In this paper we report on a study concerning the redesign of the Web portal of the Italian Ministry of Health, jointly conducted by the ministry and Sapienza Universita` di Roma. In this project, a multidisciplinary team consisting of computer scientists and engineers, sociologists and experts in communication, doctors and experts in public health was involved, in order to fully identify and understand citizens' needs in terms of health information, on the one hand, and to apply the most innovative methodologies and techniques for usercentered design and interfaces, on the other. Guidelines for on-line communication on protection and promotion of the health, and a mock-up for the future Web portal of the Italian Ministry of Health have been realized during the project.
INTRODUCTION Current Web portals of ministries of Health, in Europe and all over the world, are evolving from simple information sites, mostly oriented to offer institutional and administrative information, to really interactive e-health systems, providing citizens and operators with various services related to health promotion and prevention, as well as facilitating the access to services of the National Health Systems (NHSs) (cf. http://www.dh.gov.uk and http: //www.nhs.uk in the UK, and http://www.bmg. bund.de in Germany).
In this paper we report on a study concerning the redesign
Proceedings of ENGINEERING INTERACTIVE COMPUTING
SYSTEMS FOR MEDICINE AND HEALTH CARE (EICS4Med 2011), June
13, 2011, Pisa, Italy.
of the Web portal of the Italian Ministry of Health1, jointly
conducted by the ministry and Sapienza Universita` di Roma,
from February 2010 to January 2011. Sapienza participated
in the project with a multidisciplinary team involving
computer scientists and engineers, sociologists and experts in
communication, doctors and experts in public health, in
order to fully identify and understand citizens’ needs in terms
of health information, on the one hand, and to apply the most
innovative methodologies and techniques for user-centered
design and interfaces, on the other. The main products
realized within this investigation have been:
• Guidelines for online communication on protection and
promotion of the health and access to the Italian NHS [
THE METHODOLOGY ADOPTED IN THE PROJECT To devise the mock-up and the guidelines, we adopted a User-Centered Design (UCD) approach, which, as standardized in the ISO 13407, identifies four principal activities: (i) understand and specify the context of use, (ii) understand and specify the user and business requirements, (iii) design the product, in particular by creating a prototype, and (iv) evaluate the design.
In this project, we focused on (i) – (iii), whereas activity (iv) is currently on progress. In the initial activities, the main challenge has been to understand the context and the requirements of a portal which potentially could be visited and used by millions of citizens. In particular, we had the need to obtain useful insights on the following questions: • which are the health needs of the Italian population, i.e., what is the epidemiological situation of the main diseases and risk factors for diseases in Italy? • who searches the Internet/Web for health information, which forms she adopts to surf the Web, and which kind of health information is actually looked for? • what are other information needs in terms of protection and promotion of health that could be satisfied through online communication? • what works on Internet/Web, i.e., which types of Internet/Web health interventions are actually efficacious and effective for improving health? To this aim, we carried out our analysis in three main stages: (i) design and administration, for several months, of an online questionnaire, aimed at identifying the needs of the citizens using (also) Internet/Web to access health information and health services; (ii) systematic study of the literature concerning health needs and what has been discussed and demonstrated about the effectiveness of Internet-based interventions on public health; (iii) systematic analysis of a significative number of sites/portals of local health administrations, in order to derive possible best practices and to identify the critical points to be addressed.
Then, on the basis of the outcomes, a mock-up of the portal
has been devised. The following sections provides some
insights on the various activities. For the full details (including
all the collected data) the reader is referred to [
The questionnaire has been advertised on various sites, including the current portal of the Ministry of Health, the sites of some local health organizations, and on Facebook. We collected 2381 responses, 2324 of which have been analyzed, after checking the quality. 866 respondents were male (27%) and 1458 (63%) were female. 62% of the surveyed citizens use the Web especially for finding general information. Only around 30% use the Web in the first instance to search about an health problem, percentage that is relatively homogenous in different age groups; it varies from 23% for those who are 65 years old or more to 28% for those who are under 30. Around 58% of respondents prefer to search online information about the protection of the health rather than apply directly to a doctor. This is primarily due to the fact that through the Web they can immediately get some information. The information mainly searched includes: (i) specific diseases, therapies/treatments, side effects of therapies; (ii) hospitals or other medical facilities, booking systems for medical examinations, doctors or specialists; (iii) lifestyle. People look for information about the following diseases or health conditions: cardiovascular and/or lung diseases (23%); rheumatic and musculoskeletal diseases (16%); gastrointestinal diseases (gastritis, colitis, etc.) (12%); infectious and/or sexually transmitted diseases (9%); cancer (7%).
