terms of quality information on burn injuries as well as usability and layout, in particular to satisfy the needs of elderly people. In our opinion, the potential of burn center
burns 38 (2012) 444–449
websites to function as a knowledge base for first aid as well as preventive measurements should be considered and realized in future web site designs.
Conflict of interest
[9]
[10]
All authors declare that they have no conflicts of interest. [11]
references
[1] European Commission Europe’s Digital Competitiveness Report—Main achievements of the i2010 strategy 2005– 2009, [accessed 29.07.11]. [2] Revere L, Robinson Jr L. How healthcare organizations use the internet to market quality achievements. J Healthc Manag 2010;55:39–49. [3] The European Opinion Research Group. Eurobarometer 58.0. European Union citizens and sources of information about health, . [4] Jadad AR, Gagliardi A. Rating health information on the Internet: navigating to knowledge or to Babel? JAMA 1998;279:611–4 [accessed 29.07.11]. [5] Purcell GP, Wilson P, Delamothe T. The quality of health information on the internet. BMJ 2002;324:557–8. ¨ ffentlichkeitsarbeit fu¨r [6] Urban A. Gesunde Netze pflegen—O Kliniken, Praxen und Pflegeeinreichungen, 1st ed., Viola Falkenberg Verlag Bremen; 2007. [7] Elste F, Stadler J, Cramer D. imedON Initiative Medizin Online–fu¨r bessere Gesundheitsinformationen im Netz. Reihe: Whitepaper, Deutsches Zentrum fu¨r Medizinmarketing, [accessed 29.07.11]. [8] ARD/ZDF BR. Internet zwischen Hype, Ernu¨chterung und Aufbruch. 10 Jahre ARD/ZDF-Onlinestudie,
[12]
[13] [14] [15]
[16] [17] [18]
[19]
[20]
[21]
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onlinenutzung/pdf/0705-jubilaeumsbroschuere.pdf> [accessed 29.07.11]. Chiang MF, Starren J. Evaluation of consumer health website accessibility by users with sensory and physical disabilities. Stud Health Technol Inform 2004;107: 1128–32. Seitz J, Siegmund M, Volk M, Feuerbach S, Strotzer M. Evaluation of the Internet presence of diagnostic radiology units at German universities. Radiology 2002;42:739–44. Schenk C, Mugomba G, Dabidian R, Mayr S, Glaser F. Internet presence of surgical clinics in Germany. Current data and future prospects. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 2000;71:1521–4. Butzke I, Kramer KL. Orthopedics in the world wide web: university homepages of the G-7 states. Z Orthop Ihre Grenzgeb 2000;138:413–8. Federal Association for Burn Patients, [accessed 29.07.11]. Breckons M, Jones R, Morris J, Richardson J. What do evaluation instruments tell us about the quality of complementary medicine information on the internet? J Med Internet Res 2008;10:e3.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Evaluation of the online-presence (homepage) of burn units/ burn centers in Germany, Austria and Switzerland H.F. Selig a, D.B. Lumenta b, C. Ko¨nig a, H. Andel c, L.P. Kamolz a,b,* a
Section of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, State Hospital Wiener Neustadt, Austria Vienna Burn Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria c Department of Anaesthesia and Intensive Care, Medical University of Vienna, Austria b
article info
abstract
Article history:
Purpose: A successful online presence is an important key factor in the competition among
Accepted 20 September 2011
hospitals today. However, little is known about the internet presence and the quality of websites of burn units on the World Wide Web. The aim was to assess the online presence of
Keywords:
hospitals provided by specialized burn units in German speaking countries with a focus on
Burn center
the rate and the performance of actively run websites.
