Background: The most commonly recommended strategy in Canada for patients wishing to find a regular family physician (FP) is through the use of websites with FP listings. We aimed to explore the content and usability of these websites.

Methods: We identified publicly available websites with FP listings in Western Canada, analyzing them thematically through open coding for website content and conducting framework analysis for website usability.

Results: Twelve unique websites were identified and grouped into three categories: (1) Physician regulatory authorities ("Colleges"); (2) Governmental; and (3) Miscellaneous. College websites provided the greatest detail about the FPs and enabled searching, though had low readability. Governmental websites listed basic contact information and were credible but contained less detail than College websites. Miscellaneous websites were narrower in focus and therefore easier to navigate but lacked updated and accurate information.

Conclusion: Many websites help patients find FPs. Their content and usability are variable, suggesting a need for guidance in the development of these resources.

Introduction

In Canada, there are 83,159 active physicians, of whom 52% are family physicians (FPs) or General Practitioners (CMA 2017). This equates to 115 FPs per 100,000 persons in the population (CMA 2017). These FPs may work in healthcare facilities and hospitals, although most are based in community clinics. Patients of all ages present to FPs with undifferentiated medical or psychosocial problems, and the FPs use their expert clinical knowledge to diagnose and treat the patients (CMA 2017). They provide continuity of care to patients through repeated clinical contacts (The College of Family Physicians of Canada 2017; Walter and Jan 1999). In the Canadian healthcare system, out-patient access to diagnostic testing, procedures and referrals to specialist physicians can only be obtained through the FP.

Having continuity of care through a regular FP is associated with perceived increased access to care (Stewart et al. 1997), increased patient satisfaction (Saultz and Lochner 2005), increased use of preventative services (Bindman et al. 1996), and lower rates of hospitalizations and emergency department visits (Fung et al. 2015; Saultz and Lochner 2005). Despite their importance, 15.5% of Canadians report not having a regular FP (Statistics Canada 2014). Without a standardized or centralized method of contacting available FPs, individuals must use their own time, networks, resources and acumen to find and obtain a regular FP, by asking friends or family, or by going to websites with lists of available FPs (Alberta Health 2015; Crooks et al. 2012; MOHLTC 2009).

A majority of unattached patients indicate that they want a regular FP but attempts to find one can end in failure (MOHLTC 2009; Statistics Canada 2014). Frustrations with the process of finding an FP include the lack of FPs accepting new patients (Asanin and Wilson 2008; Randall et al. 2012; Sanmartin and Ross 2006), the inability to identify FPs who are accepting new patients resulting in the need to phone many clinics (up to 84 in one account) to inquire about FP availability (Galloway 2011; Randall et al. 2012), and the presence of outdated and inaccurate information (Randall et al. 2012). The success of finally finding an FP is seen to be a combination of luck, connections and self-reliance (Randall et al. 2012), with patients feeling the need to mobilize their own resources given systemic failures. In a universal healthcare system, these barriers in accessing primary care are seen by many Canadians as a "loss of a basic right" (Freeman et al. 2013).

Despite their accessibility, availability and high frequency of use, there has not been a study that explores the web-based resources that the public uses to search for FPs. In general, the usefulness of a website depends upon its ability to meet the user's needs by having relevant content, and also by having high usability (i.e., easy to use and is acceptable to the user) (Bevan and Maissel 1991; Interaction Design Foundation 2018; Mich et al. 2003; Nielsen 1994, 2012). There is no value in a website that is easy to use but does not meet the goal of facilitating the user in finding an available FP. Conversely, a website with valuable information that cannot be easily found or understood due to poor usability is equally inadequate (Nielsen 2017; Nielsen and Loranger 2006). We therefore undertook a research study with the dual objectives of exploring the content and usability of websites used to help individuals search for and access FPs in Western Canada (British Columbia [BC], Alberta [AB], Saskatchewan [SK] and Manitoba [MN]). An understanding of these resources is essential to develop policies and procedures related to web-based resources and begin to address some of the barriers patients face in accessing primary care.

