NOAH-New York Online Access to Health: library collaboration ... - NCBI

NOAH-New York Online Access to Health: library collaboration for bilingual consumer health information on the Internet* By Susan Voge, M.S.L.S., M.B.A. Associate Professor and Coordinator of Library Instruction

The Library Lehman College City University of New York 250 Bedford Park Boulevard West Bronx, New York 10468

New York Online Access to Health (NOAH) is a Web site that provides accurate, timely, relevant, and unbiased full-text health information in both English and Spanish. A joint project of The City University of New York Office of Library Services, The New York Academy of Medicine Library, the Metropolitan New York Library Council, and The New York Public Library, NOAH brings consumer health information to the public in New York City and around the world via the Internet. NOAH is an example of a successful collaboration among different types of libraries (academic, public, medical society) and voluntary health agencies to use new technologies to reach a very broad public. This paper discusses the involvement of the library partners in terms of the management and funding of the site. Web site construction is described including how the information is gathered and organized. Future plans and funding issues for NOAH are considered in terms of the expected increase in the need for consumer health information. NOAH can be reached at: www.noah.cuny.edu.

INTRODUCTION Recent years have seen an explosion of health information on the Internet. In 1997, for example, the Internet held an estimated 3,000 to 4,000 health information sites, including both subscription and public access [1]. Aware of the potential for growth, four New York City library organizations joined forces in 1994 to establish a single Web site that would mediate between the end-user-in this case, their patrons and other medical consumers-and the morass of the World Wide Web. The organizations were: The City University of New York Office of Library Services (CUNY), the New York Academy of Medicine Library (NYAM), the Metropolitan New York Library Council (METRO), and the New York Public Library (NYPL). Later joined by the Queens Borough and Brooklyn Public Library Systems and the New York State Li* This Project is supported by a grant from the United States Department of Commerce, National Telecommunications and Information Administration, Telecommunications and Information Infrastructure Assistance Program (Grant no. 36-40-94070).

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brary, these partner library agencies had as an overriding goal the development of a Web site that would provide health care information at a level and in a language easily accessible and comprehensible to the layperson. The result is NOAH (New York Online Access to Health), a consumer health Web sitet with the mission to provide "quality health information . . . that is accurate, timely, relevant, and unbiased" [2]. NOAH is unusual among consumer health Web sites in that it provides full-text information as well as contains detailed organization that guides a searcher to answers within four or five mouse clicks. Also notable, much of NOAH's information is available in Spanish. NOAH draws its information from three sources: voluntary health agency (VHA) publications such as patient education pages, booklets, pamphlets, calendars of events, directories; documents available at other Web sites; and a commercial database. The VHAs providing documents to NOAH in 1997 included: governmental health agencies (National Cant NOAH

can

be reached at www.noah.cuny.edu.

Bull Med Libr Assoc 86(3) July 1998

NOAH

cer Institute, New York State Department of Social Services, New York City Department of Health); national voluntary health agencies (Cancer Care Inc., March of Dimes Birth Defects Foundation, SIECUS: Sexuality Information and Education Council of the United States); local voluntary health agencies (Gay Men's Health Crisis, SHARE: Self-Help for Women with Breast or Ovarian Cancer), and health care providers (The New York Hospital-Cornell Medical Center, St. Luke's Roosevelt Hospital). Several health care companies (Aetna/U.S. Healthcare, Inc., and WELL-CONNECTED-Nidus Information Services) also supplied their publications to NOAH. Beyond documents, the providers contributed financial support to cover the cost of transforming documents into Web pages, for translation into Spanish, and for storage on the NOAH server. For those agencies that also maintain their own Web pages, inclusion of their documents on NOAH allowed an additional access point and a Spanish version. At the end of 1997, NOAH maintained 1,400 full-text provider documents on its server computer, 1,000 in English and 400 in Spanish. Another part of NOAH consists of selected links to full-text information residing at Web sites maintained by government, educational, and nonprofit agencies and some commercial groups. Clicking from titles listed on NOAH Topic Pages accesses these documents. Finally, NOAH is also a gateway to Information Access Company's Health Reference Center Gold for all partner institutions. This resource includes full-text journal articles, citations, and other information on consumer

