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Copyright © 2000, American Medical Informatics Association Methods for the Design and Administration of Web-based Surveys Affiliations of the authors: Temple University School of Dentistry, Philadelphia, Pennsylvania (TKLS); University of Southern California School of Dentistry, Los Angeles, California (JLF). Correspondence and reprints: Titus K. L. Schleyer, DMD, PhD, Department of
Dental Informatics, Temple University School of Dentistry, 3223 N. Broad
Street, TU 600-00, Philadelphia, PA 19140; e-mail:
<di/at/dental.temple.edu>. Received September 7, 1999; Accepted January 31, 2000. This article has been cited by other articles in PMC.Abstract This paper describes the design, development, and
administration of a Web-based survey to determine the use of the Internet in
clinical practice by 450 dental professionals. The survey blended principles
of a controlled mail survey with data collection through a Web-based database
application. The survey was implemented as a series of simple HTML pages and
tested with a wide variety of operating environments. The response rate was
74.2 percent. Eighty-four percent of the participants completed the Web-based
survey, and 16 percent used e-mail or fax. Problems identified during survey
administration included incompatibilities/technical problems, usability
problems, and a programming error. The cost of the Web-based survey was 38
percent less than that of an equivalent mail survey. A general formula for
calculating breakeven points between electronic and hardcopy surveys is
presented. Web-based surveys can significantly reduce turnaround time and cost
compared with mail surveys and may enhance survey item completion rates. The Web-based survey described in this article was designed to investigate
the use of the Internet in clinical practice by 450 dental professionals. The
results of the survey itself have been published
previously.1 This
paper describes the design and implementation of the survey in detail to
assist other researchers who are considering using Web-based surveys. From a
review of the background literature and our own experiences, we present issues
in sampling for electronic surveys; survey design, programming, testing, and
administration; potential problems and pitfalls; and cost comparisons between
electronic and hardcopy surveys. We developed several general breakeven
calculations based on cost, provided all other variables are equal, to help
researchers choose between electronic and traditional mail surveys. Background Several recent publications have reported use of the Internet to conduct
survey
research.2,3,4,5,6,7,8,9
Investigators in the fields of medicine, psychology, sociology, dentistry, and
veterinary medicine are recruiting participants for their research studies by
targeting specific search engines, newsgroups, and Web sites. Participants
often answer surveys by returning a completed form by e-mail or by entering
their responses directly on a Web site. Commonly cited advantages include easy
access, instant distribution, and reduced costs. In addition, the Internet
allows questionnaires and surveys to reach a worldwide population with minimum
cost and time. Researchers can contact rare and hidden populations that are
often geographically
dispersed,3 as well
as patient populations different from those typically seen in the clinical or
hospital
setting.2,10 Other reported benefits relate to graphical and interactive design on the
Web. Ideally, HTML survey forms enhance data collection, compared with
conventional surveys, because of their use of color, innovative screen
designs, question formatting, and other features not available with paper
questionnaires. They can prohibit multiple or blank responses by not allowing
the participant to continue on or to submit the survey without first
correcting the response error. This feature is somewhat controversial, because
there may be legitimate reasons for not answering questions, and responses
such as “don't know” or “prefer not to answer” force
an answer when participation and question response is supposed to be
voluntary.11
Regardless of one's view on this issue, the program can provide cues to make
sure the respondent does not inadvertently skip a question. In addition,
coding errors and data entry mistakes are reduced or eliminated while
compilation of results can be
automated.12
Finally, online forms can help minimize costs, facilitate rapid return of
information by participants, and allow timely dissemination of results by
investigators.13 Several examples show how the Internet is used for survey research.
Physicians in Germany developed a Web-based patient information system about
atopic eczema to attract patients to the Web site and Internet
survey.2 The purpose
of the survey was to explore the relations between atopic stigmata and its
symptoms, predisposing factors, patient demographics, and associations with
other diseases. As an incentive to fill out the survey, an atopy score was
calculated and presented to the participant upon completion. Approximately 240
subjects complete the survey each month. Healthy Web surfers serve as
controls.2 In another study, researchers at Columbia University explored the
properties of a new measure of sexual orientation by monitoring network
traffic on an intranet over a two-week period and collecting all postings to
two newsgroups related to their topic of
study.3 From the
formulated list of e-mail addresses, 360 subjects were randomly selected.