Methods

Identification of websites

We identified websites used to help individuals find or access FPs in the four provinces in Western Canada. These provinces were specifically chosen for their similarities in size, geography, culture, and need for improved resources, given their high proportions of unattached patients at 15–20% of the population (Statistics Canada 2014). Study investigators independently identified websites for evaluation by using a Google search for the phrase "Find a family physician in 'province'", where "province" was substituted by British Columbia, Alberta, Saskatchewan and Manitoba. The only inclusion criterion was that the website must allow or facilitate contact by patients to FPs or vice versa. Websites that give general suggestions regarding modalities of finding an FP or that only link to other websites were excluded. All websites meeting this inclusion criterion were identified. If an organization (such as a provincial government) created similar websites within a province, one representative website from each rural and urban location in the province was analyzed. If an organization created identical websites across the four provinces with the only difference being a province-specific directory of FPs, only one representative website from one province was analyzed.

Within the included websites, the web pages that were analyzed were: (1) the home page, (2) the web pages that described the organization responsible for the website (usually "About Us", "Mission, Vision and Values", "Goals" and "Frequently Asked Questions" pages), and (3) the web pages used to find or search for physicians (usually "Find a Physician" or "Physician Directory" pages).

Data analysis

The websites were accessed and analyzed between February and March 2015. Two separate approaches were undertaken to address the separate objectives of exploring website content and website usability. The approach used to explore website content was thematic content analysis (Braun and Clarke 2006; Braun and Clarke 2013; Braun et al. 2015). Study investigators thoroughly read all the included web pages from all websites to familiarize themselves with the data. Both text and images were included in data analysis. The investigators independently performed open coding of each web page, where codes identified data that aligned with the study objectives and represented the most basic segment of data that could be meaningfully analyzed (Braun and Clarke 2006). Web pages were analyzed in a systematic line-by-line fashion. When new codes were generated, each team member re-reviewed previously analyzed web pages looking for these newly generated codes in an iterative way through constant comparison. After coding of the web pages was completed, the study investigators met to group the codes into potential themes and sub-themes related to website content. An inductive approach was used to explore website content, as there are no standards or framework by which to study this topic area. That is, the study team had no pre-conceived ideas of what content would be found on these websites; themes were generated through observations of the data.

The approach used for the second research objective, to explore website usability, was framework analysis. This, in contrast, was more deductive in nature, as usability has been widely studied and there are known features that are important in enhancing usability. The study team familiarized themselves with the data and performed open coding of the web pages as previously outlined. In framework analysis, additional steps were undertaken, which included the grouping of codes into pre-determined themes on website usability, then indexing these themes (that is, applying them to the entire data set), and charting or summarizing the data by this thematic framework (Gale et al. 2013; Green and Thorogood 2014; Smith and Firth 2011). The four pre-determined usability themes were: (1) ease of search; (2) ease of navigation; (3) accuracy and ease of understanding of information; and (4) typography (i.e., readability and legibility) of websites. These four themes were obtained from the literature, where empiric studies utilizing user testing have identified these as the most important features in web usability (Nielsen and Loranger 2006), especially for websites that provide medical or health information, provide educational resources or are governmental in nature (Zhang and von Dran 2001).

For both analytic approaches, the study team met consistently to compare codes, constructively question each other's coding and interpretations, and have a critical dialogue to reach a consensus about coding wherever there were coding differences. Because all websites included in data analysis were publicly available, and because there were no human participants recruited for the study, institutional ethics board approval was not required.

Results

A total of 12 unique websites were included in data analysis (Table 1). A salient theme that emerged was the "identification of the organization and individuals responsible for the website." The identified organizations fell into three groups: (1) Physician Regulatory and Licensing Authorities (also known as the "Colleges"); (2) Governmental; and (3) Miscellaneous. The College websites were those of the regulatory/licensing bodies for physicians and surgeons (College of Physicians and Surgeons of Alberta 2015; College of Physicians and Surgeons of British Columbia 2015; College of Physicians and Surgeons of Manitoba 2012; College of Physicians and Surgeons of Saskatchewan 2013). Websites created by primary care networks (Primary Care Network Calgary Foothills 2010; Primary Care Networks 2015), health regions (Saskatoon Health Region 2014; Sunrise Health Region 2015) and the ministries of health (Province of Manitoba 2015) were deemed to be governmental. Miscellaneous websites included those created by business organizations (Alberta Doctor Directory 2014) or those where no information was provided regarding the organization represented by the website (Canadian Office for Applied Research Studies 2015; FindaBCdoctor 2010). Instead of referencing websites directly, we have denoted the College websites (n = 4) as "C1" to "C4", governmental websites (n = 5) as "G1" to "G5" and miscellaneous websites (n = 3) as "M1" to "M3".