Internet
Methods: A multicenter, observational, cross-sectional study was performed over a period of
Website
1.5 month (October–December 2010). Forty-four burn units were assessed by using a
Information
previously generated criteria list. The list included 36 criteria with following topics: ‘‘re-
World Wide Web
search and teaching’’; ‘‘patient care’’; ‘‘clinical emphases’’, ‘‘general information’’; ‘‘information brokerage’’. Results: Overall, the websites examined offered a good overview about their different online services with many multimedia-based elements included. All websites consisted of hyperlinks, general multimedia-based elements and information on means of communication with the hospital, respectively. In contrast, the quality of specific information for burn patients was relatively poor. With regard to the need of elderly people, the usability and the layout, the different websites offer a lot of options for future improvements. Conclusion: Burn centers in Germany, Austria and Switzerland already consider the World Wide Web as an important tool for self-promotion and communication. The potential of burn center websites to function as a knowledge base for first aid as well as preventive measurements should be considered and realized in future web site designs. # 2011 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
In the course of the past decades the internet has gone through considerable and fast-paced changes. In the 21st century, the World Wide Web has finally become a vital part of our lives. An increasing number of letters is gradually being replaced by emails and very often the internet is used as a source of information rather than newspapers.
In 2008, more than half (56%) of the 500 million of citizens in the EU used the internet regularly [1]. Due to the increasing number of households having access to the internet (up from 33% in 2004 to 80% in 2008) [1] and the large number of virtual information sources, it is inevitable to offer high-quality websites in the medical field. Having an online presence is also very important for hospitals [2]. Since using the internet has become a part of our daily lives and access to the internet has become fast and easy, a majority
* Corresponding author at: Section of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, State Hospital Wiener Neustadt, Corvinusring 3-5, A-2700 Wiener Neustadt, Austria. E-mail address: [email protected] (L.P. Kamolz). 0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.09.018
445
burns 38 (2012) 444–449
of people searches for information on diseases, treatment methods and prognoses on their own on the net. Some of them simply look up medical information because they are interested in it. A survey of the European Union in 2003 indicated that approximately one quarter of the Europeans look up information on medical issues on the internet [3]. The particular problem in the relation between medicine and the internet is that on one hand, the large number of information sources have a positive aspect, on the other hand, the potentially negative aspects resulting of inappropriate handling of the information provided on the websites (by patients as well as by professionals) has to be taken into account [4]. Thus, it is important, in particular in the medical field, to operate high-quality websites that provide correct information and are easy to use for the patients [5]. That is the only way how the danger of misinformation or incomplete information can be faced. The competition among the hospitals is fierce. A successful online presence is an important key factor for the hospitals in that competition. The internet is an additional source of information for numerous interested individuals. That is the reason why communication and external presentation have become so important today [6]. However, websites are not extensively evaluated today. Overall, it appears to be difficult to find standardized evaluation criteria for medical websites. According to Urban [6] and the ‘‘Initiative Medizin Online’’ (imedOn) [7] several factors are important to achieve a successful web presence. Websites should provide the newest information and keep featured events up-to-date. Names and the respective addresses should also be kept up-to-date. Texts need to be written clearly and straight-forward, the content on the pages needs to be well organized and if possible, loading times should be kept low [7]. Another useful feature for online users is a route description [6]. Internal links (e.g., to another department) or external links to other websites (e.g., to partner hospitals) are also very helpful. These are called ‘‘hyperlinks’’ and provide cross-references from a certain keyword to further information; short name: link. According to imedOn; it is extremely important that all (hyper-) links are up-to-date and working. An online survey of German TV channels ARD and ZDF [8] indicates that also elderly and old individuals, who have only little experience in the field of information research, are increasingly using the internet to find information. In most cases the eyesight of these people is poor. Thus, the fonts on the websites need to be well readable and adjustable in terms of size. The internet should be well accessible also for handicapped individuals [9]. With regard to the online presence of hospitals and its website quality, several studies from diagnostic radiology units [10], surgical [11], orthopaedic and traumatology departments [12] exist, indicating substantial failures in their online performance. However, information of the internet presence of burn units is scarce. Therefore, we aimed to perform a study about the online presence of hospitals with burn units in German speaking countries, namely in Germany, Austria and Switzerland. We focused on the rate and the performance of actively run websites of hospitals provided by specialized burn units.
2.
