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Journal of Medical Internet Research

The leading peer-reviewed journal for digital medicine, and health & healthcare in the Internet age

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

Journal Description

The Journal of Medical Internet Research (JMIR), now in its' 20th year, is the pioneering open access eHealth journal, and is the flagship journal of JMIR Publications. It is the leading digital health journal, in terms of quality/visibility (Impact Factor 2016: 5.175, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now joined by almost 30 specialty JMIR sister journals, which have a broader scope (peer-review reports are portable across JMIR journals). 

As open access journal we are read by clinicians and patients alike and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    A Natural Language Processing System That Links Medical Terms in Electronic Health Record Notes to Lay Definitions: System Development Using Physician Reviews


    Background: Many health care systems now allow patients to access their electronic health record (EHR) notes online through patient portals. Medical jargon in EHR notes can confuse patients, which may interfere with potential benefits of patient access to EHR notes. Objective: The aim of this study was to develop and evaluate the usability and content quality of NoteAid, a Web-based natural language processing system that links medical terms in EHR notes to lay definitions, that is, definitions easily understood by lay people. Methods: NoteAid incorporates two core components: CoDeMed, a lexical resource of lay definitions for medical terms, and MedLink, a computational unit that links medical terms to lay definitions. We developed innovative computational methods, including an adapted distant supervision algorithm to prioritize medical terms important for EHR comprehension to facilitate the effort of building CoDeMed. Ten physician domain experts evaluated the user interface and content quality of NoteAid. The evaluation protocol included a cognitive walkthrough session and a postsession questionnaire. Physician feedback sessions were audio-recorded. We used standard content analysis methods to analyze qualitative data from these sessions. Results: Physician feedback was mixed. Positive feedback on NoteAid included (1) Easy to use, (2) Good visual display, (3) Satisfactory system speed, and (4) Adequate lay definitions. Opportunities for improvement arising from evaluation sessions and feedback included (1) improving the display of definitions for partially matched terms, (2) including more medical terms in CoDeMed, (3) improving the handling of terms whose definitions vary depending on different contexts, and (4) standardizing the scope of definitions for medicines. On the basis of these results, we have improved NoteAid’s user interface and a number of definitions, and added 4502 more definitions in CoDeMed. Conclusions: Physician evaluation yielded useful feedback for content validation and refinement of this innovative tool that has the potential to improve patient EHR comprehension and experience using patient portals. Future ongoing work will develop algorithms to handle ambiguous medical terms and test and evaluate NoteAid with patients.

  • Internet-based CBT for pediatric dental phobia. Source: Image created by the Authors; Copyright: Shervin Shahnavaz; URL:; License: Creative Commons Attribution (CC-BY).

    Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental Anxiety: Open Trial


    Background: Cognitive behavioral therapy (CBT) is an evidence-based method for treating specific phobias, but access to treatment is difficult, especially for children and adolescents with dental anxiety. Psychologist-guided Internet-based CBT (ICBT) may be an effective way of increasing accessibility while maintaining treatment effects. Objective: The aim of this study was to test the hypothesis that psychologist-guided ICBT improves school-aged children’s and adolescents’ ability to manage dental anxiety by (1) decreasing avoidance and affecting the phobia diagnosis and (2) decreasing the dental fear and increasing the target groups’ self-efficacy. The study also aimed to examine the feasibility and acceptability of this novel treatment. Methods: This was an open, uncontrolled trial with assessments at baseline, posttreatment, and the 1-year follow-up. The study enrolled and treated 18 participants. The primary outcome was level of avoidance behaviors, as measured by the picture-guided behavioral avoidance test (PG-BAT). The secondary outcome was a diagnostic evaluation with the parents conducted by a psychologist. The specific phobia section of the structured interview Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) was used. Other outcome measures included level of dental anxiety and self-efficacy. The ICBT, which employed exposure therapy, comprised 12 modules of texts, animations, dentistry-related video clips, and an exercise package (including dental instruments). Participants accessed the treatment through an Internet-based treatment platform and received Web-based guidance from a psychologist. Treatment also included training at dental clinics. Feasibility and acceptability were assessed by measures of engagement, adherence, compliance, completed measures, patient and parent satisfaction scale, and staff acceptability. Results: The level of avoidance (according to the primary outcome measure PG-BAT) and dental anxiety decreased and self-efficacy increased significantly (P<.001), within-group effect sizes for both the primary outcome (Cohen d=1.5), and other outcomes were large in the range of 0.9 and 1.5. According to K-SADS-PL, 53% (8/15) of the participants were free from diagnosable dental anxiety at the 1-year follow-up. At the 1-year follow-up, improvements were maintained and clinically significant, with 60% (9/15) of participants who had been unable to manage intraoral injection of local anesthetics before ICBT reporting having accomplished this task at a dental clinic. The target group showed improvement in all the outcome measures. High levels of feasibility and acceptability were observed for the treatment. Conclusions: ICBT is a promising and feasible treatment for dental anxiety in children and adolescents. Integrating it into routine pediatric dental care would increase access to an effective psychological treatment. The results of this open trial must be replicated in controlled studies.