Subjects were notified of their selection, and those who consented to
participate were e-mailed a survey. Of the participants who were contacted,
66.1 percent provided their consent to participate and 56.4 percent of that
group returned completed
surveys.3 Veterinarians conducted research via e-mail and Web pages to investigate
causes of dog death in small veterinary
practices.4 In this
study, 25 veterinarians submitted case material. On the basis of analysis by
region and school attended, the investigators found that participants were
representative of the veterinarian population in the United States. Nursing researchers have found the Internet a valuable vehicle for
collecting data from cancer
survivors.7 In this
study, three cancer-related newsgroups were used to distribute the Cancer
Survivors Survey Questionnaire. This method proved useful for collecting
preliminary data, which are often needed to demonstrate the feasibility of
conducting a large-scale study and for determining adequate sample size. Theoretically, conducting research over the Internet has many benefits.
However, survey experts and researchers warn that the current online
population is not representative of the general population in the United
States. Estimates of computer ownership and e-mail access vary depending on
how data were gathered, e.g., face-to-face or via telephone, and how it is
reported, e.g., household computer ownership vs. “access to”
computers.14,15
For example, in 48,000 face-to-face interviews conducted in 1997, 37 percent
of households in the United States reported owning a computer, 19 percent
reported online access, and 17 percent reported e-mail access. In comparison,
through telephone polls, 67 percent reported having access to a computer and
31 percent had an e-mail address. While access to e-mail and the Internet grow daily, a “digital
divide” exists among age and racial groups, income levels, and
geographic
settings.14
Ensuring that each potential respondent has an equal chance of being selected
to participate poses a major challenge in conducting a scientifically sound
survey. This is especially true in the health sciences, where electronic
access to specific provider or patient groups cannot easily be
obtained.9
Currently, not all health professional associations or licensing boards
collect e-mail addresses, nor is it possible to estimate the number of
individuals with the particular health state of interest who have access to
computers and the
Internet.7 However,
rigorous sample selection procedures must be followed if results are to be
generalized to a population and sources of coverage and sampling error are to
be kept to a
minimum.11,16 Unfortunately, the sampling procedures reported in many electronic surveys
reflect unknown
samples.2,3,5,13
When subjects are recruited by targeting newsgroups or search engines, it is
nearly impossible to determine the distribution of the sample population.
These survey procedures should be used only when sampling and self-selection
biases can be tolerated. Another concern unique to conducting electronic surveys is the variation of
the level of computer literacy among respondents and the capabilities of their
computers. Internet users tend to be highly educated white men between the
ages of 26 and 30
years.13 Even so,
their experience responding to online questionnaires may be limited. Thus,
Web-based surveys need to have clear directions on how to perform each needed
skill, e.g., how to enter answers with a dropdown box or erase responses from
a check box11 so
that responding to the questionnaire does not become a frustrating
experience. Providing specific instructions will assist respondents in accurately
completing and returning the survey, provided their computer is capable of
receiving it in the first place. Differences among computers, such as their
processing power, memory, connection speeds, and browsers, potentially negate
some of the benefits purported for using the Web. For example, the use of
graphics and animation may increase the attractiveness and novelty of
participating. However, advanced Web progamming features, such as Java,
JavaScript, DHTML, or XML either may be incompatible with certain browsers or
may cause them to respond slowly or crash. In The Influence of Plain vs.
Fancy Designs on Response Rates for Web Surveys, Dillman et
al.17 showed that
such features can actually lower response rates. In this study, a plain
questionnaire obtained a higher response rate than one that used tables and
colors. The plain design also was more likely to be fully completed in a
shorter period of time. Dillman et al. proposed three criteria and 11 supporting principles for
designing respondent-friendly Web questionnaires, some of which were used to
guide the development of the study presented in this
article.11 These
criteria include:
The next section describes the purpose of the survey described in this
article, how the sample was selected, and how the survey was designed, pilot
tested, and administered. Survey Development and Administration The Study The Web-based survey described in this article was designed to investigate
the use of the Internet in clinical practice by 450 dental professionals.