According to those who filled out the questionnaire, the health campaigns that should be promoted through the web sites of the Ministry of Health and other NHS organizations, as first option, should concern blood donation (20%), organ donation/transplantation (16%), workplace safety (13%), and responsible use of medicines (12%). If we consider more than one answer option for each respondent, preferences also include issues concerning the responsible use of drugs, screening cancers (breast, cervical and colorectal), proper nutrition/obesity. About half of the respondents consider important to find on institutional sites information on attitudes and actions necessary to maintain good health (49%), and indications concerning the levels of quality of health services provided by the local health organizations and hospitals (50%). For the 78% of respondents, the data on levels of quality should be published on the portal of the Ministry of Health. For what concerns the quality3 of health 3The quality of information is expressed in term of usefulness, accuracy, level of update. information currently available on the Web, the best overall score has been obtained by the sites of associations of patients with specific diseases. Interestingly, the most useful information currently available on the portal of the Ministry of Health has been considered the one on transplantation, statistical data and materials on contests, announcements and legislation.
THE REVIEW OF THE LITERATURE
The epidemiological analysis of the health status of the
Italian population was made through consultation of official
data and reports of the Italian Ministry of Health, the
National Observatory of Health of the Italian Regions and the
National Institute of Statistics [
To understand the Internet health information needs of the
population, also in order to validate the online questionnaire,
a systematic review of the literature was performed. A
total of 52 cross-sectional surveys were retrieved, carried out
mainly in the USA and Europe. The analysis of the three
main surveys performed in USA, Europe and Italy [
The evaluation of the effectiveness of health interventions
delivered through Internet is a difficult task. The field has
suffered from a lack of clarity and consistency. The absence
of professional leadership and of accepting governing
approaches, terminology, professional standards, and
methodologies has caused the field of the evaluation of these
intervention to be diffused and unstructured. Only recently
some categorizations have been proposed, as the
classification proposed by Strecher [
The results of the review of the literature allow us to draw a set of recommendations for the construction of a national evidence-based health website. In summary it should: 1. contain information concerning the physiopathology of the human body, the most frequent diseases, risk behaviors, and health interventions of proven effectiveness, in order to improve the health literacy of citizens (cf. Salute A–Z in Figure 1); 2. include tailored interventions, with adaptation, personalization and feedback, aimed to promote healthy behaviors for disease prevention and compliance to secondary prevention programs of proven effectiveness (cf. the availability of applications on the portal, see Section 6); 3. give accurate information on the organizational structure of the national NHS, in order to facilitate the access to the health care organizations and, at the same time, to promote the appropriate use of them (cf. Esplora SSN in Figure 1); 4. contain information about the performance of the different health care organizations (hospitals, etc.) and, possibly, of physicians; 5. include systems and tools able to endorse the participation of citizens, as well as the human-to-human interactions (cf. the use of Web 2.0 tools, as discussed in Section 6). AN ANALYSIS OF ITALIAN HEALTH WEBSITES An analysis of Italian health organizations’ websites has been carried out in order to obtain useful indications in planning for an effective online communication strategy. Its objective was to respond to the following questions: • what kind of health information is available on the websites of such organizations (aims, logical information structure, content, online services, technologies, etc.)? • do the websites satisfy the health information needs of the population concerning the available healthcare services, the promotion of public health and the prevention of diseases? (a) Homepage
(b) Menu • do they observe the standards set by the Italian egovernment policy? We have identified a set of indices and organised them in 4 dimensions, that explain the concept of “quality of online health information supply”: 1. institutional identity and networking attitude: the possibility to easily identify the site with a specific authority, and also its attitude towards the development of thematic and operative networks with other public health administrations or professional associations or patients’ associations working in the health service; 2. administrative transparency, based on the availability of online information regarding the organizational structure of the NHS, tasks and performance, and the availability of citizen protection mechanisms/tools; 3. availability and quality of the online services, concerning not only the quality of the website content and the use of Internet healthcare interventions, but also the quality (interactivity) of electronic forms and of facilities for on line booking of such services 4. accessibility and ICT quality, referring to the different solutions for presenting and organising the website content, regarding both accessibility for Internet users and technological criteria.