  • Partners in Parenting (PiP) program, a tailored Web-based parenting intervention (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Tailored Web-Based Intervention to Improve Parenting Risk and Protective Factors for Adolescent Depression and Anxiety Problems: Postintervention Findings...


    Background: Depression and anxiety disorders in young people are a global health concern. Parents have an important role in reducing the risk of these disorders, but cost-effective, evidence-based interventions for parents that can be widely disseminated are lacking. Objective: This study aimed to examine the postintervention effects of the Partners in Parenting (PiP) program on parenting risk and protective factors for adolescent depression and anxiety, and on adolescent depression and anxiety symptoms. Methods: A two-arm randomized controlled trial was conducted with 359 parent-adolescent dyads, recruited primarily through schools across Australia. Parents and adolescents were assessed at baseline and 3 months later (postintervention). Parents in the intervention condition received PiP, a tailored Web-based parenting intervention designed following Persuasive Systems Design (PSD) principles to target parenting factors associated with adolescents’ risk for depression and anxiety problems. PiP comprises a tailored feedback report highlighting each parent’s strengths and areas for improvement, followed by a set of interactive modules (up to nine) that is specifically recommended for the parent based on individually identified areas for improvement. Parents in the active-control condition received a standardized package of five Web-based factsheets about adolescent development and well-being. Parents in both conditions received a 5-min weekly call to encourage progress through their allocated program to completion. Both programs were delivered weekly via the trial website. The primary outcome measure at postintervention was parent-reported changes in parenting risk and protective factors, which were measured using the Parenting to Reduce Adolescent Depression and Anxiety Scale (PRADAS). Secondary outcome measures were the adolescent-report PRADAS, the parent- and child-report Short Mood and Feelings Questionnaire (depressive symptoms), and parent- and child-report Spence Children’s Anxiety Scale (anxiety symptoms). Results: Parents in the intervention condition completed a mean of 73.7% of their intended personalized PiP program. A total of 318 parents (88.6%, 318/359) and 308 adolescents (92.8%, 308/332) completed the postintervention assessment. Attrition was handled using mixed model of repeated measures analysis of variance. As hypothesized, we found a significant condition-by-time interaction on the PRADAS, with a medium effect size, Cohen d=0.57, 95% CI 0.34-0.79. No significant differences between conditions were found at postintervention on any of the secondary outcome measures, with adolescent depressive (parent-report only) and anxiety (both parent- and adolescent-report) symptoms decreasing significantly from baseline to postintervention in both conditions. Conclusions: The fully automated PiP intervention showed promising short-term effects on parenting behaviors that are associated with adolescents’ risk for depression and anxiety. Long-term follow-up is required to ascertain whether these effects translate into reduced adolescent depression and anxiety problems. The intervention may be useful as a low-cost universal public health program to increase parenting practices believed to benefit adolescents’ mental health. Trial Registration: Australia New Zealand Clinical Trials Registry: ACTRN12615000328572; Trial/Registration/TrialReview.aspx? id=368274 (Archived by WebCite at

  • Source: Wikimedia Commons; Copyright: Walton LaVonda; URL:; License: Public Domain (CC0).

    Leveraging Social Networking Sites for an Autoimmune Hepatitis Genetic Repository: Pilot Study to Evaluate Feasibility