Content of websites

We identified five elements that comprise the content of these websites (Table 2). First, websites within each of the three categories contained similar objectives. The goal of College websites was to regulate the medical profession, while a key purpose of governmental websites was to help individuals find FPs. None of the miscellaneous websites explicitly stated their objectives. Second, the methods by which websites assisted patients in finding FPs differed. College websites tended to contain search functions such that a list of FPs matching the inputted characteristics could be obtained. Governmental and miscellaneous websites often provided an undifferentiated physician directory. Two governmental websites (G1, G5) provided a service to directly connect individuals to available FPs. Third, the extent of detail available for listed FPs varied. Although all College websites provided sufficient name, specialty and contact details, half (C1 and C4) did not contain information about whether doctors were accepting new patients, making these websites incomplete resources on their own. In contrast, governmental websites listed only FPs who were accepting new patients.

Miscellaneous websites were variable, although they tended to lack basic information, with practice discipline (i.e., FP versus specialist) not even being universally available. Fourth, websites contained a diverse set of health-related resources. These resources were targeted to doctors rather than the general public on the College websites, while the resources were relevant to the public on governmental and miscellaneous websites. Lastly, websites contained varying degrees of visual and multimedia elements. There were few graphics on College websites in direct contrast to governmental websites that contained many graphics and images including cartoons that were likely to appeal to the public. Advertisements were present only on miscellaneous websites (M1 and M3) and were often not health-related.

Usability of websites

We examined website usability specifically with regard to the search function and results, navigation, accuracy and ease of understanding of information, and typography (Table 3). College websites consistently had a search function, although the ease of use of this search function was variable, with some websites having excessive options for search inputs, and others having too few search parameters. Governmental and miscellaneous websites provided a listing or directory of doctors by city. When this list was small (such as with smaller towns), it was easy and quick to browse and no additional search function was needed. However, when this list was long, the user was required to browse through many pages of FPs without the ability to select certain preferred characteristics, such as location of the clinic. This resulted in a long and tedious search, especially for urban areas where there is a large number of available FPs. Navigation on College websites was compromised by not having a clear division between physician-specific web pages and those targeted to the public. Duplication in links or having multiple ways to arrive at the same destination, as well as links not being clear (for example, a picture could act as a link, but it was not immediately clear that the picture was clickable), were issues with both governmental and miscellaneous websites. The information provided on College and governmental websites was current and credible, while the information provided on miscellaneous websites was often out of date, wrought with errors, compromised by advertisements, and lacked basic information about the organization or individuals represented and responsible for the websites. All three categories of websites had a high Flesch–Kincaid reading level (between grades 10 and 12). College websites were text heavy, while the legibility of governmental websites was weakened by the use of many different font types, colors and sizes that competed for attention. The legibility of miscellaneous websites was variable, although they tended to be low due to small font sizes and dense text.

Discussion

Given that websites are a primary way by which patients find FPs, an exploration of their content and usability is imperative in understanding how they may facilitate or hinder Canadians seeking to access primary care. To our knowledge, this is the first study to examine these websites. We classified these websites into three categories (physician regulatory authorities or the "Colleges", governmental and miscellaneous) based on the organizations responsible for the website. There was wide variability in terms of both content and usability across websites, although some similarities existed within the three categories.

The importance of website content cannot be overstated; the "ultimate failure" of a website is the inability to provide the information that users are seeking (Nielsen 2011). Whether a listed physician is an FP (rather than a specialist) and whether FPs are accepting new patients constitute essential information for patients searching for an available FP. However, this information was not universally available. Furthermore, in contrast to College and governmental websites, which otherwise provided current, robust and credible physician information, the information provided on miscellaneous websites was outdated and replete with errors. This is a significant shortcoming of miscellaneous websites, given the importance of accurate information (Hoffmann and Worrall 2004).

