What You Get Depends on Who Owns the Web Site

Let’s say that, like at least 70 million other Americans this year, you’re going on to the Internet in search of information about a medical condition. In this case, you’re wondering whether you have an allergy to latex and decide to visit several commercial personal health sites to learn more.

Perform a search using the words “latex allergy” at Discoveryhealth.com, a Web offshoot of the cable giant Discovery Channel, and you’ll find nine articles, including one excellent question-and-answer interview with a doctor at Johns Hopkins University.

At Americasdoctor.com, a site that offers live e-consultations with docs, the search results in just two references, but one is handily titled Treatment for Latex Allergies. CBSHealthwatch.com, the consumer-oriented site of an electronic publishing company that primarily serves doctors, puts out three well-researched articles on the topic. Healthcentral.com yields 10 good hits. Onhealth.com, soon to be absorbed into Healtheon/WebMD, coughs out three useful items.

But Drkoop.com, the site founded by the popular former U.S. surgeon general, C. Everett Koop, is oddly silent on the topic. Zero hits on latex allergies. Searching with just the word “latex” kicks out a list of items, including stories involving latex condoms, but none provides substantial information about diagnosis or treatment of latex allergies.

One lesson here is that online health Web sites vary significantly in quality and ambition. But in the case of Drkoop.com’s performance on the latex-allergy search, there could be something more unsettling at work.

In 1999, Koop testified before Congress that fears of latex allergies in medical personnel were highly exaggerated--without disclosing that he had held a $1-million consulting contract with a company that makes, among many other things, latex medical gloves. The episode was one of several embarrassing ethical controversies that have dogged the medal-laden public servant since he entered private life. A Drkoop.com spokesman says the omission is “totally unrelated” to the controversy over Koop’s latex testimony.

Welcome to the murky world of Internet health and medicine for consumers, where it’s hard to tell who is providing information, how good it is and what the provider’s ulterior motives might be.

Although the sites offer what could be some of the most important information for which people turn to the World Wide Web, the operators of these sites are not necessarily committed foremost to meeting that public need.

Insurer’s Role Isn’t Explained Clearly

Take, for instance, InteliHealth.com, one of the Internet’s most popular and well-regarded health sites, and a just-announced partner, beginning July 31, with Harvard Medical School. InteliHealth uses (and has trademarked) the slogan “the Trusted Source.” Unfortunately, it is not a very good source of information about who owns it--the financially troubled health insurer Aetna U.S. Healthcare, which is under fire for practices that allegedly rewarded doctors for denying care to patients.

Although Aetna’s president recently proclaimed InteliHealth “a critical component of our Internet strategy,” you won’t find a reference to Aetna on the home page, in the About Us area or even in the news releases. (If you enter the word “Aetna” in the site’s search engine, you’ll find a few pages mentioning Aetna and several Aetna insurance products, but none clearly identifies it as the owner of InteliHealth.)

Things get curiouser at WebMD, where if you click on a link called My Health Plan--a place where users might reasonably expect (cool!) to find information about the plan they happen to be in--you get only a page of links listing services available to members of a health plan operated by Humana Inc. The My Health Plan link is not identified as a sponsored page--something the site’s proprietors piously promise in a series of online pledges will never happen on its turf. It also fails to note that Humana, the pioneering for-profit health care company, is among Healtheon/WebMD’s strategic partners.

Explore the ownership of other leading health-related information sites and the stories get more complicated still. The WebMD site, for example, is just a small part of a colossal health care transformation plan whose partners and investors include Microsoft, DuPont, Rupert Murdoch’s News Corp. (and his Fox TV networks), Silicon Graphics and Netscape founder Jim Clark, drug maker Eli Lilly, and EDS, the computer services company founded by H. Ross Perot. HealthCentral, an online medical source conceived by the mediagenic Dr. Dean Edell and the founder of Web-based travel agent Preview Travel, has bought conglomerateur Bobby Haft’s Vitamins.com to expand its role in e-commerce, and Haft will take a seat on HealthCentral’s board. Thriveonline.com is operated by Oxygen Media, a cable TV and Internet multimedia company whose owners include Oprah Winfrey, another woman described as a “visionary” behind the Nickelodeon cable network and several wealthy producers of syndicated TV shows.