    Background: Conventional approaches to participant recruitment are often inadequate in rare disease investigation. Social networking sites such as Facebook may provide a vehicle to circumvent common research limitations and pitfalls. We report our preliminary experience with Facebook-based methodology for participant recruitment and participation into an ongoing study of autoimmune hepatitis (AIH). Objective: The goal of our research was to conduct a pilot study to assess whether a Facebook-based methodology is capable of recruiting geographically widespread participants into AIH patient-oriented research and obtaining quality phenotypic data. Methods: We established a Facebook community, the Autoimmune Hepatitis Research Network (AHRN), in 2014 to provide a secure and reputable distillation of current literature and AIH research opportunities. Quarterly advertisements for our ongoing observational AIH study were posted on the AHRN over 2 years. Interested and self-reported AIH participants were subsequently enrolled after review of study materials and completion of an informed consent by our study coordinator. Participants returned completed study materials, including epidemiologic questionnaires and genetic material, to our facility via mail. Outside medical records were obtained and reviewed by a study physician. Results: We successfully obtained all study materials from 29 participants with self-reported AIH within 2 years from 20 different states. Liver biopsy results were available for 90% (26/29) of participants, of which 81% (21/29) had findings consistent with AIH, 15% (4/29) were suggestive of AIH with features of primary biliary cholangitis (PBC), and 4% (1/29) had PBC alone. A total of 83% (24/29) had at least 2 of 3 proposed criteria: positive autoimmune markers, consistent histologic findings of AIH on liver biopsy, and reported treatment with immunosuppressant medications. Self-reported and physician records were discrepant for immunosuppressant medications or for AIH/PBC diagnoses in 4 patients. Conclusions: Facebook can be an effective ancillary tool for facilitating patient-oriented research in rare diseases. A social media-based approach transcends established limitations in rare disease research and can further develop research communities.

  • Source: Pixabay; Copyright: William Iven; URL:; License: Public Domain (CC0).

    Facebook Groups for the Management of Chronic Diseases


    The use of Facebook groups by health care researchers and professionals for chronic disease management, namely type 2 diabetes mellitus and coronary heart disease, is in its early stages and challenges are emerging. While Facebook groups offer great potential to deliver health support, research of Facebook groups for chronic disease management remains in its infancy, with robust evidence not yet available. Designing Facebook groups that are acceptable to users, health care researchers as well as health care professionals is a challenge, and there is a poor fit with traditional research and evaluation methods. Key recommendations for future research of Facebook groups for chronic disease management include: (1) iterative content development with input from the target patient population; (2) further understanding of the potential role of group “champions”; (3) ensuring the social media policies of health care institutions allow for real time online communication; and (4) utilizing comprehensive evaluation strategies, including the use of process evaluations.

  • Patient monitoring his blood pressure. Source: Pixabay; Copyright: Gerald Oswald; URL:; License: Public Domain (CC0).

    Evaluation Criteria of Noninvasive Telemonitoring for Patients With Heart Failure: Systematic Review


    Background: Telemonitoring can improve heart failure (HF) management, but there is no standardized evaluation framework to comprehensively evaluate its impact. Objective: Our objectives were to list the criteria used in published evaluations of noninvasive HF telemonitoring projects, describe how they are used in the evaluation studies, and organize them into a consistent scheme. Methods: Articles published from January 1990 to August 2015 were obtained through MEDLINE, Web of Science, and EMBASE. Articles were eligible if they were original reports of a noninvasive HF telemonitoring evaluation study in the English language. Studies of implantable telemonitoring devices were excluded. Each selected article was screened to extract the description of the telemonitoring project and the evaluation process and criteria. A qualitative synthesis was performed. Results: We identified and reviewed 128 articles leading to 52 evaluation criteria classified into 6 dimensions: clinical, economic, user perspective, educational, organizational, and technical. The clinical and economic impacts were evaluated in more than 70% of studies, whereas the educational, organizational, and technical impacts were studied in fewer than 15%. User perspective was the most frequently covered dimension in the development phase of telemonitoring projects, whereas clinical and economic impacts were the focus of later phases. Conclusions: Telemonitoring evaluation frameworks should cover all 6 dimensions appropriately distributed along the telemonitoring project lifecycle. Our next goal is to build such a comprehensive evaluation framework for telemonitoring and test it on an ongoing noninvasive HF telemonitoring project.

  • A patient presents a smartcard to a health worker. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria:...