Usability depends upon the target audience, which varies across the three categories of websites. Regardless of the broader context though, the function of helping patients find an FP is specifically intended for the general public. Therefore, if there are other intended target audiences, there should be a clear division between public-facing web pages versus those targeting these other audiences (such as physicians, on College websites) (Hoffmann and Worrall 2004; Hussey 1997). Furthermore, the physician directory or "find a physician" function was at times difficult to find. Given the importance of this function, the link/search should be placed at the top of the web page (as only 12% of users will get to the bottom of a web page) (Nielsen 2013) and should be distinct, rather than being hidden within long multi-level drop-down menus (Nielsen and Loranger 2006). We also found very high reading levels for all websites, across all three categories. The average reading level of patients is 6^th grade (Davis et al. 1990); websites should therefore have reading levels no higher than this (Safeer and Keenan 2005).

Our findings suggest that many websites that exist with the purpose of helping individuals search for FPs are of varying quality and usability. We have summarized the unique strengths and limitations of three categories of websites (Table 4). The ideal website would combine the strengths of each, such as by having comprehensive and up-to-date physician information and by containing a search function to allow narrowing of searches by desired characteristics such as clinic location. The weaknesses of the websites analyzed in this study also provide important lessons learned. For example, the ideal website should be written at a much lower reading level and the presence of less relevant information (such as information on specialists, which the Canadian public cannot access without a referral) minimized. This study has the potential to inform the optimization of existing websites and the creation of new ones.

Limitations

We recognize that there are several limitations to our study. First, our study is based on an evaluation of publicly available websites, with no input from end users. Although we feel that our data sources adequately address our research question, eliciting views of individuals who have tried using these websites may enhance our discussion on essential website elements. Second, we limited our study to websites from Western Canada. This restriction improved comparability across the provinces and allowed us to concisely synthesize a diverse and large volume of data. It does, however, limit transferability of findings to the provinces not included in the analysis, although there is no reason to believe that there are major differences in website content based on geography alone.

The current landscape of web-based resources to help patients find an FP in Western Canada is diverse and varied in both content and usability. In exploring these websites, we encountered content and usability elements that made the search for FPs difficult and time-consuming; this echoes the same frustrations that have been reported by the public (Asanin and Wilson 2008; Galloway 2011; Randall et al. 2012; Sanmartin and Ross 2006). In laying out differences in how websites present key content elements and their potential implications, our findings can inform efforts to improve the content and construction of the resources used by Canadians to find and access FPs.

Exploration du contenu et de l'utilisabilité des ressources Web employées par des particuliers pour trouver et consulter les médecins de famille

Résumé

Contexte: La stratégie la plus recommandée aux patients canadiens pour trouver un médecin de famille régulier (MF) est le recours aux sites Web qui listent les MF. Notre objectif était d'explorer le contenu et l'utilisabilité de ces sites.

Méthode: Nous avons répertorié les sites Web disponibles au public dans l'Ouest canadien, nous les avons analysés au moyen du code ouvert et nous avons recouru à un cadre d'analyse pour en évaluer l'utilisabilité.

Résultats: Douze sites Web ont été répertoriés et regroupés en trois catégories: (1) organismes de réglementation (« collèges de médecins »); (2) gouvernementaux; et (3) divers. Les sites Web des collèges fournissent plus de renseignements sur les MF et permettent de mener des recherches, bien qu'ils offrent une plus faible lisibilité. Les sites Web gouvernementaux présentent les coordonnées de base et sont crédibles, mais ils contiennent moins de renseignements que les sites des collèges. Les sites Web divers sont plus ciblés et offrent donc une meilleure navigabilité, mais les renseignements y sont moins précis et moins actualisés.

Conclusion: Plusieurs sites Web permettent aux patients de trouver un MF. Leur contenu et leur utilisabilité varient, ce qui laisse croire qu'il y a un besoin en matière d'orientation pour le développement de ces ressources.

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