health. NOAH'S BEGINNINGS NOAH began in October 1994 as a demonstration project partially funded by the United States Department of Commerce, Telecommunications and Information Infrastructure Assistance Program (TIIAP). The original partner library agencies sponsoring the Web siteCUNY, NYAM, METRO, NYPL-contributed funds and guidance. Employing a group approach that combined the resources of various types of libraries with health agencies to offer health information at publicaccess computers in public locations has been praised as farsighted [3]. In the division of responsibilities for NOAH, CUNY is in charge of network and database management, hosting the database on its T3 network, and housing the staff. The TIIAP funds of $275,000 were matched by CUNY to bring the total project resources to $559,150. NYAM is a not-for-profit corporation founded to promote the health of the public. It is one of eight National Library of Medicine (NLM) Regional Medical Libraries and manages a contracted program to train health and information professionals to search the online medical databases produced by NLM. NYAM is Bull Med Libr Assoc 86(3) July 1998

the only medical research library in New York City that is open to the public. NYAM staff participates in the selection of appropriate topics and serve as liaisons to voluntary health organizations. METRO's Hospital Library Service Program brings full Intemet access to the libraries in the region's ninety-four hospitals licensed by the State Department of Health. A METRO Consumer Health Committee, functioning for over ten years, has raised awareness among METRO members about the need for public health information in New York City. METRO participates by publicizing NOAH through its publications and Web site. NYPL serves approximately 7.1 million users through its eighty-five branches and four research centers. It was the first major public library in New York State to create its own Internet gateway and provide menu-driven access to its online catalogs. NYPL staff participate in NOAH through the selection of relevant topics and online resources and in the on-going evaluation of the service. Three additional libraries joined NOAH as partners in 1998, Queens Borough Public Library, Brooklyn Public Library and The New York State Library. The participation of the Brooklyn and Queens library systems permits NOAH better access to the resources of all five boroughs of New York City. Inclusion of the New York State Library allows for increased coverage of state and county health information resources.

Initial topics When NOAH debuted online in July 1995, the first health topics covered were AIDS, cancer, pregnancy, sexually transmitted diseases, and tuberculosis [4]. NOAH staff decided to emphasize depth rather than breadth in creating these pages and covered a few topics thoroughly in order to develop a model NOAH page. The initial health topics were selected from a document citing infant mortality, heart disease, cancer, AIDS, and tuberculosis as the most serious concerns for New Yorkers [5]. VHAs working with these issues were also the first contacted for participation in the site. SPECIAL CHARACTERISTICS OF NOAH

The philosophy behind NOAH is clarity and simplicity, and its design is deliberately devoid of gimmicks. Frames are not used and information is listed in a detailed outline form that is clear and intuitive. Drawings and pastel colors are used to illustrate the site (Figure 1). Material on NOAH consists of full-text materials, not just a list of hyperlinks to other Web pages. Constructing pages involves examining each linked document to verify that it meets the criteria for inclusion as stated in the mission statement; that is, the infor327

Voge Figure 1 NOAH Topics Page F

Search by Vskrd

Health TO p ics

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Ask NOAH About: Health Topics and Resources TOPICS. AGING & ALZHEIMER'S DISEASE updatED'

AIDS & HIV

ALTERNATIVE MEDICINE ARTHRITIS & RHEUMATIC DISEASES

ASTHMA CANCER updantedl

XHEART DISEASE & STROKE

LYME DISEASE N MENTAL HEALTH

NEUROLOGICAL & NEUROMUSCULAR DISEASES

NEW YORK CITY, STATE and REGIONAL HOSPITALS HMOs and HOSPICES %Lpdatatt

NEW YORK COUNTY RESOURCES: Buffalo/Erie Counts Rochester/Monroe County Svracuse/Onondaea County

'NUTRITION PERSONAL HEALTH: Children Men Women

"PATIENTS RIGHTS and RESOURCES, and PHYSICLAN INFORMATION SUPPORT GROUPS

DENTISTRY DIABETES ENVIRONMENTAL HEALTH 'PREGNANCY 'STATISTICS (NY State) THE EYE Updated' 'OTHER INTERNET 'SEXUALITY RESOURCES 4 THE FOOT & ANKLE 'SEXUALLY TRANSMITTED DISEASES HEADACHE 4 TUBERCULOSIS 4 HEALTHY LIVING X OTHER HEALTH CONCERNS

Disclaimer: NOAH is an information guide only. This information has been culled from a variety ofconsumer health resources. NOAH offers this information to you with the understanding that it not be interpreted as medical or professional advice. All medical information needs to be carefully reviewed with your health care provider.