    Background: Community-based strategies to test for HIV, hepatitis B virus (HBV), and sickle cell disease (SCD) have expanded opportunities to increase the proportion of pregnant women who are aware of their diagnosis. In order to use this information to implement evidence-based interventions, these results have to be available to skilled health providers at the point of delivery. Most electronic health platforms are dependent on the availability of reliable Internet connectivity and, thus, have limited use in many rural and resource-limited settings. Objective: Here we describe our work on the development and deployment of an integrated mHealth platform that is able to capture medical information, including test results, and encrypt it into a patient-held smartcard that can be read at the point of delivery without the need for an Internet connection. Methods: We engaged a team of implementation scientists, public health experts, and information technology specialists in a requirement-gathering process to inform the design of a prototype for a platform that uses smartcard technology, database deployment, and mobile phone app development. Key design decisions focused on usability, scalability, and security. Results: We successfully designed an integrated mHealth platform and deployed it in 4 health facilities across Benue State, Nigeria. We developed the Vitira Health platform to store test results of HIV, HBV, and SCD in a database, and securely encrypt the results on a Quick Response code embedded on a smartcard. We used a mobile app to read the contents on the smartcard without the need for Internet connectivity. Conclusions: Our findings indicate that it is possible to develop a patient-held smartcard and an mHealth platform that contains vital health information that can be read at the point of delivery using a mobile phone-based app without an Internet connection. Trial Registration: NCT03027258; (Archived by WebCite at

  • Source: Unsplash; Copyright: Ilya Pavlov; URL:; License: Public Domain (CC0).

    “Why Do They Need to Check Me?” Patient Participation Through eHealth and the Doctor-Patient Relationship: Qualitative Study


    Background: Roles in the doctor-patient relationship are changing and patient participation in health care is increasingly emphasized. Electronic health (eHealth) services such as patient accessible electronic health records (PAEHRs) have been implemented to support patient participation. Little is known about practical use of PAEHR and its effect on roles of doctors and patients. Objective: This qualitative study aimed to investigate how physicians view the idea of patient participation, in particular in relation to the PAEHR system. Hereby, the paper aims to contribute to a deeper understanding of physicians’ constructions of PAEHR, roles in the doctor-patient relationship, and levels and limits of involvement. Methods: A total of 12 semistructured interviews were conducted with physicians in different fields. Interviews were transcribed, translated, and a theoretically informed thematic analysis was performed. Results: Two important aspects were identified that are related to the doctor-patient relationship: roles and involvement. The physicians viewed their role as being the ones to take on the responsibility, determining treatment options, and to be someone who should be trusted. In relation to the patient’s role, lack of skills (technical or regarding medical jargon), motives to read, and patients’ characteristics were aspects identified in the interviews. Patients were often referred to as static entities disregarding their potential to develop skills and knowledge over time. Involvement captures aspects that support or hinder patients to take an active role in their care. Conclusions: Literature of at least two decades suggests an overall agreement that the paternalistic approach in health care is inappropriate, and a collaborative process with patients should be adopted. Although the physicians in this study stated that they, in principle, were in favor of patient participation, the analysis found little support in their descriptions of their daily practice that participation is actualized. As seen from the results, paternalistic practices are still present, even if professionals might not be aware of this. This can create a conflict between patients who strive to become more informed and their questions being interpreted as signs of critique and mistrust toward the physician. We thus believe that the full potential of PAEHRs is not reached yet and argue that the concept of patient empowerment is problematic as it triggers an interpretation of “power” in health care as a zero-sum, which is not helpful for the maintenance of the relationship between the actors. Patient involvement is often discussed merely in relation to decision making; however, this study emphasizes the need to include also sensemaking and learning activities. This would provide an alternative understanding of patients asking questions, not in terms of “monitoring the doctor” but to make sense of the situation.

  • Source: Flickr; Copyright: Cory Doctorow; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Exploring Entertainment Medicine and Professionalization of Self-Care: Interview Study Among Doctors on the Potential Effects of Digital Self-Tracking


    Background: Nowadays, digital self-tracking devices offer a plethora of possibilities to both healthy and chronically ill users who want to closely examine their body. This study suggests that self-tracking in a private setting will lead to shifting understandings in professional care. To provide more insight into these shifts, this paper seeks to lay bare the promises and challenges of self-tracking while staying close to the everyday professional experience of the physician. Objective: The aim of this study was to (1) offer an analysis of how medical doctors evaluate self-tracking methods in their practice and (2) explore the anticipated shifts that digital self-care will bring about in relation to our findings and those of other studies. Methods: A total of 12 in-depth semistructured interviews with general practitioners (GPs) and cardiologists were conducted in Flanders, Belgium, from November 2015 to November 2016. Thematic analysis was applied to examine the transcripts in an iterative process. Results: Four major themes arose in our body of data: (1) the patient as health manager, (2) health obsession and medicalization, (3) information management, and (4) shifting roles of the doctors and impact on the health care organization. Our research findings show a nuanced understanding of the potentials and pitfalls of different forms of self-tracking. The necessity of contextualization of self-tracking data and a professionalization of self-care through digital devices come to the fore as important overarching concepts. Conclusions: This interview study with Belgian doctors examines the potentials and challenges of self-monitoring while focusing on the everyday professional experience of the physician. The dialogue between our dataset and the existing literature affords a fine-grained image of digital self-care and its current meaning in a medical-professional landscape.