Methods
This study was a descriptive, quantitative, multicentre observational cross-sectional study to evaluate the internet/ websites of German-speaking hospitals provided by burn centers in Germany, Austria and Switzerland. Overall, 45 hospitals provided by specialized burn units exist in Germany (n = 37), Austria (n = 5) and Switzerland (n = 3) summarized in Table 1. Over a period of 1.5 months (October–December 2010) the websites of hospitals with burn units were assessed by using a previously generated list of criteria. Collective search was based on the online website list of burn centers available from the German Association of Burn Medicine (DGV) and the Federal Association for burn patients [13,14].
2.1.
Criteria list for evaluation
Previously published criteria to assess online performance were used [10] and adjusted for the field of surgical burn care. The generated list included in total 36 criteria and consisted of the following topics: ‘‘general information’’, ‘‘research and teaching’’, ‘‘patient care’’, ‘‘clinical emphases (burning)’’, and ‘‘information brokerage’’ (Table 2). Closed-ended questions (yes–no) were used in 31 criteria, whereas multiple answers were allowed in five criteria (including language, introduction of staff member, availability of multimedia-based resources in general and with regard to burn injuries, staff member contact information). Each question was followed by point allocation (negative answer: 0 point; positive answer: 1 point); in case of multiple answer possibilities, 2 points were allocated. The total maximum score of each website was equivalent to 41 points.
2.2.
Burn center’s quality record
After primary evaluation of online performance of selected hospitals, each website was searched for the availability of detail quality records with regard to structure and performance data of hospitals, as well as quality control and management. The available quality records were assessed for following information: ‘‘total number of treated patients’’; ‘‘information on treatment possibilities’’; ‘‘technical equipment’’; ‘‘total number of beds available for burn patients’’; ‘‘introduction of burn ward’’.
2.3.
Statistical analysis
Descriptive statistics were used for data analysis by using ExcelTM (Microsoft, Seattle, WA, USA). Numbers are given as
Table 1 – Number of hospitals providing specialized burn care in Germany, Austria and Switzerland. Pediatric
Adults
Pediatric + adults
Total
Germany Austria Switzerland
19 1 1
17 3 1
1 1 1
37 5 3
Total
21
21
3
45
446
burns 38 (2012) 444–449
Table 2 – List of criteria for website evaluation (in total: n = 36). Topics
Description of each criteria
General information Status quo of the website (e.g., availability, under construction) Linkage to other hospitals or universities Linkage to bibliography Information of glossary, medical terms, dictionary, learning programs Information of supporting groups for burn victims Language selection (German, English, others) Introduction of staff members (physicians and nursing staff) Contact references of staff members Introduction of the ward General information of the hospital (e.g., history, information on the city) Information on visiting hours Information brokerage Integration of multimedia-based elements with regard to burn injuries Integration of multimedia-based elements for patients in general Hyperlinks Means of communication (e.g., email, telephone, chat) Search aid Possibility to define the text size of the website Research Key scientific aspects in Burn Surgery Publication or scientific projects in Burn Surgery Teaching Information on current courses Introduction on lecturers Information on clinical clerkships or rotations for students Information on meetings (e.g., congress, course) Patient care Site plan ‘‘How to reach the hospital’’ Site plan ‘‘How to reach the burn unit’’ Information on the preparation for medical examination Information on possible waiting times Information on first aid measurements for burn injuries Background information on burn wound depth Background information on burn severity Information for patients and relatives (e.g., staff members, social counselling, spiritual guidance Total number of burn patients annually treated Emergency number(s) Key aspects of clinical treatment Information on primary care, skin grafting, post-operative treatment or scar revision procedures Information on technical and diagnostic equipment Total available number of ICU beds for burn victims
means (SD) for normally distributed continuous variables or fractions for nominal and ordinal data.
3.
Results
multimedia-based. Not any website contained details with regard to possibly existing waiting times. While the majority of websites (86.3%) achieved a total score between 18 and 35 points, not one website scored 9 points or lower.