This page has been published by the NOAH team. Unfortunately, NOAH is unable to answer personal health-related questions; however, please check our additional medical information resources. Ifyou have queries or comments ofa technical nature, please send e-mail to webmaster(inoah.cunv.edu or visit our feedback page.

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NOAH

mation must be accurate, timely, relevant, and unbiased. VHA documents are automatically accepted as meeting this criteria. Corporate and personal Web pages require review by page editors and NOAH staff before links to them are added. The information on NOAH is organized so that within four to five mouse clicks, a person arrives at actual information or text. To accomplish this, each Topic and Resource Page is arranged into a detailed outline. The outlines follow a model page format, yet are allowed to expand down to subdivisions to provide the best organization for each topic. Everyday vocabulary is used whenever possible (Figure 2). The model page format noted above was designed to ensure coverage of the most pertinent aspects of each topic. Five standard sections form the rough divisions-what is (disease), care and treatment, complications and related concerns, research, and additional information resources. Within each section, an attempt is made to include certain issues. For example, the first section describing the disease or condition will aim to include basic description, anatomy, diagnosis, types, symptoms, causes, glossaries, statistics, and a question-answer category. NOAH also includes helpful add-on features such as the Hospital Page where a table gives access to the hospitals in the TriState area of New York, New Jersey, and Connecticut by hospital name, city, county, and state. Much attention is given to the detailed arrangement of information within NOAH pages. The subject terms used on Topic Pages are selected from a controlled list of terms with more terms added when needed for a specific topic. A medical librarian has compiled a list of words to be used in section and division headings. The emphasis is on ease of use and providing a clear structure to all aspects of the subject covered. Additional links to existing NOAH pages are added where necessary. Links to sites are repeated within NOAH wherever topics overlap. And the NOAH team constantly refines pages for ease of use. For example, when many sites on the Neurological Diseases Page were linked to a site requiring registration, an extra button was added for this purpose. The Spanish language version of the NOAH home page exists along side the English; therefore the Spanish speaker can immediately see appropriate material. Information listed on NOAH can be found using Spanish words, and a Spanish translation for many of the documents is available with a click of the "Espanol" button found at the top of every page. As one of the few bilingual Internet sites for consumer health information, NOAH has attained recognition in the Spanish speaking community in North and South America [6]. At least half of the mail received by NOAH during 1996 was from Spanish speakers. NOAH's Spanish translator created a page of other Spanish-language Bull Med Libr Assoc 86(3) July 1998

health material available on the Web to which to refer inquiries for additional information.

Searching options One way to search NOAH is to go directly to a topic or resource page. These pages are headed by an outline of all aspects of the topic as it is covered at NOAH. Topic Page searching gives an overview of a health subject, disease, or condition. Keyword searching is also possible on NOAH. Three types of keyword searches were offered: Harvest, Excite, and Wide Area Information Server (WAIS). Keyword searching is also possible on NOAH. Originally three types of keyword searches were offered: Harvest, Wide Area Information Server (WAIS), and Excite. Problems were experienced using Harvest and WAIS searching and they were removed in April 1998 leaving Excite as the sole search engine for the site. The Excite search engine permits individual word searches and locates only those documents housed on the NOAH server that include all of the search terms. Patrons are advised to use specific words, repeat words to get a weighting effect, and use a string of words for the best Excite searches. Excite has two search types, concept and keyword. A concept search has a built-in synonym searching ability to retrieve documents that appear to be relevant even though they may not contain any of the exact keywords that were entered in the search. Excite keyword searches retrieve only NOAH documents that have one or more of the words searched. NOAH STAFF AND EQUIPMENT