  • Source:; Copyright: picjumbo_com; URL:; License: Public Domain (CC0).

    Turning Good Intentions Into Actions by Using the Health Action Process Approach to Predict Adherence to Internet-Based Depression Prevention: Secondary...


    Background: Many individuals engaging in Internet-based interventions fail to complete these treatments as intended. The processes responsible for treatment adherence in Internet-based interventions are still poorly understood. Objective: The aim of this study was to investigate to what extent adherence in an Internet-based intervention can be predicted by motivational and volitional factors outlined in the health action process approach (HAPA). Methods: This study investigated motivational and volitional factors included in HAPA in a randomized controlled trial to predict treatment adherence of N=101 individuals with subclinical depression in the intervention group of a depression prevention intervention (GET.ON Mood Enhancer). Adherence was operationalized as the number of completed treatment modules. Using longitudinal structural equation modeling, HAPA variables (motivational, maintenance, and recovery self-efficacy, outcome expectancies, intention, and planning) were assessed at baseline and their associations with adherence 7 weeks later. Results: Planning predicted adherence. Better planning was, in turn, associated with higher levels of maintenance self-efficacy, and the latter significantly affected treatment adherence via planning. The other hypothesized direct associations were not significant. In total, the HAPA variables accounted for 14% of variance in treatment adherence. Conclusions: Planning emerged as the strongest predictor of treatment adherence in highly motivated participants in an Internet-based intervention out of all HAPA variables investigated. Findings are in line with the hypothesis that planning facilitates the translation of good intentions into actions. The findings imply that systematically fostering planning skills and maintenance self-efficacy prior to or during Internet-based interventions would help participants to successfully complete these treatments. Trial Registration: German Clinical Trials Register DRKS00005973; navigationId=trial.HTML&TRIAL_ID=DRKS00005973 (Archived by WebCite at

  • Homepage of isafe (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Efficacy of a Web-Based Safety Decision Aid for Women Experiencing Intimate Partner Violence: Randomized Controlled Trial


    Background: Intimate partner violence (IPV) is a human rights violation and leading health burden for women. Safety planning is a hallmark of specialist family violence intervention, yet only a small proportion of women access formal services. A Web-based safety decision aid may reach a wide audience of women experiencing IPV and offer the opportunity to prioritize and plan for safety for themselves and their families. Objective: The aim of this study was to test the efficacy of a Web-based safety decision aid (isafe) for women experiencing IPV. Methods: We conducted a fully automated Web-based two-arm parallel randomized controlled trial (RCT) in a general population of New Zealand women who had experienced IPV in the past 6 months. Computer-generated randomization was based on a minimization scheme with stratification by severity of violence and children. Women were randomly assigned to the password-protected intervention website (safety priority setting, danger assessment, and tailored action plan components) or control website (standard, nonindividualized information). Primary endpoints were self-reported mental health (Center for Epidemiologic Studies Depression Scale-Revised, CESD-R) and IPV exposure (Severity of Violence Against Women Scale, SVAWS) at 12-month follow-up. Analyses were by intention to treat. Results: Women were recruited from September 2012 to September 2014. Participants were aged between 16 and 60 years, 27% (111/412) self-identified as Māori (indigenous New Zealand), and 51% (210/412) reported at baseline that they were unsure of their future plans for their partner relationship. Among the 412 women recruited, retention at 12 months was 87%. The adjusted estimated intervention effect for SVAWS was −12.44 (95% CI −23.35 to −1.54) for Māori and 0.76 (95% CI −5.57 to 7.09) for non-Māori. The adjusted intervention effect for CESD-R was −7.75 (95% CI −15.57 to 0.07) for Māori and 1.36 (−3.16 to 5.88) for non-Māori. No study-related adverse events were reported. Conclusions: The interactive, individualized Web-based isafe decision aid was effective in reducing IPV exposure limited to indigenous Māori women. Discovery of a treatment effect in a population group that experiences significant health disparities is a welcome, important finding. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000708853; (Archived by Webcite at http://www.webcitation/61MGuVXdK)