3.1. Forty-four websites, of whom all were present on the World Wide Web, were examined for further evaluation. One French website of a Swiss hospital was excluded. An online quality record was available on 32 websites. Overall, 39 (88.6%) of the websites were fully available to the users during the time of research; 6 website or parts of those were found to be under construction. In total, 4 out of 36 criteria (11.1%) were available on each evaluated website, including support for patients or relatives, information on means of communication with the hospital, hyperlinks availability and integration of general
General information
Twenty-three websites (52.3%) provided only one language selection. Websites in German or English were available in 31.8% (n = 14), in German or Russian in 2.3% (n = 1) and in German, English or any other language selection in 18.2% (n = 8). Forty-one websites (93.2%) contained links to different hospitals or universities and 34 (77.3%) provided linkage to supporting groups for burn-related victims. The majority of websites (95.5%, n = 42) consisted of staff member introduction and provided their contact references (93.2%, n = 41). Information on visiting hours was available in 95.5% (n = 42).
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information on current courses and lectures. Overall, 75% (n = 33) of all assessed websites were found to offer clinical clerkships or rotations for students. The evaluation revealed the tendency of university hospitals providing more information on research activities than hospitals without any university affiliation.
3.4.
Fig. 1 – Example for a multimedia element in terms of an audio-podcast available from Hannover Medical SchoolMHH (http://www.mhhannover.de/ index.php?id=17180&L=1). English translation: The burn center of Hannover Medical School-MHH. Severe burns are among one of the worst injuries that can happen. Victims are often in a critical condition and they have to cope with the subsequent scars. Burn centers guarantee an ideal patient care for burn victims. The MHH accounts for one of the most efficient burn center in Germany.
3.2.
Information brokerage
All websites (n = 44) consisted of hyperlinks, general multimedia-based elements (Fig. 1) and information on means of communication with the hospital, respectively. Forty-one websites (93.2%) contained the function of using a search aid. The possibility to define the size of the text on the website was found in 34.1% (n = 15).
3.3.
Research and teaching (Fig. 2)
Scientific projects and publications were found in 45.5% (n = 20) of all websites. Twenty-one websites (47.7%) provided
75,0
Clinical rotations 50,0
Scientific focus
47,7
Lectures Current projects
45,5
Publications
45,5 0
20
40
60
80
Frequency in % Fig. 2 – Frequency distribution of criteria found with regard to research and teaching. While the majority of all assessed websites were found to offer clinical clerkships or rotations for students, information on lectures, publications, current projects and the scientific focus were available in only up to 50% of all websites.
Patient care
Fig. 3 demonstrates the rate of available information with regard to patient care. While 43 websites (97.7%) comprised information on direction to the hospital, 29 (65.9%) provided a detailed position plan of the burn center and 8 (18.2%) offered information on first aid measurements for burn injuries. Background information on possible depth and degree of burn injuries were available in 18.2% (n = 8). Emergency numbers were present in 75% (n = 33), of whom 63.3% (n = 21) were found to be accessible on the start page. All websites (100%) offered information or support for patients and relatives in terms of social counselling or spiritual guidance.
3.5.
Key aspects of clinical treatment
Overall, 81.8% (n = 36) of all websites consisted of information on primary care, skin grafting, post-operative treatment or revision operation. Thirty-four (77.3%) burn centers provided information on technical or diagnostic equipment, whereas 26 burn centers (59.1%) listed the total available number of ICU beds for burn victims.
4.
Discussion
In recent years, the World Wide Web has been evolving as an essential source for patients and laypersons gaining health related information or details of health facilities and its key aspects of treatment possibilities [15]. Therefore, the online presence of hospitals and its quality information seem to be crucial today [2]. Because only limited data have been available about the online presence of burn centers and its website performance, we aimed to describe these variables from a cross-sectional study. To guarantee a representative evaluation, we performed a multicenter website evaluation of all burn centers from German-speaking European countries, albeit with a predominance of burn centers in Germany. Because scarce information exist about a standard procedure for medical website evaluation, our criteria list was mainly based on criteria from another study in the field of radiology performed in Germany [11]. Whether these criteria satisfied considerations of validity were not found to be clearly stated. Additional resources were gained from the imedonhomepage that gave recommendations how to assess usability and layout [8]. Based on these criteria were have adjusted our survey for the field of surgical burn care. Overall, the websites examined offered a good overview about their different online services with many multimediabased elements included. While the online-presence of burn centers was found to be sufficient, the quality of specific information about burn injuries, even on first aid measures for laypersons, was relatively poor. With regard to the need of
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Direction to the hospital
97,7
Treatment
81,8
Equipment
77,3
Emergency number(s)
75.0
Social counseling, spiritual guidance
65,9
Site plan
65,9
ICU beds
59,1
Burn depth
18,2
First aid
18,2
Preparation
11,4
Waiting time
0 0
10
20
30
40
50
60
70
80
90 100
Frequency in %
Fig. 3 – Frequency distribution of criteria found on the websites with regard to patient care and key aspects of treatment.
