Table 1.

Proposed conceptual and methodological framework for describing, comparing, and analyzing the structure and quality of e-health

	Structural Quality		Process (Performance) Quality	Outcome Quality
What do we want to evaluate / improve?	Communication setting, infrastructure, resources		Communication process itself	Effect of communication
	Real structure	Virtual Structure
Evaluation Level	Level 1	Level 2	Level 3	Level 4
Unit of evaluation	Information providers	Websites and webpages, or other Internet venues	Medical advice and support given, messages and statements made	Users
What can external evaluators assess?	Technical capabilities of ehealth providers, way of presentation, completeness of disclosure/metainformation provided		Quality of advice and standard of ehealth care (evaluating information)	Impact on patients
Aims of measures directed to improve quality	Providing access and facilitating communication Helping users to find and to navigate Building trust Making the information context clear for the user (disclosure etc.) Enabling informed consent Providing efficient feedback channels Giving insight into the editorial process and enable checking		Acting in line with clinical and ethical guidelines	Improving patient outcome
Methods of evaluation	Obtaining information from the information provider	Checking for presence of technical criteria	Checking the information content for accuracy, Testing the service and comparing advice against guidelines	Obtaining outcome variables from patients
Criteria	Level 1	Level 2	Level 3	Level 4
	Resources (capital, infrastructure)	Ease of access	Actual accuracy (includes currency and completeness) of content	Mortality
	Staff (number, qualification, leadership)	Speed	Accuracy of advice	Morbidity
	Training	(Readability)	Ethical behavior, including privacy, confidentiality	Quality of life
	Internal Standard Operating Procedures and quality assurance processes, commitment to quality	Disclosure	Validity of health risk assessment tools	Cost effectiveness
		Attribution		(Behaviour change, change in attitude and knowldege)
		Displaying the date
		Clarifying the target population
		Accountability
		Indirect measures: Popularity, number of links pointing to the site
Information about compliance with criteria accessible for	Information provider	User, particularly consumers	Experts	Researchers in collaboration with information provider
Universality of quality criteria	Universal criteria	"General" quality criteria, specific to the Internet venue and (partly) aim	"Subject specific" quality criteria, specific to the medical domain	Universal criteria, but quantifiable outcome measures specific to the aim