A Practice Web Site
Whats it for? What does it cost? Why should we bother?

Myles Clough, M.D., FRCSC
Kamloops, BC

Dr. David Nelson, a recent speaker at the AAOS Technology Pavilion caught the audiences attention by comparing his practice web site (www.davidlnelson.md) to his entry in the Yellow Pages. Most people would agree with his assumption that every North American orthopaedic surgeon pays $250 for an ad in the Physicians section of the Yellow Pages. Many of those same people would hesitate before committing themselves to a practice web site. Here is the table of comparison:

Feature

Yellow Pages

Web site

Colour

Yellow & Black

Unlimited

Large Print/Bold type

Extra

Unlimited

Maximum amount of information

3 lines

Unlimited

Can be updated

Annually (if you move)

Any time for any purpose

Patient accessibility

Phone

Internet and phone

Cost

$250 pa

Free with most Internet Service Providers

Feedback

None

If you want it

Pictures

Logo if you pay extra

Unlimited

We will return to the surprising issue of the low cost of a web site shortly. For now, let us assume that the reasons most orthopaedic surgeons dont have a practice web site are because they dont know the purpose, they dont know the mechanics, they are nearly sure it is ruinously expensive and they arent comfortable with the Internet.

The Purpose of a Practice Web site
This can be summed up in one sentence. On a practice web site you can provide the type of information you and your staff give out again and again. This may include mundane things like the office address and hours but that is not, by any means, the only item of information you are constantly repeating. Descriptions of the risks and benefits of surgery, pre and postoperative instructions, rehab instructions, drug precautions. If you have talked to your patients once about NSAIDS and Glucosamine you must have done it a hundred times. Consider for a moment what would happen if your patients had already read up that subject on your web site before seeing you and so could save you time and focus their concerns on whatever part of the subject they were still uncertain about.

There is a great deal of misunderstanding about the purpose of a practice web site, and a big industry geared to the supposition that a web site will attract patients to your (US) practice. Most overworked Canadian orthopaedic surgeons would react to that notion with more or less profane versions of Heaven forbid! But there is actually very little scientific evidence that web sites attract anybody. The Internet savvy patient may check out their specialist but referral through another physician is still the norm. The unsupported misconception about the purpose of web sites could lead Canadian orthopaedic surgeons to believe they dont need what a web site is supposed to provide. What they do need is more time, better communication with their patients and less hassle. So the real purpose of a practice web site is to reduce the amount of time you have to spend in repetitive explanation and maximize the amount of useful interaction you have with your patients.

Dr. Nelson has put a lot of thought and planning into his web site and has integrated it fully into his practice. When a patient calls for a first appointment his secretary tells them the address of the web site and the fact that the doctor will expect his new patient to have visited the web site and filled in the forms which they will find there (emphasis mine). These forms include a demographic form, an introduction to the present condition and a history of past conditions. His secretary will also enquire about the apparent diagnosis and, if there is a page on that subject on the web site, will give the address to the patient and say that the doctor will expect them to have read that material. Once he has seen the patient Dr Nelson may continue with what he calls Information Therapy and provide a checklist of other pages he would like the patient to read. Despite the quality of his site and the effort he has put into it he has told me he doubts that more than one patient a year comes to his practice because of the web site. He believes it helps his existing patients, makes their experience more predictable and friendly, and saves him time.

The Mechanics
A webpage is actually a very simple file which contains text and tags. The text contains the information which you see printed on the page and the tags tell the browser programme on your computer (e.g. Internet Explorer) what else to do in the way of providing background and graphics, forming links, formatting and layout. Most tags are quite simple; <p> starts a paragraph and </p> finishes it. Virtually all modern word processing programmes will convert a document from word processing format to webpage format with a single simple operation. You can create your document and then Save As a webpage. So if you or your secretary can use a Word Processing programme to prepare and lay out a document, then you can also produce a webpage. Getting it on the Internet is only a little extra work. You need an Internet Provider who will assign you space and give you a password, and a simple programme (FTP for File Transfer Protocol) to transfer files from your computer to the site on the Internet. This really is an administrative function.