Initial grant and matching funds for NOAH were used to hire staff, purchase equipment to run the database, and provide access to the database in the partner organizations. The first staff hired consisted of a project director, a server administrator, hypertext markup language (HTML) programmers, a translator, and a medical librarian. The creative director had a background in writing and designing multimedia projects. The server administrator maintained the database, managed the user interface by making changes to the site design, and tracked usage statistics. HTML programmers reviewed bookmarks for updating, created and updated page templates, and made changes to pages in the database. Much of the standard HTML work was done by computer science college interns. A Spanish language translator converted provider documents into Spanish language documents and suggested additional Spanish language Web sites for links. For the first three years, a part-time medical librarian reviewed consistency in page structure and indexing, developed a model page format and list of 329

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Figure 2 Ask NOAH about Diabetes

Ask NOAH About: Diabetes 4 WHAT IS DIABETES? * THE BASICS * TYPES

COMPLICATIONS AND RELATED CONCERNS * AGE-SPECIFIC ISSUES * COMMON CONCERNS * GENDER- SPECIFC ISSUES * RACE-SPECIFC ISSUES 4- CARE AND TREATMENT * COPING * EXERCISE * MEDICATIONS * MONITORING * NUTRION * PREVENTION * TRIALS 4 DIABETES RESOURCES

* GENERAL HIN * NEWS * RESEARCH * SUPPORT

4 WHAT IS DIABETES?

* THE BASICS @ Diabetes * Diabetes Overview * Profile of the Diaenosed i Standards of Care, What To Expect * What Is Diabetes? 0 What Is Diabetes?

0 Blood Suear and Diabetes

@ Hynerulvcemia. Hish Blood Su2ar @ Hypoglycemia

* Hvvolvcemia * Hvuonlvcemia. Low Blood Sugar

* Connection to Obsitv * The Dangerous Toll of Diabetes 0 Diabetes Dictionary/Glossary

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controlled vocabulary for page sections, and evaluated new sites for inclusion. Equipment purchased with the initial grant included an IBM RISC6000 server, a scanner, and required software. A machine translation system program developed by the Pan American Health Organization (PAHO-MTS) was purchased to perform rough translation of documents. Initial database access in the partner organizations was provided by twenty-eight workstations (eight adapted for the visually handicapped) distributed to NYPL branches, CUNY campuses, NYAM, and three METRO hospital libraries. A DEC Alpha 3000 computer and peripherals were purchased and placed at NYAM so that its online public access catalog would be available to the sponsors and the users of the health network. NOAH MANAGEMENT NOAH is managed by two groups, the steering committee and the content committee. Both are composed of representatives from the eight partner organizations. Steering committee members meet six times a year. They decide on issues such as the budget, new sponsors, funding sources (sponsorship, contributions, and advertising), and they mediate grant support for NOAH from their organizations. Members of the steering committee are directors of their public libraries and partner organizations. The content committee manages the scope of NOAH and suggests topics based on the needs of patrons who use the partner libraries. This committee is composed of public service librarians from the public, medical, and academic partner organizations and meets monthly to decide the direction of NOAH coverage. Committee members suggest new topics and sites, evaluate recommended additions and changes, discuss new programs, share feedback from NOAH end-users, and promote NOAH at their home institutions. A number of these librarians also volunteer as page editors.

Content page editors

After NOAH's first successful year, expansion into additional health topics was desirable but difficult with the limited staff. Following the practice at other educational Web sites, NOAH staff and committees decided to invite subject experts who had a personal background or interest in a particular health topic to serve as volunteer page editors. This program was publicized through local librarian e-mail discussion lists and newsletters. The content committee reviewed the resumes received in response and selected experienced individuals to serve as editors. The director defined the procedures for submitting new topic information Bull Med Libr Assoc 86(3) July 1998

and gathered information from potential editors about their equipment, software, and Internet connections. As a result of this screening process, eight content page editors have joined NOAH, and each has submitted a new Topic Page. Serving as an editor involves evaluating Web sites for inclusion, locating information on all aspects of a health topic, and determining the best subject arrangement of the information for health consumers. If editors wish to add HTML codes to their information, they are provided with a basic template, style sheet, and help from NOAH staff. The director and the content committee review the page editor's suggestions before uploading them onto NOAH. Current editors are identified on the Web page, including e-mail address for comments and suggestions, and they are expected to keep page information updated. Software called InContext Web Analyzer (produced by InContext Corp., Toronto, ON, 800-263-0127, www.incontext.com) resides on the NOAH server and can identify out-dated or misdirected sites automatically for the editors. Membership credit for this voluntary editorial work with the Academy of Health Information Professionals (AHIP) is being investigated. GROWTH OF NOAH