  • Source: Flickr; Copyright: Cory M Grenier; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Identifying Opinion Leaders to Promote Organ Donation on Social Media: Network Study


    Background: In the recent years, social networking sites (SNSs, also called social media) have been adopted in organ donation campaigns, and recruiting opinion leaders for such campaigns has been found effective in promoting behavioral changes. Objective: The aim of this paper was to focus on the dissemination of organ donation tweets on Weibo, the Chinese equivalent of Twitter, and to examine the opinion leadership in the retweet network of popular organ donation messages using social network analysis. It also aimed to investigate how personal and social attributes contribute to a user’s opinion leadership on the topic of organ donation. Methods: All messages about organ donation posted on Weibo from January 1, 2015 to December 31, 2015 were extracted using Python Web crawler. A retweet network with 505,047 nodes and 545,312 edges of the popular messages (n=206) was constructed and analyzed. The local and global opinion leaderships were measured using network metrics, and the roles of personal attributes, professional knowledge, and social positions in obtaining the opinion leadership were examined using general linear model. Results: The findings revealed that personal attributes, professional knowledge, and social positions predicted individual’s local opinion leadership in the retweet network of popular organ donation messages. Alternatively, personal attributes and social positions, but not professional knowledge, were significantly associated with global opinion leadership. Conclusions: The findings of this study indicate that health campaign designers may recruit peer leaders in SNS organ donation promotions to facilitate information sharing among the target audience. Users who are unverified, active, well connected, and experienced with information and communications technology (ICT) will accelerate the sharing of organ donation messages in the global environment. Medical professionals such as organ transplant surgeons who can wield a great amount of influence on their direct connections could also effectively participate in promoting organ donation on social media.

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  • Trigger tool based automated adverse event detection in electronic health records: a systematic review

    Date Submitted: Jan 22, 2018

    Open Peer Review Period: Jan 22, 2018 - Mar 19, 2018

    Background: Adverse events (AEs) in healthcare entail substantial burdens to healthcare systems, institutions, and patients. Retrospective trigger tools are often manually applied to detect AEs, altho...

    Background: Adverse events (AEs) in healthcare entail substantial burdens to healthcare systems, institutions, and patients. Retrospective trigger tools are often manually applied to detect AEs, although automated approaches using electronic health records (EHRs) may offer real-time AE detection, allowing timely corrective interventions. Objective: This systematic review aimed to describe current study methods and challenges regarding the use of automatic trigger tool-based AE detection methods in EHRs. In addition, we aimed to appraise the applied studies’ designs and to synthesize estimates of AE prevalence and diagnostic test accuracy (DTA) of automatic detection methods, using manual trigger tool as a reference standard. Methods: PubMed, Embase, CINAHL, and the Cochrane Library were queried. We included observational studies applying trigger tools in acute care settings, and excluded studies using non-hospital and outpatient settings. Eligible articles were divided into DTA studies and prevalence studies. We derived the study prevalence and estimates for the positive predictive value (PPV). We assessed bias risks and applicability concerns using QUADAS-2 for DTA studies and an in-house developed tool for prevalence studies. Results: Eleven studies met all criteria: two concerned DTA, nine prevalence. We judged several studies to be at high bias risks for their automated detection method, definition of outcomes, and type of statistical analyses. Across all the eleven studies, AE prevalence ranged from 0 to 17.9%, with a median of 0.8%. The PPV of all triggers to detect AEs ranged from 0% to 100% across studies, with a median of 40%. Some triggers had wide ranging PPV values: 1) in six studies, hypoglycaemia had a PPV ranging from 15.8% to 60%; 2) in five studies, naloxone had a PPV from 20% to 91%; 3) in four studies, flumazenil had a PPV ranging from 38.9% to 83.3%; and 4) in four studies, protamine had a PPV ranging from 0% to 60%. We were unable to determine the AE prevalence, PPV, preventability, and severity in 40.4%, 10.5%, 71.1%, and 68.4% of the studies, respectively. These studies did not report the overall number of records analysed, triggers, or AEs; or the studies did not conduct the analysis. Conclusions: We observed broad inter-study variation in reported AE prevalence and PPV. The lack of sufficiently described methods led to difficulties regarding interpretation. To improve quality, we see the need for a set of recommendations to endorse optimal use of research designs and adequate reporting of future AE detection studies.

  • Perceived Attitudes About Substance Use in Anonymous Social Media Posts Near College Campuses

    Date Submitted: Jan 21, 2018

    Open Peer Review Period: Jan 22, 2018 - Mar 19, 2018

    Background: Substance use is a major issue for adolescents and young adults, particularly college students. With the importance of peer influence, as well as the ubiquitous use of social media among t...