There were three primary reasons for choosing a Web-based survey method.
First, the survey population used e-mail, since all participants subscribed to
an Internet discussion list. Use of e-mail is not an absolute indicator of Web
use; however, since discussions often referenced Web sites, it seemed likely
that the majority of individuals used the Web. The survey results confirmed
this assumption. Second, because of an imposed deadline, survey development,
implementation, and data analysis had to be completed within eight weeks,
which made it impossible to conduct a traditional mail survey. Finally, funds
or other resources for the production of a hardcopy survey, postage, and data
entry were not available. Sample Selection A random sample of dentists could not be selected because no comprehensive
list of dentists with e-mail addresses was available. Consequently, the
largest discussion list for general dentistry (Internet Dental Forum) was
identified. Selection of the discussion list permitted identification of the
total population and controlled follow-up with nonrespondents, blending a
methodologically sound approach with a new method of collecting data. The
investigators believed that selection of this convenience sample, although not
representative of all dentists with Internet access, was more appropriate than
soliciting volunteers from general sites with unknown populations. Dr. D.
Dodell, list owner of the Internet Dental Forum and member of the project
team, made the list of e-mail addresses available. Institutional Review Board
approval for this survey was not sought, since the project was exempt under
CFR §46.101 (b) (2). Survey Design A 22-question survey instrument with a total of 102 discrete answers was
developed. Rather than being presented on a single, lengthy Web page,
questions were grouped on 18 sequential screens, for two reasons. First,
sequential screens kept transmission time to a minimum and avoided potential
server time-outs for respondents with slow modem connections (33 KBps and
below). Second, the use of sequential screens allowed questions to be
displayed completely and prevented the need for participants to scroll through
pages and potentially get lost. Figure 1
Several published recommendations and findings for designing survey screens
were
followed.11,17,18
The small file size minimized download time. Formatting clearly differentiated
questions and answers and deemphasized secondary screen elements. Consistent
layout reduced the number of required cognitive adjustments and allowed
participants to concentrate on answering the questions. The “next”
button, combined with the relative screen indicator, encouraged a page-turning
rhythm that resembled completing a hardcopy survey. To minimize incompatibilities with browsers, survey pages were compliant
with HTML 3.0. Neither JavaScript, which is often employed to validate entry
fields on the Web, nor Java, ActiveX controls, and other advanced Web
programming concepts were used for the reasons cited above. The survey was programmed in PL/SQL on an Oracle 8 database server.
Programming took approximately 35 hours. Code review and testing added another
eight hours. Since the code was going to be used only once, the programmer
neither optimized the code for performance and maintenance nor added detailed
comments. The total length of the program was 2,471 lines. During the code
review, the program was reviewed line by line. In the testing phase, each
question was answered and the corresponding entry checked in the database.
Initially, the survey was programmed to validate every screen (e.g., to check
that all fields were filled out, that the zip code was formatted correctly).
This feature was deactivated on the basis of the results of the pilot test. A
second program also was developed to send survey messages to all participants.
This program took three hours to develop and test and totaled 895 lines. Pilot Testing After programming, the survey was pilot-tested inhouse and with several
remote participants. The program was tested with two different browsers
(Netscape Communicator versions 4.0 and 4.5 and Internet Explorer version
4.0), three operating systems (Windows NT 4.0, Windows 95, and Macintosh OS
7.5), two types of Internet access (high-speed local area network and modem
dial-up line), and three different Internet service providers. The pilot test
did not uncover any technical problems. However, the wording on some questions
was slightly modified, and the validation for required input fields was
dropped. Several pilot-testers felt that requiring entries in all fields was
too restrictive, especially when they felt that a question did not apply to
them personally or when the response choices did not exactly match their
expectations. Survey Administration Next, a list of participants' e-mail addresses was generated from the list
of subscribers to the discussion list. This list was imported into Microsoft
Excel and a unique, random four-character survey ID for each participant was
generated. The IDs were composed of letters and numbers. Participants entered
their IDs to authenticate themselves and access the survey. The list was then
imported from the Excel file into the Oracle database. The main survey page (for introduction and login) was hosted on the
discussion list server
(idf.stat.com)
rather than the Oracle server
(heracles.dental.temple.edu).