The analysis has considered the websites of all the Regional Governments (in fact, 19 regions and 2 autonomous provinces) and the websites of a sample of 84 Local Health Authorities (out of 195 in total). The main results of the analysis highlight that Regional Government health websites show: • a strong institutional identity, because they present the local health policy as an outcome of the approach taken by Regional Governments and have a low international perspective; • a weak attitude to networking with other public health administrations or private associations working in the local health service; • a satisfactory level of administrative transparency, even though citizen protection mechanisms/tools are mainly normative statements; • an high level of attention to the promotion of public health, even though they rarely make use of the communication campaigns offered by the Ministry of Health; • a good level of ICT quality.
Instead, the websites of the Local Health Authorities are characterized by: • a significant institutional identity, with frequent references to their respective Regional Government rather than to the Ministry; • a good level of administrative transparency, even though the citizen protection mechanisms are mainly normative statements; • a satisfactory level of availability of information regarding online services, even though electronic forms and facilities for online booking of health services are not very frequent; • a good level of ICT quality.
Therefore, analyzing the websites of the Regional Governments and of the Local Health Authorities we can see a scenario revealing different online health communication strategies, with a strong local identity and with weak coordination by and towards the central institutional level (Ministry). In order to improve on line health communication, we suggested the following strategies: • to recognize the centrality of citizens/patients, both in the phase of identifying and structuring the content of websites, and during the editing of the website and the organization of health services via the Internet; • to strengthen the orientation and coordination role that the Ministry of Health should play in respect of other healthcare administrations as regards information and communication activities; • to view online health information as the result of cooperative networking between the Ministry of Health and the other healthcare administrations (at national and local level); • to build a network of health public administrations and professional associations and patients’ associations working in the health services, aimed at exchanging information and strengthening mutual legitimacy, in order to reduce the fragmentation of information and to promote wider communication.
THE PORTAL Figure 1 shows the homepage of the proposed mock-up. The four main pillars of the proposal are (i) a navigation interface, on the top of the page, based on ”buttons” instead of the classical links, (ii) a large number of interactive applications, either accessible on the portal or downloadable on mobile devices, (iii) the possibility to customize the home page through the MyPage application (a-la iGoogle) and (iv) advanced search functionalities and page-to-page correlations based on taxonomies. In terms of contents, the (mock-up of the) portal respects the suggestions previously described. The navigation menu based on buttons has the twofold aim of being aesthetically more catchy than the classical one, and ready for visualization on touch devices (e.g., iPads, touchpads, etc.), which represent the future of Web surfing. In order to enforce the citizen-oriented vocation of promoting good life habits, a lot of applications will be made available, e.g., for dietary calculation, alcohol abuse control, pregnancy check schedule, etc.; such applications, which enhance the level of interactivity of the portal and therefore attract users, can be mobile apps to be downloaded on devices, or Web applications accessible through the portal. The possibility of customizing the page of the portal is an absolute novelty wrt existing public administrations/agencies, not only in Italy but, at the best of our knowledge, all over Europe. This has been obtained by including a MyPage application, which allows each registered user to personalize the information she wants to access.
The portal provides four main “channels”, i.e., sections specifically tailored to particular categories of information and possible interested users: citizens (corresponding to La nostra salute), health and administrative operators (Attivita` e professioni), users interested in institutional and organizational information (Ministro e Ministero), and users interested in News e Media. Each section, which is managed by a specific editorial board, has its own space in the home page, even if, in compliance with the user-centered approach previously described, the section dedicated to citizens is predominant.
Moreover, in order to satisfy the suggestion 4 of Section 4, a specific information system, collecting quality and performance data of healthcare organizations, will be developed and made accessible through the portal. It is also worth remarking that Web 2.0 tools are used throughout the portal (e.g., tag clouds, wiki and blogs, correlations with Facebook, Twitter, etc.), in order to promote user interaction.
To provide users with powerful and effective means to retrieve the information they are looking for on the portal, its contents are being classified according to a taxonomy, i.e., a classification scheme which organizes in a hierarchical structure the main categories of interest in the domain. By virtue of this classification, the user can query the portal by referring to the categories of the taxonomy, and get as reply those documents that belong to the same or related categories. Notably, the reference to the categories does not need to be explicit, i.e., the user is not required to a priori know the taxonomy to pose queries to the portal (see also below).