To be fair, most of the sites we looked at for this report do at least a modestly successful job of providing users with information that can help them become better patients and consumers.

Some, like CBSHealthwatch and WebMD, devote a lot of money and energy into reporting and editing health and medical news for their users. Others, like Drkoop.com, Discovery.com and HealthCentral, deliver and organize news derived from other sources. Others specialize by seizing on a demographic niche (Thriveonline aims at healthy women) or a specific feature (Americasdoctor lets you chat, live and online, with board-certified docs 24 hours a day).

For this story we have looked only at eight large commercial health information sites that attempt to attract a broad audience. Many smaller sites that claim to educate the public about health are, in fact, designed to sell specific products or treatments, and we have not included them here. There are also many government, academic and nonprofit sites that offer useful health information on the Web.

But the health sites’ different strategies and competencies can mean consumers get very different information from similar requests. To see how the sites responded to a test of their timeliness and utility, we decided to ask each site for information about the diabetes drug Rezulin, which was withdrawn from the market March 22 following FDA action and reports that the drug may have caused acute liver failure and up to 28 deaths. The results:

* HealthAtoZ.com: Failing. No reference to the recall appears on the diabetes conditions page. Drug Checker provides outdated information, without news of the recall added. A general site search yields only a list of Web sites on diabetes that mention Rezulin.

* WebMD: Barely passing. Nothing on the recall appears in the diabetes condition area or the drugs and herbs area, whose resources predate the recall. A general site search yields many articles, several of which are on the recall (but as on many other sites, stories predating it appear on the list before the recall notice). Odd commercial success: The diabetes areas, as well as results pages of diabetes searches, feature ads asking former Rezulin users to click for information on a drug alternative. The ads are for a diabetes drug distributed by Eli Lilly, a partner of Healtheon/WebMD.

* Discoveryhealth.com: Passing. Diabetes conditions area is silent on the recall. A sitewide search for Rezulin calls up 14 documents, the first one a general document on the drug topped by a note that it had been recalled. RxCentral’s disease-specific drugs area on diabetes was silent.

* Drkoop.com: Direct hit. Diabetes conditions page features link to the Diabetes Library; one link there, under medications and insulin, features text about the recall about two-thirds of the way through. Drug Checker listing is topped by a red warning message about the recall. On a sitewide search, the drugs’ withdrawal is the first document to come up.

* CBSHealthwatch.com: Barely passing (but nice recovery!). The conditions area was silent on the recall. The drugs area was silent too, providing only dated information, until we called and asked the editors about this. They had fixed it the following day. A sitewide search yielded the recall news immediately.

* HealthCentral.com: Barely passing. Its diabetes area had nothing on the recall on the front page, but if you click “more” under “news” you get a long list of stories, some of which do report on the recall. A site-wide search yielded (misordered) stories on the recall. Its RxList feature provided, via one link, a note about the recall.

* Thriveonline.com: Direct hit. Click on diabetes, and the page is topped with a big red warning about the drug recall. The Health Library search of the medical area turned up only 1999 documents. But a sitewide search featured, in the Newsstand area at the bottom of the screen, a recall news report.

* Americasdoctors.com: Direct hit. On the diabetes community page the recall is featured in the top story, which goes on to analyze the issue and talk about treatment alternatives. Its drug encyclopedia listing, however, is not updated.

Now it is true that it’s unfair to judge a site based on its performance on a single test, but we feel that a site’s ability to handle such a recent, high-profile, possibly life-threatening piece of news about a common condition provides at least a snapshot of its competence. It also illuminates one of the primary challenges facing producers of online information. It’s easy to license databases and news from outside sources and proclaim a site a “comprehensive information source”; it’s another matter entirely to successfully anticipate why people might come to the site and deliver the material they are looking for.

Little Differs Among Most Medical Sites

Despite such differences, we found many similarities among the sites’ offerings. All offer some sifting of health news. All have databases on conditions and treatments, drugs, alternative therapies and nutrition. All feature a selection of interactive tools like body-mass-index calculators, online health assessments, medical knowledge quizzes and more.