Beginning in 1996, NOAH became a gateway to Information Access Company's Health Reference Center Gold for the original partner organizations. NYPL provided the major funding for this database of articles, books, and pamphlets, many available in full-text. Also during this year, new Topic Pages were added: Aging and Alzheimer's; Diabetes; Alternative Health; Asthma; Healthy Living; Heart Disease and Stroke; Personal Health of Men, Women, and Children; and Sexuality. In the summer of 1996, NOAH launched a newly designed home page. New colors and graphics graced the entry page and new features were added, such as the Most Read and What's New sections, as well as expanded NOAH Team biographies. Aetna/ U.S. Healthcare and New York University Medical Center became NOAH sponsors that same year. In 1997 content page editors began contributing new Topic Pages including the Eye, Environmental Health, Neurological and Neuromuscular Disorders, Arthritis and Rheumatic Diseases, and Foot and Ankle. In 1998, three new pages have been added. A separate Resource Pages section was established, for topics such as: Hospitals, HMOs, and Hospices in the TriState Area; Patient Rights and Resources; and Support Groups. In an attempt to deter personal health questions from being sent to NOAH editors and staff, a statement was appended to each page advising readers that NOAH could not answer individual health requests. Despite this announcement, personal questions continued to be received, so the Additional Internet Resources Page was expanded. 331

Voge Table 1 NOAH hits-September 1996 by health category (English and Spanish versions) and May 1997 Health category Aging AIDS Alternative Medicine Asthma Cancer Diabetes Healthy Living Heart Disease Mental Health Nutrition Personal Health Pregnancy Sexuality Sexually Transmitted Diseases Tuberculosis Total hits-health categories Other NOAH pages Total hits, September 1996 Total hits May 1997 Difference in hits by month Sept. 1996 compared with May 1997 Percent change in hits by month Sept. 1996 compared with May 1997

Spanish hits

English hits 478 4,047 855 257 23,439 1,928 1,112 1,588 1,019

1,083 4,145 110 172

597 590 38,972

1,696 3,432 929 80,939 28,346 (English & Spanish) 117,468 (English & Spanish)

110 1,829 289 314 131

8,183

282,894

165,462 + 141 percent

A "Hit" is counted every time any NOAH page is accessed/opened over the Internet. English hits are counted when an English language page is accessed and Spanish hits, when a Spanish language page is accessed.

Table 1 lists the number of times each health category of NOAH was used in September 1996, illustrating the popularity of the Pregnancy Page. This table also shows how the use of NOAH has grown between September 1996 and May 1997. The number of hits or uses of the NOAH site have increased 141% during this period. At the end of 1997, NOAH was receiving 100,000 users each month. PUBLICITY NOAH has been advertised through published articles and brochures, through program presentations and letter writing, and through Internet Web site links and index or search engine registry. During 1995, several articles about NOAH were published in its provider organizations' newsletters and in medical library newsletters [7]. Additionally, a black and white three-fold brochure listing NOAH's topics in English and Spanish with NOAH's Web address was issued. It was superseded in June 1997 by a four-fold color brochure describing NOAH, again in English and Spanish. The brochure can be folded so that either language appears on top. Various programs describing NOAH have been presented to health care providers as well as medical and public librarians. Letters introducing NOAH were sent to education officers and patient educators at all hos332