The Do-It-Yourself (DIY) approach involves you and your office staff undertaking the following steps:

 

  1. You almost certainly have free space allotted to you somewhere on the Internet. Contact your service provider and find out how much you have and how you access it. If it is more than two megabytes, then you have enough space to begin with.
  2. With your secretary plan three initial documents: 1) a welcome page, 2) a contacts page and 3) patients first contact pages. The welcome page will contain a description of your practice and the web site. It will have links to all other parts of the site and will become the de facto contents page. The contacts page will include office address, parking information, hours, telephone etc. The first contact page will detail everything you want the patient to do before they come in for their first appointment. It might include the history and demographic forms that we alluded to above.
  3. You and/or your secretary should then prepare these pages. He/she may need to focus on parts of the word processing programme that he/she may not use frequently like inserting images and links or using tables for lay-out. This is all easy to learn and the three core pages should be interlinked. The site should then be converted from Word Processing to Web Page files and viewed on a web browser to make sure they will appear as you wanted.
  4. Post those pages and the graphics files they need on your server. It doesnt need to be perfect. You will need to update as necessary. Ensure that all patients know about and visit the web site and encourage them to tell you and your staff what they liked and didnt like about it and what else they would like to see.
  5. Guided by your patients, increase the number of pages providing the information they need on the subjects that occur frequently. Link to the new pages from the Welcome page so that all information on the site is one or (at most) two clicks away.
  6. If your web site grows and becomes difficult to maintain, then is the time to ask for help from a professional web site designer. By then you and your practice will know what the web site should be like and the designer just has to execute that design and tidy up instead of creating, in a vacuum, something which may be way off the point.

Costs
The costs of a practice web site can be considered in three sections, 1) the cost of hosting the pages on the Internet, 2) the cost of designing the web site and writing the pages and 3) the costs of keeping up the web site. Especially if you involve a professional web designer in the process, make sure you are informed of the costs of all three parts.

Hosting Costs
Most Internet Service Providers (like AOL, Shaw or Look) provide their users with quite large amounts of space on the Internet as part of the service they provide. You already pay for this but there is no added cost if you use it. The only drawback to using this space for a practice web site is the fact that the address is a trifle clumsy. I subscribe to Shaw and the space made available to me has an address something like http://members.shaw,ca/m/mylesclough/ . If you want your Internet address to be relevant like www.drbonesmccoymd.com you would have to obtain the right to a particular domain name ($25 USD per year) and make arrangements with your host to use that address (also for extra cost usually). If you want to make separate arrangements to host a page, these can be made for $5/month and upward (Amray http://www.amrayhosting.com/) There are over 400 Canadian orthopaedic surgeons listed as members or fellows of the American Academy of Orthopaedic Surgeons (AAOS) and only 10% have availed themselves of the free web site offered by the AAOS. If you become an International Member at a cost of $350 USD pa you receive a free practice web site hosted on the AAOS site (see http://orthodoc.aaos.org/MylesClough/) as a part of your membership benefits. The web site is template driven so all you have to do is answer the questions about your address, qualifications etc. The Patient Information links are to the AAOS own library of patient information but you can also provide your own pages.

If you are looking for free hosting and are not a member of AAOS, I suggest you turn to your Internet Service Provider. Free hosting on places like GeoCities (www.geocities.com) is paid for by pop-up advertising which will annoy both you and your patients.

Designing the Web Site
At the top end of the scale you can pay a large amount of money to a web designer who will create a custom web site and arrange for hosting. The business case for this is presumably to attract more patients. If I was thinking about doing this I would certainly ask to see evidence that previous clients were satisfied and had experienced an increase in patient referrals. If you believe, as I do, that web sites are valuable mostly in informing your existing patients, it is difficult to make a business case for an expensive set-up. However, if you consider that an attractive web site is a necessary part of doing business in the 21st Century, then it falls into the same category as decorating your office.

Updating
It is very important that you and your staff are able to update your site without having to go through the web designer. There will constantly be things you want to change on the site. It only takes seconds to make the changes and it makes no sense to have a process to go through to make them or to pay anyone except your secretary to do it.

Maintenance
This issue is often forgotten. A web site is always a work in progress with constant alterations and improvements. This is particularly the case if you are using it to inform your patients. Refinements, improved illustrations and new subjects will suggest themselves often. If you have to involve professional web designers in these updates it will be expensive, unless maintenance costs have been included in the original contract. This is another argument for DIY web sites. Content, not form is the part of the web site valuable to your patients and only you can provide it satisfactorily.

Overall Recommendation
Setting up and maintaining a practice web site is a significant step which will consume some time, perhaps cost something and may be stressful. Before taking this step you should be clear and realistic about what you expect to gain. It is probable that time and effort put into informing your patients about your practice and expectations will be repaid in better patient relations and less time spent repeating the same information. However, this is a supposition which would not hold for all practitioners. If you think it would hold for you, I recommend the DIY approach because it is the cheapest; it places the emphasis on you as the provider of the most important information; it makes it easier for you to undertake updates and puts you in the drivers seat should you require a professionally designed web site in the future.

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