elderly people, the usability and the layout, the different websites offered a lot of options for future improvements. Substantial differences in web performance were not found between Austria, Germany and Switzerland, maybe due to the fact that the health care systems are quite similar. In addition, the quality of burn center websites was found to be independent of its hospital size. Only a well-designed general homepage of the analyzed hospitals revealed the tendency of a better website performance of its affiliated burn centers. The comprehensive presence of burn centers on the World Wide Web in our analysis underlined the value for introduction, self-promotion and communication of that specific subarea of plastic surgery. However, the transmission of valuable and detail information for patients to overlook the main aspects of burn injuries were found to be insufficient. Even information on first aid measurements was lacking. Previously, burn-related first aid information on the Internet has been reported to be inaccurate and of poor quality [16]. This issue may have to be addressed by burn centers that can provide quality information for lay- or interested persons. In addition, there is evidence that the main topics of burn patients, their relatives and their friends who search on the internet include skin grafting, scar management and rehabilitation [17]. However, commercial websites with regard to burn scar management have been reported to be of poor information quality, even if academic and organizational websites were found to be better rated [18]. Therefore, these topics may have to be emphasized at burn center websites in the future. Our study revealed that only up to half of all websites offered information of key aspects in research, current projects or provided papers of lecture for students. This may be based on the circumstance that our sample included but were not limited to university hospitals which give different emphases on these topics compared to nonuniversity hospitals. However, information on research and teaching are considered to be a substantial quality criteria of hospital websites [10] that should not be omitted. Only in about half of all assessed websites, relevant information was possible to be translated into another language than German. Apparently, most burn centers consider their online-presence only for the German-speaking population to be sufficient. Despite the fact that translation
service may incur additional charges [10], hospital websites with at least English as additional language seem to be of substantial necessity in the age of globalization. Nevertheless, Singh and colleagues reported that Internet users preference the local language, rather than English, to obtain healthrelated information [19]. Overall, only one out of three websites provided the possibility to define the text size, indicating a great need for improvement in terms of user-friendly online service. For elderly and visually impaired users, this has been considered as an important quality criteria of websites [7]. In addition, improvements are demanded because of the German Disability Discrimination Act (BGG) that gives the legal bases for the access to online-media without obstacles for disabled people [20]. Unfortunately, not any website provided information of possible occurring waiting times, limiting the ability for patients to schedule in advance. A possible explanation may be that the information of actually existing longer waiting times is withheld. Notwithstanding, this information could be particularly useful for employed persons. The internet is also increasingly used for educational purposes. A study on future gynaecologists tested if the kind of education (clinically standardized electronic learning course versus traditional lectures) has any effect on knowledge expansion [21]. The study indicated that both means of learning were equally effective and that the e-learning course was well accepted (independent studying, documentation easy to update). With regard to this result and the fact that elearning is the least expensive method, it might be worth considering integrating an e-learning course into the postgraduate curricula particularly.
5.
Conclusion
Burn centers in Germany, Austria and Switzerland already consider the World Wide Web as an important tool for selfpromotion and communication. Improvements may be required in terms of quality information on burn injuries as well as usability and layout, in particular to satisfy the needs of elderly people. In our opinion, the potential of burn center
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websites to function as a knowledge base for first aid as well as preventive measurements should be considered and realized in future web site designs.
Conflict of interest
[9]
[10]
All authors declare that they have no conflicts of interest. [11]
references
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