pitals in the New York Metropolitan Area and to all HMOs serving the region during its first year. With regard to Web-based publicity, NOAH has been made a key link from the library home pages of both NYPL and NYAM. Further, the staff has registered NOAH with several Internet subject indexes and search engines available at the time. Using the "submit-it" site, a Web page can announce itself to many key Internet indexes at once [8]. Another way to ensure high retrieval by search engines is through metatags embedded in the HTML coding of each Web page. Metatags are used by some search engines to allow them to list a site more accurately in their indexes. The metatag field, taking the form of several words describing the content of each page, is scanned during many automatic keyword searches on the Internet [9]. A consultant publicity manager was hired early in 1998 to create a press kit and develop a fundraising campaign for additional sponsors to expand publicity. The kit will also be sent to regional public and medical library organizations and local and national media. NOAH will especially target the Spanish-language press and healt and Internet reporters of television, radio, and the paper press. EVALUATION AND RECOGNITION A focus group of public service librarians from the partner organizations met in February 1996 to evaluate Bull Med Libr Assoc 86(3) July 1998

NOAH

NOAH at its six-month mark. They discussed the various search methods offered at the site and analyzed the search results of test questions. Focus group members said that they wanted drug information, more and better keyword searching capability, and more topics such as the eye and communicable diseases. They also wanted more help online in constructing searches, such as online dictionaries and glossaries, and a help section attached to keyword searching. They agreed that a more visual, less text-based approach to presenting the information would be especially useful for people and children with limited knowledge of English. Many of the group's suggestions have been incorporated into NOAH. As of January 1998, NOAH earned fifteen Web awards, which are displayed on a link from its home page. Also, it had been recommended in articles about consumer health Web sites by Haskin [10], James-Catalano [11], Judkins [12], and Moeller [13]. NOAH was cited as a model Web site for promoting public health [14] and was among a group of less than twenty health Web sites receiving the highest rating from Alan Rees in his latest consumer health resource guide [15]. FUTURE OF NOAH

Options for the future of NOAH include more visual and audio access to the material. Aware of literacy issues concerning both reading level and language differences, the staff plan to offer multi-media choices to visitors in searching and receiving information. The staff also hope that NOAH eventually can provide information in other languages besides Spanish, with Chinese and Russian most needed in the Tri-State area. Topics will continue to be added, with disabilities and communicable diseases expected to be next. Updating and expansion of existing pages is ongoing. Alternative health, AIDS, pregnancy, and women's and children's health are those to be targeted first. Enhancements are also planned for the guide bar heading each page. Sections to be added include a glossary or dictionary related to each subject page, drug information, and travel and map guide. The staff is considering the addition of evaluation questions to the feedback form to allow visitors to rate the usefulness of NOAH. Another avenue currently being explored involves testing NOAH's impact at a local hospital's prenatal clinic by measuring how it affects outcomes for mothers and infants. This would allow for a formal evaluation of NOAH's use in a clinical setting. Funding Since the original grant ended in September 1996, the partner organizations have maintained NOAH Bull Med Libr Assoc 86(3) July 1998

through smaller grants and support from their organizations. NYPL secured a LSTA (Library Services and Technology Act) Grant of $40,000 for NOAH to include resources of upstate New York. NOAH and NYPL, working together with Onondaga County Public Library in Syracuse, the Rochester Public Library, and the Buffalo and Erie County Public Library, identified local health information resources and communitybased organizations that have formed a new Resource Page [16]. CUNY and its partners are spending nearly $300,000 annually in cash and in-kind contributions to maintain NOAH as a public service [17]. Published reports of Web site support show that the Discovery Network costs well in excess of $1 million to design and requires a staff of ten designers to keep it up-to-date [18]. Another Web design firm reported charging from $15,000 to $1 million to create a Web site depending upon features included [19]. Regular financial commitment from the sponsoring organizations and governmental funding is needed to secure NOAH's future. Until that happens, other options continue to be explored, including securing additional sponsors and instituting a voluntary contribution program for individuals and institutions similar to those used by public television and radio stations. The Joint Commission on Accreditation of Healthcare Organization now requires hospitals to include a patient education component in their care as part of a patient's rights [20]. Participation in NOAH has the potential to fulfill this obligation for hospitals. NOAH also exemplifies the recommendation of the Consumer and Patient Health Information Section of the Medical Library Association (CAPHIS/MLA), which advises "creating and compiling consumer health information and patient health information resources and pathfinders that are accessible to the public electronically via the Internet and other national information networks"