Although this method avoided confusion about the origin of the survey, it
prevented the investigators from providing a URL that would have directly
logged participants into the Oracle server. To begin data collection and
identify any significant problems, a survey message was initially sent to 47
participants. The messages originated on the Oracle server were sent through
an SMTP mailer program that
spoofed* an e-mail
address on the server hosting the discussion list. Participants received a
personal message stating the purpose of the survey, who was conducting it, the
estimated time required to complete it, the URL of the survey, the survey ID,
and who to contact with questions. The survey also instructed them to return
duplicate e-mail messages with the subject line “DUPLICATE.” Once
authenticated through their survey ID, participants could begin answering
questions. The group of individuals who responded to the first mailing did not report
any problems. However, several problems were identified when the survey was
mailed to the remaining 403 individuals:
Three additional messages were sent to non-respondents during the following
two weeks. Figure 2
The response rate for surveys entered via the Web was 32.9
percent—144 of 438 (adjusted) participants—after the initial
mailing. The first follow-up mailing resulted in receipt of 76 surveys and
brought the total response up to 50.2 percent. The second follow-up mailing
raised the response rate to 57.1 percent, and the third raised it to 64.4
percent (30 and 32 responses, respectively). The 52 surveys returned by e-mail
or fax were entered by hand and increased the final response rate to 74.2
percent (334 of 438 participants). We sent a total of 1,132 e-mail messages to
participants of this survey. To increase the response rate, the survey was
directly included in the e-mail message in the second and third follow-up
mailings. In addition, while the initial messages and the first follow-up
messages were sent from a generic e-mail account
(survey/at/stat.com),
the subsequent follow-up messages were sent from the listowner's account
directly, with a personal request for a response to the survey. The next section compares the costs of this survey with costs if the survey
had been administered by mail. General breakeven equations for the sample size
using Web-based vs. mail surveys are presented. The section concludes with a
comparison of characteristics of Web and e-mail/fax respondents. Cost and Response Pattern Analysis Costs Costs were calculated to assess the cost-effectiveness of the Web-based
survey method for planning future surveys.
Table 1 shows the costs for the
Web-based survey compared to the costs of an equivalent mail survey. The
comparison excludes costs that are the same regardless of the survey
methodology, such as design of the survey instrument and pilot-testing. Also
excluded is the cost of obtaining the mailing list.
As Table 1 shows, the total
cost of the Web survey was $1,916, comprising the costs for programming and
testing the survey, programming the bulk mailer program, and performing
limited manual data entry. If all respondents had completed the Web-based
survey successfully, the cost would have dropped by $206. Costs for an
equivalent mail survey are calculated both for a non-anonymous survey (our
case) and an anonymous survey. The two alternatives differ in their cost of
preparing and mailing surveys. In non-anonymous surveys, surveys are prepared
for and sent to non-respondents only after the initial mailing. Anonymous
surveys require that all participants receive the initial and all follow-up
mailings and are thus somewhat more expensive. We present different breakeven
calculations (see below) for these two options. If our survey had been administered as a mail survey, its total cost would
have been $3,092, including the cost of preparing 1,132 mailings, mailing
costs, postage for returned mailings, and data entry. The Web-survey was 38
percent cheaper than the equivalent (non-anonymous) mail survey. The figures
used for the calculations in Table
1 represent local costs for a mail survey of 450 individuals. In
other settings, costs might differ on the basis of factors such as sample
size, reproduction costs, study requirements, programming costs, and data
entry costs. Costs arising from handling technical problems for the Web-based
survey (e.g., responding to user questions) were disregarded, since the
required time was minimal and an improved design could have avoided most of
those problems. As Table 1 shows, the cost
of a Web-based survey is independent of the sample size, whereas the costs of
a mail survey vary with the initial sample size as well as with the
incremental and the total response rate. Avoiding manual entry of completed
surveys generated significant cost savings, a fact that has not been lost on
transaction-intensive industries such as airlines and banks. To assist others in choosing between Web-based and mail surveys on the
basis of cost (assuming that all other variables are equal), we use a standard
breakeven
calculation19 to
determine the sample size for which both types of surveys cost exactly the
same. This point is the threshold for which conducting one type of survey
becomes more cost-effective than the other. Equations 1 and 2 in Table 2
are used to calculate the breakeven point for non-anonymous and anonymous
surveys, respectively, when the incremental and/or the final response rates
can be estimated. When that is not possible, equations 3 and 4 can be used to
calculate lower and upper bounds for the breakeven point.
