In a graduate course this semester (at the Temple University College of Public Health) on Healthcare Quality and Safety, one of the assignments is to explore the internet to learn about how consumers/patients without specific healthcare knowledge might get information on quality of care. When students enter “consumer healthcare information” in Google, the first result from this search is the American Hospital Association’s (AHA) Consumer Information website. At first glance, this seems like a great resource – it lists 21 topics, ranging from “Glossary of Insurance Terms” to “Understanding Medical Research”, with web links to each.
However, if you take time to go through the links, you will be disappointed to find that almost half don’t work:
- Guide to long-term care insurance (http://membership.hiaa.org/pdfs/2002LTCGuide.pdf);
- HIPAA insurance reform (https://www.cms.gov/hipaa/hipaa1/content/cons.asp);
- Medicare Health Plan Compare (https://www.medicare.gov/MPHcompare/home.asp);
- Patient Glossary of Billing Terms (http://www.patientfriendlybilling.org/pdf/Glossary.pdf);
- Protecting the Privacy of Patient Health Information (https://www.hhs.gov/news/facts/privacy.html);
- How to File a Health Information Privacy Complaint with the Office for Civil Rights (https://www.hhs.gov/ocr/privacyhowtofile.htm);
- Top 10 Ways to Make Your Health Benefits Work for You (http://www.dol.gov/ebsa/Publications/10working4you.html);
- What is a Doctor of Osteopathic Medicine? (http://www.aoa-net.org/Consumers/whatdo01.htm);
- Which Medical Specialist for You? (http://www.abms.org/which.asp);
The AHA, of course, does not control the sites referenced on their website. The organizations at the other end of these links certainly change their web structures, and some of these changes may have occurred recently (and for government websites, website changes are especially common after administrations change).
Unfortunately, the average life of a webpage is only around 100 days. As the AHA Consumer Information website is the first search result returned by Google, this may be a website consumers frequent to obtain health information. It is disturbing that nearly half of these consumer-focused resources didn’t work.
How common is this type of barrier? More common than you might think. The problem goes by several evocative names — reference rot, reference decay, link rot, link death — and is a scourge of knowledge work in the modern age. Reference rot refers to both the problem of pages and sites disappearing or moving as well as situations in which the page may still exist, but the content has changed (also called content decay).
The problem is not limited to websites: there are high rates of reference rot in medical journals and non-medical publications. A few things could help:
- First, organizations and individuals should run regular automatic AND manual checks to identify dead links on their websites and remove or replace them as needed.
- When companies redesign websites, they should invest the time to set up the appropriate automatic “redirects” wherever possible.
- Before an author team submits the final version of anything with URL references, the reference links should be checked and updated where necessary.
- Authors should consider using one of the free services like Perma.cc or WebCite to provide a permanent archive for their citations; readers of the future will then be able to see exactly what the authors saw at the time they cited that page.
When you hit a dead link, sometimes there are alternative ways to find the information you seek:
- Entering the name of the website, file, study, or report in quotes into a search engine may lead you to the file’s new home.
- Entering the title of a study or paper into Google Scholar may locate alternative sites with copies.
- Entering the broken link into the Internet Archive’s Wayback Machine or Time Travel may pull up an archived version.
- Automatic, browser-based tools such as the Google Toolbar, the Google 404 widget, and the Linkgraph widget may be able to help track down the right webpage if you encounter a “404 page not found” error.
There are solutions to the problem of reference rot, but there is no magic bullet. We hope you are motivated, as we have been, to at least start archiving your scholarly citations! The internet can be a powerful tool for research, education, and information, for both consumers and health care professionals, but only if it is regularly maintained by content providers – and skillfully navigated by savvy users.
Michael Halpern
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