[21]. CONCLUSION As the relationship between health care professionals and patients moves to a more collaborative model of discussion of treatment options, the need for health information that is comprehensible and available to all health care consumers will only increase. More studies are being published that show that "public release of consumer reports may be useful not only in assisting consumers to make informed health care choices, but also in facilitating improvements in the quality of hospital services offered and care provided" [22]. Projects such as NOAH are working to fulfill this purpose by providing clear, current health information and making it available from any Internet-accessible computer. 333

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ACKNOWLEDGMENTS I would like to acknowledge the assistance of Kirsten Dehner, creative director/producer of NOAH; Marsha Ra, director of library services, The City University of New York; Virginia Manbeck, consultant to The New York Public Library; Patricia Gallagher, special projects coordinator, The New York Academy of Medicine; and Nancy Panella, director, Bolling Memorial Medical Library, St. Luke's Roosevelt Hospital Center.

REFERENCES 1. ZIMM A. Hopkins and US Healthcare form medical data company funded with $25 Million from national HMOJoint venture expected to soon become the 'Gold Standard' for consumer health information. Daily Record 1996 Jul 11:1. 2. THE NOAH TEAM. About NOAH-Mission Statement [Web document]. New York: The Team. [cited 7 Jan 1998] Available from Internet: (http://www.noah.cuny.edu/

about.html#Mission Statement). 3. MILIo N. Electronic networks, community intermediaries, and the public's health. Bull Med Libr Assoc 1996 Apr;84(2): 223-8. 4. NOAH gets launched. For Reference from METRO. 1995 Jul/ Aug;(256):3-4. 5. NEW YORK CITY PLANNING COMMISSION. Annual Report of Social Indicators, 1993. New York: The Commission, 1994. 6. CONNORS M. Se habla espanol? Spanish-language patient education resources hit cyberspace. Medicine on the Net 1998

Jan;4(1):15-8. 7. MARINE S, GALLAGHER P. Two new consumer health Web sites announced. MLA News 1996 May;(285):13. 8. SUBMIT-IT!, INC. Submit-It [Web document]. [cited 7 Jan 1998] Available from Internet: (http: / /free.submit-it.com). 9. BRADLEY P. Meta tags-what, where, when, why? [Web

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document]. [rev. 14 Jun 1997; cited 7 Jan 1998] Available from Internet: (http://www.philb.com/metatag.htm). 10. HASKIN D. Health and nutrition. Yahoo Internet Life, 1996 May/Jun;2(2):25-6. 11. JAMES-CATALANO CN. Baby makes three. Internet World. 1996 Feb;7(2):32-3. 12. JUDKINS DZ. Health resources on the Internet: a basic list. Med Ref Serv Q 1996 Winter;15(4):13-20. 13. MOELLER KA. Consumer health libraries: a new diagnosis. Libr J, 1997 Jul;122(12):36-8. 14. RESTINO A, RATZAN SC. Public health campaigns go electronic. Medicine on the Net 1997 Aug;3(8):22-3. 15. REES AM. The consumer health information source book. 5th ed. Phoenix: Oryx Press, 1998. 16. NOAH to expand statewide. For Reference from METRO, 1997 Jan/Feb;(269):4. 17. RA M. Creating a consumer health information network. Collection Building 1997;16(4):167-72. 18. RIFKIN G. Increasingly, top designers are drawn to the Web. New York Times 1995 Nov 27:D7. 19. SINGER P. As Web pages blossom, so does a firm. New York Times 1997 Feb 9:WC10. 20. JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. 1996 Accreditation manual for hospitals, Vol. 1 Standards. Oakbrook Terrace, IL: The Commission, 1996. 21. MEDICAL LIBRARY ASSOCIATION AND THE CONSUMER AND PATIENT HEALTH INFORMATION SECTION (CAPHIS/ MLA). The librarian's role in the provision of consumer health information and patient education-a Policy Statement. Bull Med Libr Assoc 1996 Apr;84(2):238-9. 22. LONGO DR, LAND G, SCHRAMM W, FRAAS J, ET AL. Consumer reports in health care. Do they make a difference in patient care? JAMA 1997 Nov 19;278(19):1579-84.

Received August 1997; accepted February 1998