For the described survey, n would have been 245 under the
idealistic assumption that all respondents successfully answered the survey
through the Web. Even if the costs of entering of the surveys manually are
included, the breakeven point rises only to 274. Thus, with a sample size of
approximately 275 or below, a mail survey would have been more economical than
a Web-based survey. Equation 1 makes two assumptions of practical significance. First, it
assumes that exactly as many hardcopy surveys are prepared as needed. In
reality, this is rarely possible. Equation 1 thus will often reflect slightly
lower costs for a mail survey than are achievable, slanting the comparison in
favor of mail surveys. Second, it assumes that incremental and final response
rates can be estimated. When this is not possible, we can calculate a range
for the breakeven point by approximating the extreme values of equation 1
through equations 3 and 4. Using our costs, the lower bound for the breakeven
point would have been 190 and the upper bound 347. This means that for a
sample size of 189 or less, a mail survey would have been more economical, and
with a sample size of 348 or more, a Web-based survey. In between, the cost
advantage would have depended on the actual incremental and final response
rates. Equations 3 and 4 thus provide a useful heuristic for determining a
range for the breakeven point if basic costs for the two survey methods are
known. Comparison of Web and E-mail/Hardcopy Responses The goal of using a Web-based survey was to have all respondents complete
the questionnaire using the Web. However, we had to provide an alternative
method to avoid converting individuals with technical or user problems into
non-respondents. Once we allowed participants to answer the survey by e-mail
or fax, some may have chosen one of these methods based on personal preference
or convenience. The data were reviewed to discern potential patterns that
might distinguish Web from hardcopy respondents. Sixteen percent of the 334 respondents returned the completed survey by
e-mail or fax. Although no differentiation was made between e-mail and fax
responses, the majority were received by e-mail. America Online users
submitted 31 percent of the e-mail/fax responses and 12 percent of the Web
responses. E-mail messages about technical problems were received most
frequently from America Online users. Thus, at least some of the technical
problems were due to incompatibilities with America Online. One reason that
some AOL users were successful in submitting the survey through the Web may
have been their use of different versions of the AOL client software. Chi-squared tests (P = 0.05) were used to test for independence
between the type of response (either Web or e-mail/fax) and the following
variables: top-level domain of the participant (either com, net, or other);
self-reported computer experience (“not at all comfortable,”
“not very comfortable,” “comfortable,” “very
comfortable”); self-reported years of Internet experience (1, 2, 3, 4,
5, 6, >6); and, the number of fields left empty on the survey (<21,
21-25, 26-30). Self-reported computer experience showed a significant
relationship with the type of response (X2 = 10.3;
df = 2; P = 0.006), indicating that respondents more
comfortable with computers tended to be more successful in completing the Web
survey. Respondents answering the Web survey also tended to complete more
fields on the survey (X2 = 37.3; df = 2;
P = 0.001). The other two variables showed no relationship to the type of response.
Thus, two hypotheses for future studies could be that successful completion of
Web surveys is dependent on computer experience and that respondents to Web
surveys complete more questionnaire items than e-mail/hardcopy
respondents. Conclusion Several authors have proposed guidelines on how to conduct Web-based
surveys.11,13,17,18,20
However, few papers report the use of this method, and none describe its
procedural aspects in
detail.2,3,4,5
One primary reason that the Web is not used frequently for largescale or
general surveys may be that Web access is not a given. Although 19 percent of
households in the United States reported being online in 1997, not all members
of each household may use the
computer.21 Even in
a recent study, the first step in the survey was to find out whether
participants used the Internet or
not.17 Although
consumer research companies are beginning to tap AOL's 17 million users for
market research,22
it has not been proved that AOL's users are representative of the U.S.
population at large. Until the e-mail address becomes as widely used as the
postal address, large survey populations cannot be surveyed using the Web or
e-mail alone. As previously mentioned, some authors advocate publishing Web surveys
through newsgroups, indexes, and search
engines.13 However,
the resulting selection bias makes the results less valid and generalizable.