    Background: Substance use is a major issue for adolescents and young adults, particularly college students. With the importance of peer influence, as well as the ubiquitous use of social media among these age groups, it is important to assess what about substance use is discussed on social media. One particular mobile application (Yik Yak) allowed users to post anonymously to nearby persons, often in areas with close proximity to major colleges and universities. Objective: The current study describes social media discussions that occurred near college campuses and involved substances. The authors hypothesized that posts about one’s own substance use would display a more positive attitude toward the substance mentioned, compared to posts about other’s use. Methods: Four hundred and ninety-three posts about drugs and alcohol on Yik Yak were reviewed and coded for their content, as well as the poster’s attitude about the substance. Results: Alcohol (226/493; 45.8%), marijuana (206/493; 41.8%), and tobacco (67/493; 13%) were the most frequently mentioned substances. Posts about use (442/493) were generally positive toward the substance mentioned (262/442; 59.3%), unless the post was about abstinence. Additionally, posts that commented on the substance use of others tended to be less positive (18/92; 19.6% positive) compared to posts about one’s own use (132/202; 65.3% positive). Conclusions: This study provides a description of anonymous discussions on or near college campuses about drugs and alcohol, which serves as an example of data that can be examined from social media sites for further research and prevention campaigns.

  • Title: Playing Telephone: Understanding the state of medication decision making in growing healthcare teams in the time of electronic health records

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: Primary care needs to be patient-centred, integrated and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing pro...

    Background: Primary care needs to be patient-centred, integrated and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, there is increasing attention on how and when medication-related decisions should be coordinated across multi-disciplinary care teams. Improved knowledge on how integrated EHRs can support interprofessional shared decision-making for medication therapy management is necessary to continue to improve patient care. Objective: This objective of this study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of electronic health records. Methods: This study is part of a broader cross-Canada study between patients and health care providers around how health-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Semi-structured interviews were conducted with physician and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data. Results: Data was collected at 19 pharmacies and 9 medical clinics and we identified six main themes from 34 health care professionals. Interprofessional Shared Decision Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care further compounded by electronic health records not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician/Pharmacist Relationship which was often predicated by co-location. Conclusions: When managing medications, there was limited communication and collaboration between primary care providers and pharmacists. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management, so that pharmacists and physicians move beyond task-based work toward a collaborative approach Clinical Trial: n/a

  • Social processes of online empowerment on a cancer patient discussion form: using text mining to analyze linguistic patterns of empowerment processes

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: Peer-to-peer online support groups and the discussion forums in these groups can help patients by providing opportunities for increasing their empowerment. Most previous research on online...

    Background: Peer-to-peer online support groups and the discussion forums in these groups can help patients by providing opportunities for increasing their empowerment. Most previous research on online empowerment and online social support uses qualitative methods, or questionnaires to gain insight into the dynamics of online empowerment processes. Objective: The overall goal of this study was to analyze the presence of the empowering processes in the online communication of people affected by cancer, using text mining techniques. Use of these relatively new methods enable to study social processes such as empowerment on large scale and with unsolicited data, avoiding unintended biases caused by research tools. Methods: The sample consisted of 5534 messages in 1708 threads by 2071 by users of a forum for cancer patients and their relatives. Supervised and unsupervised text mining techniques were used to explore the online communication of the users. Supervised text mining techniques were applied to operationalize empowerment: a random subsample of 2051 messages in the forum was manually labeled with five empowerment processes (sharing narrative, asking a question, providing information, emotional support, reference to information), using a coding scheme based on knowledge from previous research. Machine learning classifiers (Linear Support Vector Classification and Logistic regression) were then trained on the content of the messages with their manually assigned labels and the remainder of the sample was automatically labeled with empowerment processes using the generated model. For the unsupervised part, the messages in the sample were automatically labeled with categories from the Linguistic Inquiry and Word Count (LIWC). Subsequently, the supervised and unsupervised data were studied in conjunction. Empowerment was studied in relation to the intensity of online participation in relation to the LIWC categories. Results: The precision of the automatic labeling was 85.6%, which was considered to be sufficient for automatically labeling the complete corpus and doing further analyses on the labeled data. 62.9% of the messages contained a narrative, 23.8% a question, and 27.5% informational support. Emotional support and references to external sources were less frequent. Users with more posts more often referred to an external source, provided informational support, and emotional support (Kendall τ > 0.2, p < 0.001) and less often shared narratives (Kendall τ = -0.297, p < 0.001). A number of LIWC categories are significant predictors for the empowerment processes. Words expressing assent (‘ok’, ‘yes’) and emotional processes (expressions of feelings) are significant positive predictors for emotional support (p = 0.002). Conclusions: Empowerment processes are associated with intensity of online use. The relation between linguistic analyses and empowerment processes indicates that empowerment processes can be identified from the occurrences of specific linguistic cues.

