(see also: Example handout to help illustrate the problem of reading comprehension and some useful tips to help improve your writing.)

Because Web pages are read, comprehension issues are particularly relevant. The AMA has addressed this in its "Report of the Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs".

The 1992 National Adult Literacy Survey (NALS), the most accurate portrait of English-language literacy in the United States, found that 40 to 44 million Americans, or approximately one quarter of the US population, are functionally illiterate, and another 50 million have marginal literacy skills. This means that almost half of our adult population has deficiencies in reading or computational skills. Of these, 5% have learning disabilities and 15% were born outside the United States. However, the vast majority of adults with poor literacy are white, native-born Americans. ... An individual's functional health literacy -- the ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials required to successfully function as a patient-may be significantly worse than their general literacy, because functional literacy is context specific. That is, an individual may be able to read and understand materials with familiar content but struggles to comprehend materials written at the same level of complexity if that material contains unfamiliar vocabulary and concepts.

• Low-literacy patients, by definition, cannot be empowered consumers in a market-driven health care system.
• Patients who do not understand health care professionals' instructions will not receive quality medical care.
• Evidence in case law documents health care professionals' and hospitals' medicolegal liability for adverse outcomes by patients who do not understand important health information.
• Clinical management problems related to poor health literacy problems probably result in substantial but avoidable costs for the US health care system, for individual health plans and providers, and for patients and their families.
• Health literacy problems are more common in certain populations (e.g., Medicare beneficiaries, Medicaid recipients, and uninsured individuals) that are heavily dependent for their health care on public policymakers.

For the reasons cited herein, health policymakers should be alerted to the broad problem of poor physician-patient communication. Both the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance have developed guidelines on patient communication and the readability of informed consent documents and patient education materials.68, 69 The US Congress and the US Food and Drug Administration have long recognized the need to improve patients' knowledge and understanding of prescription drugs.

Much good information about effective patient education materials (and e-health materials fall into this category) exist online; a few examples:

• Criteria for evaluating patient education materials
• Guidelines for preparing patient education materials
• A UI study on readability of e-health sites
• FDA Guidance on Medical Device Patient Labeling (helpful "how to" in Appendix B)

I've been involved in creating patient education materials for about 15 years, and it seems to me that the online information we provide via our e-health sites and our digital libraries requires even more care in its creation than that destined to appear on the printed page. Audiences approach a web page differently than they do a printed piece. Skillful composition and design are more important.

I think our responsibility is not one of censorship, determining in some inexplicable way what is or is not appropriate to communicate. Rather, it is to see that the information we each distribute is as accurate, honest, and understandable as we can make it.