Where defined populations are accessible through the Internet, a Web-based
survey can be an effective method of gathering data using rigorous survey
methodologies. However, even a relatively large group of Internet users may
still represent a convenience sample that allows generalization to only that
group. Several authors have made recommendations for Web-survey
design.11,18
On the basis of our experiences in this case study, some additional
recommendations can be made:
This case study has shown that surveys administered through the Web can,
compared with mail surveys, potentially lower costs, reduce survey
administration overhead, and collect survey data quickly and efficiently.
However, it also confirms that a number of variables have the potential to
influence survey response and measurement negatively, such as incompatibility
with the target computing environment, survey usability, computer literacy of
participants, and program defects. In this case study, respondents to the Web
survey tended to complete more questionnaire items than respondents who used
e-mail or fax. Because of its potential impact on the quality of data
collection, this finding should be validated in future studies. Acknowledgments The authors thank Dr. R. Kenney, Dr. D. Dodell, and N. Dovgy for their help
in conducting this project, Dr. Sorin Straja for his help with the statistical
analysis, Ms. Syrene Miller for her assistance in the literature review, and
the reviewers for their helpful suggestions and comments. Notes This work was supported in part by grant T15-LM07059 from the National
Library of Medicine/National Institute of Dental and Craniofacial
Research. Footnotes *Spoofing is a common technique to fool hardware and software in networked
environments. Spoofing an e-mail address, for instance, makes a message appear
to be sent from someone else than the actual sender. References 1. Schleyer T, Forrest J, Kenney R, Dodell D, Dovgy N. Is the Internet
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orientation. Am J Public Health.
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death of dogs, using the Internet to survey small animal veterinarians.
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251-6. [PubMed] 5. Schleyer T, Spallek H, Torres-Urquidy MH. A profile of current
Internet users in dentistry. J Am Dent Assoc.
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1748-53. [PubMed] 6. Lakeman R. Using the Internet for data collection in nursing
research. Comput Nurs.
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269-75. [PubMed] 7. Fawcett J, Buhle EL Jr. Using the Internet for data collection: an
innovative electronic strategy. Comput Nurs.
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273-9. [PubMed] 8. Swoboda WJ, M lberger N, Weitkunat R,
Schneeweib S. Internet surveys by direct mailing. Soc Sci Comput
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American adults access the Internet/online services. Available at:
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J Am Vet Med Assoc. 1998 Jul 15; 213(2):251-6.
[J Am Vet Med Assoc. 1998]J Am Dent Assoc. 1998 Dec; 129(12):1748-53.
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[Comput Nurs. 1997]Comput Nurs. 1995 Nov-Dec; 13(6):273-9.
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[Comput Nurs. 1995]Can J Gastroenterol. 1999 May; 13(4):327-32.
[Can J Gastroenterol. 1999]Comput Nurs. 1995 Nov-Dec; 13(6):273-9.
[Comput Nurs. 1995]J Am Dent Assoc. 1998 Dec; 129(12):1748-53.
[J Am Dent Assoc. 1998]MD Comput. 1998 Mar-Apr; 15(2):116-20.
[MD Comput. 1998]MD Comput. 1998 Mar-Apr; 15(2):116-20.
[MD Comput. 1998]MD Comput. 1998 Mar-Apr; 15(2):116-20.
[MD Comput. 1998]J Am Vet Med Assoc. 1998 Jul 15; 213(2):251-6.
[J Am Vet Med Assoc. 1998]J Am Dent Assoc. 1998 Dec; 129(12):1748-53.
[J Am Dent Assoc. 1998]MD Comput. 1998 Mar-Apr; 15(2):116-20.
[MD Comput. 1998]