All offer discussion boards on medical topics (few of them particularly coherent, active or useful), live chats with medical experts and references to other places on the Web to get more information. All offer assurances that user privacy will be protected as much as possible and that advertising does not affect editorial material. Truth told, any of the sites can be accessed to gather useful information on most health topics.

But whether the sites will remain available in their current forms is another question. Nearly all of these sites were launched around the idea of “consumer empowerment”--that the Web could provide consumers with information that can help them manage their health and deal more knowledgeably with doctors, hospitals and the health care system. The business plan was for the sites to draw consumers to the site with useful information and make money by selling advertising, attracting sponsors and sharing in revenues from electronic commerce generated by visitors to the site. That plan has failed.

“Pure play health-content sites are dead,” says health-site analyst Catherine Monaghan of Gomez Advisors, a Boston firm that tracks Web businesses. Operating the sites has become too expensive, and revenues from sponsorships and advertising have proved too small, to make this model work, she says. “Just about everybody is looking for a different business model.”

One of the most intriguing is the plan by Healtheon/WebMD. In February, the Atlanta-based firm announced that it would buy OnHealth, a Seattle-based site that had become very successful at attracting female Web-health surfers; it leads most surveys of online health traffic.

By combining that audience with the more medically oriented followers of WebMD, Healtheon will draw more than six times as many visitors as its nearest competitor, Drkoop.com (according to statistics gathered by Media Metrix, a Web traffic measurement firm). This could provide the “critical mass” of users needed to make an electronic publishing plan financially successful.

But in Healtheon/WebMD’s model, attracting health-seeking users is just one small part of its plan. Most of the firm’s business is devoted to creating an electronic network linking doctors, patients, insurance companies, labs and others in the health care business. It has purchased companies that provide medical office management systems and billing operations, and intends to make most of its money in the world of back-office industrial automation. It hopes patients and doctors can communicate online while viewing the same records, that health insurers can track treatment online and that money among the various entities will flow through the Healtheon network. While Healtheon/WebMD has more than 5,000 employees, only about 100 work for its flagship consumer Web site.

Whether Healtheon can afford to run a top-flight Web site for consumers when it’s making most of its money from back-office operations is an open question. Most of its competitors are working on simpler, less capital-intensive survival strategies.

On the theory that doctors’ eyeballs are more valuable than a consumer’s, several firms surveyed (HealthAtoZ.com, CBSHealthwatch’s Medline parent) operate companion sites for medical professionals, hoping relationships with practitioners can be more lucrative than those with consumers (and planning a less ambitious version of Healtheon’s doctors-meet-patients-online scheme). Most (Discoveryhealth, HealthCentral, WebMD) are moving ambitiously into electronic commerce partnerships. HealthCentral is selling software and services to health care companies to set up their own Web sites. Americasdoctors has merged with a company that plans to recruit site visitors for participants in clinical trials, for which it will receive a fee from those funding the trials. Drkoop licenses its material to other sites, such as those operated by hospitals or doctor groups, to generate revenue.

“A lot of these companies are looking for [a business strategy] that will stick,” Monaghan says.

Most of these strategies position the Web companies as partners to companies that, at least occasionally, have not always had the best interests of patients at heart--pharmaceutical companies and hospital corporations, for example.

“These sites are going to have to work even harder to win the public’s trust,” Monaghan says.

Interestingly, one of the Web publishing relationships being carefully tracked by industry analysts involves health insurers--not because they can use the Web to make money, but because they can use it to control costs.

As analysts David Restrepo and Claudine Singer of Jupiter Communications, an online consulting firm, point out in a recent report, annual estimates of health care costs just for asthma care are more than $6 billion a year. And health insurers, more so than doctors, hospitals, pharmacies or drug makers, have strong and persistent financial relationships with patients. If health insurers can learn to use the Web as a communication device with their patients--to help customers manage their chronic conditions with information, online records and even online interaction with care providers--they can save a whole lot of money without having to deny care and take other potentially harmful, or at least controversial, actions.

Which means that health insurers--of all possible players!--might become some of the most important and prolific publishers of health information on the Web.

Whether they prove to be the most trusted, of course, is another matter entirely.