  • Video outpatient consultations: a case study of real-world implementation at macro, meso and micro level

    Date Submitted: Jan 20, 2018

    Open Peer Review Period: Jan 20, 2018 - Jan 29, 2018

    Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe and effective in selected conditi...

    Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe and effective in selected conditions and circumstances. But this service model has rarely been mainstreamed and sustained in real-world settings. Objective: To a) define good practice and inform implementation of video outpatient consultations, and b) generate transferable new knowledge about challenges to scaling up and routinizing this service model. Methods: Multi-level mixed-method study of Skype™ video consultations (micro-level) embedded in an organizational case study (meso-level), taking account of national context and wider influences (macro-level). The study followed the introduction of video outpatient consultations in three clinical services (Diabetes, Diabetes Antenatal, Cancer Surgery) in a National Health Service acute trust (covering three hospitals) in London, UK. Data sources included 36 national-level stakeholders (exploratory and semi-structured interviews); longitudinal organizational ethnography (300 hours of observations; 24 staff interviews); 30 videotaped remote consultations; 17 audiotaped face-to-face consultations; and national and local documents. Data were analysed using sociotechnical change theories and the Roter Interactional Analysis System. Quantitative data included uptake of video consultations by staff and patients and micro-categorization of different kinds of talk. Qualitative data addressed staff and patient experience and organizational and system drivers. Results: When clinical, technical and practical preconditions were met, video consultations in this setting appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter; patients did slightly more talking; and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when clinician and patient already knew and trusted each other. Some clinicians used Skype™ adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2 and 22 percent of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate or video consultations were considered impractical, technically unachievable or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Conclusions: Video outpatient consultations appear safe, effective and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily while others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially at a time of austerity. Clinical Trial: Not applicable.

  • Behind the scenes of online therapeutic feedback in blended therapy for depression: a mixed methods observational study

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 19, 2018 - Jan 27, 2018

    Background: In internet-delivered cognitive-behavioral therapies (iCBT), written feedback by therapists is a substantial part of therapy. However, it is not yet known how this feedback should be given...

    Background: In internet-delivered cognitive-behavioral therapies (iCBT), written feedback by therapists is a substantial part of therapy. However, it is not yet known how this feedback should be given best and which specific therapist behaviors and content are most beneficial for patients. General instructions for written feedback are available, but the uptake and effectiveness of these instructions in iCBT have not been studied yet. Objective: To identify therapist behaviors in written online communication to patients in blended CBT for adult depression in routine secondary mental health care; to identify the extent to which the therapists adhere to feedback instructions; and to explore whether therapist behaviors and adherence to feedback instructions are associated with patient outcome. Methods: Adults receiving blended CBT for depression in routine mental health care were recruited in the context of the European implementation project MasterMind. A qualitative content analysis was used to identify therapist behaviors in online written feedback messages, and a checklist for the feedback instruction adherence of the therapists was developed. Correlations were explored between the therapist behaviors, therapist instruction adherence, and patient outcomes (number of completed online sessions and symptom change scores). Results: 45 patients received 219 feedback messages given by 19 therapists. The most frequently used therapist behaviors were informing, encouraging and affirming. However, these were not related to patient outcomes. Although infrequently used, confronting was positively correlated with session completion (r=.342, P=.02). Therapists adhered to most of the feedback instructions. Only two feedback aspects were correlated with session completion: The more therapists adhere to instructions containing structure (limiting to two subjects and sending feedback within three working days) and readability (short sentences and short paragraphs) the less online sessions were completed (r=-.340, P=.02 and r=-.361, P=.02 respectively). No associations were found with depression symptom change scores. Conclusions: The therapist behaviors found in this study are comparable to previous research. The findings suggest that online feedback instructions for therapists provide sufficient guidance to communicate in a supportive and positive manner with patients. However, the instructions might be improved by adding more ‘therapeutic’ techniques besides the focus on style and form.