In order to simplify the process of definition, validation, and maintenance of the taxonomy, and to ease the possible integration in the portal of contents coming from external information sources, to realize our taxonomy we analyzed existing (de-facto) standards. Among various proposals for content classification and terminological representation in the biomedical domain (e.g., UMLS4, ICD5, SNOMED CT6, GALEN7), in our project we referred to MeSH (Medical Subject Headings)8 a taxonomy developed by the National Library of Medicine (NLM) of the United States. This choice has been motivated by the fact that MeSH is specifically tailored to information retrieval (and thus suited to our aims), contains also non-biomedical or clinical categories, and with respect to other proposals has more compact dimensions (it includes around 22000 terms), which makes it simpler to use.
In fact, to make easier the process of content classification, we operated a simplification of the MeSH, aimed at both reducing the number of categories and eliminating the most technical ones. However, to not loose the advantages of adopting a (de-facto) standard, we simply “cut” some branches of the “MeSH tree” so as to exclude too detailed categories. In this process, we have been helped by domain experts. The resulting taxonomy contains around 3500 MeSH terms.
Despite MeSH includes general purpose categories (e.g., the ones of the Disciplines and Occupations or Phenomena and Processes branches), we found out cases in which MeSH results insufficient in order to satisfactory classify some documents included in the portal. To overcome this problem, we decided to include in our taxonomy some of the categories used for article classification in (the Italian version of) Wikipedia9, and in particular we selected the categories included in the Human Activities branch of the Wikipedia classification schema10, which in fact substitutes in our taxonomy the (more limited) Humanities branch of MeSH. We choose the Wikipedia classification for two main reasons: 4http://www.nlm.nih.gov/research/umls/index. html 5http://www.who.int/classifications/icd/en/ 6http://www.ihtsdo.org/snomed-ct/ 7http://www.opengalen.org 8http://www.nlm.nih.gov/mesh/meshhome.html 9http://www.wikipedia.org/ 10http://it.wikipedia.org/w/index.php?title= Speciale:AlberoCategorie&target=attivita´+ umane&mode=categories&dotree=Vai (i) Wikipedia is one of the most popular portal on the Internet, and its contents are widely shared among several millions of users; (ii) its category tree is designed through a collaborative process aiming at including categories proposed by the users, and therefore particularly suited for information retrieval activities.
We finally observe that, to further support the process of
content classification in the portal, we foreseen the development
of tools helping the research of the categories in the
taxonomy. In this respect several directions can be followed: (i)
realization of keyword-based search mechanisms to directly
access the categories of interest in the taxonomy (thus
avoiding to manually navigate the taxonomy); (ii) use of a
dictionary (extending the one already available with MeSH) to
include in the taxonomy also synonyms of categories, thus
both expanding the lexicon of the taxonomy and including
more terms in it, in a way transparent to the user; (iii)
definition of techniques for automatic keyword extraction from
text documents, in such a way that document classification
could be done according to extracted terms, in the spirit
of [
CONCLUSIONS In this experience paper we have presented a project, carried out during 2010, focused on the definition of guidelines for online communication on protection and promotion of the health in the Italian NHS (including regional health web portals, local health authorities websites, hospital websites, etc.), and the realization of a mock-up to serve as input for a redesign of the web portal of the Ministry of Health. The guidelines, as well as the mock-up, were successfully presented in a workshop on February 17, 2011. They are published online and are currently in the process of being formally adopted by all the interested administrations. In a scenario in which all websites of the NHS organizations are realized in accordance with the guidelines, the portal of the Ministry of Health can be also able to act as a broker, in order to offer a centralized access to information and services of the NHS. An interesting future issue will be to consider how users will react, with respect to trust and privacy concerns, about the personalization features of the portal offered through the MyPage, as they may feel as their information access requests on the portal might be logged and analysed for potential medical information.
Acknowledgements.
The authors would like to thanks the team of the Italian Ministry of Health for the fruitful and active collaboration during the project, in particular Daniela Rodorigo, Massimo Aquili, Claudia Biffoli, Claudia Spicola, Daniela Cricenti, Cristina Giordani. Moreover, they would like to thank all the Sapienza people collaborating in the project, namely Sara Ausiello, Andrea De Angelis, Priscilla Carcione, Eliana Ferroni, Emanuele Leoncini, Lucia Marinelli, Orazio Giancola and Domenico Lovecchio.