Journal of Medical Internet Research

The leading peer-reviewed journal for health and healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 3.4 for 2014

Unpacking the black box of text messages in mobile health interventions: A formative research approach to the development of theory-driven, evidence-based, and culturally safe messages

Background: Mobile-cellular subscriptions have increased steadily over the past. The accessibility of SMS messages over existing mobile networks is high and has almost universal availability even on older and unsophisticated mobile phones and in geographic settings where wireless coverage is weak. There is intensive exploration of this inexpensive mobile telecommunication technology to improve health services and promote behaviour change among vulnerable populations. However, a neglected area of research is the documentation and critical analysis of this formative research process required in the development and refinement of effective SMS messages. Objective: We address this gap in the literature by reporting on our formative research project on the development and refinement of SMS messages for an international research project designed to address health inequalities in hypertension called DREAM-GLOBAL. This paper describes our research to develop evidence-based health knowledge in SMS messages, their theoretical grounding in health behaviour theory and the cultural mediators of meaning that had to be considered to ensure optimal effectiveness of the transmission of the content of messages to the target population. Methods: Qualitative research with the target populations was conducted to deconstruct the content and to study the transmission of evidence-based health knowledge contained in DREAM-GLOBAL SMS messages and to develop a grounded theory of the major factors that may impact on the effectiveness of this communication. We also examined how advice in each message impacts on the three essential conditions (capability, opportunity, and motivation) of the behaviour system of the Behavioural Change Wheel and on cultural safety. Results: Four focus groups with 45 participants were conducted. Our grounded theory research involving Indigenous people from Canada and Tanzania revealed how differences develop between the evidence-based message created by researchers and the message received by the recipient in mobile health interventions. These differences were primarily generated by six mediators of meaning in SMS messages: (1) clarity and practicality of content; (2) framing of advocacies (positive or negative); (3) fear or stress inducing content; (4) oppressive or authoritarian content; (5) congruency with cultural and traditional practices and (6) fit with the reality of SDOH and especially diversity of cultures. The six mediators of meaning impact directly on of the necessary conditions of behaviour of the BCW. Conclusions: Our research underscores the urgent need for mobile health interventions to incorporate and evaluate the quality of SMS messages and to examine the mediators of meaning within each cultural and demographic target group, because the quality of text messages impact significantly on the effectiveness of a text message-based health intervention. Reporting the formative research will allow more transparent research in mobile health interventions and allow researchers in the field to move away from the current back box of SMS text message development.

2015-07-04

Thomson Reuters has published the Journal Citation Reports (JCR) with its Journal Impact Factors for 2015. The Journal Impact Factor 2015 is defined as the number of citations in 2014 to the citations to articles published in the previous 2 years (2012-2013), divided by the number of articles published during that time. The Journal Impact Factor is a metric of excellence for a journal, it is not an article-level metric.

The Impact Factor is an increasingly controversial metric due its frequent misuse, e.g. administrators comparing the "raw" impact factor score across disciplines. This disadvantages journals in smaller disciplines such as medical informatics, which traditionally have less citations than for example multidisciplinary or general medicine journals. As one innovation, Thomson Reuters is now ranking journals by quartile (Q1, Q2, Q3, Q4), within their discipline.

While we at JMIR discourage obsession over the journal impact factor (in particular if abused as proxy to assess the quality of individual articles), our ranking in the JCR is an important validation that even as small open access publisher we can compete with journals published by publishing giants.

JMIR continues to be ranked in the first quartile (Q1) in both of it's disciplines, medical informatics (Q1) and health services research (Q1).

However, even these category-specific rankings are sometimes questionable, in particular for multidisciplinary journals such as JMIR which fit into more than the categories selected by the JCR editors. Moreover, the current JCR categories sometimes lump together journals which do not belong together, for example statistics journals are part of the medical informatics category, and oddly enough, the journal Statistical Methods in Medical Research is now suddenly the top-ranked journal in the medical informatics category.

It may therefore make more sense to compare JMIR against other leading multidisciplinary open access journals, as shown below. However, once again, the impact factor should not be the only determining factor when submitting an article. The journal scope and audience (who reads the journal) are equally important if one wants to maximize impact and influence of an article on key stakeholders and researchers, which is not measurable by citations (perhaps better measured with social media uptake and altmetrics).

We continue to encourage our authors to consider the full range of JMIR journals when submitting an article and consider the scope of the journal and the topic of the article.

Quiz: Which of the following #openaccess journals has the highest impact factor:

1) PloS One,

2) PeerJ,

3) BMC MDM,

4) BMJ Open,

5) JMIR 

(scroll down for the answer)

Journal Quartile (in their category)   Impact Factor 2015
1. JMIR Q1, Q1 3.428
2. PloS One Q1 3.234
3. BMJ Open Q2 2.271
4. PeerJ Q1 2.112
5. BMC Med Inform Med Dec Mk Q2 1.830

Beyond the Journal Impact Factor

Authors care (and should care) about other metrics/ratings such as author satisfaction with reviews and turnaround times, as for example evaluated by SciRevJMIR is ranked highly here as well (compare for example against PlosOne ratings).

scirev ranking of JMIR vs PlosOne

Other metrics to look at are the twimpact factor (social media impact) as well as post-publication dissemination activies by the publisher (JMIR is using TrendMD to promote published articles across other publishers such as BMJ and the JAMA network).

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  • This image was purchased from Shutterstock. Image ID: 94930510 Copyright: Maryna Pleshkun.

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  • Screenshot of the Bite Back website.

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  • Photoaged image of a 17 year old woman showing the consequences of smoking one pack a day for one year (vs. non-smoking).

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    Abstract:

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    Abstract:

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  • (cc) Frederix et al. CC-BY-SA-2.0, please cite as (http://www.jmir.org/article/viewFile/4799/1/62062).

    Medium-Term Effectiveness of a Comprehensive Internet-Based and Patient-Specific Telerehabilitation Program With Text Messaging Support for Cardiac Patients:...

    Abstract:

    Background: Cardiac telerehabilitation has been introduced as an adjunct or alternative to conventional center-based cardiac rehabilitation to increase its long-term effectiveness. However, before large-scale implementation and reimbursement in current health care systems is possible, well-designed studies on the effectiveness of this new additional treatment strategy are needed. Objective: The aim of this trial was to assess the medium-term effectiveness of an Internet-based, comprehensive, and patient-tailored telerehabilitation program with short message service (SMS) texting support for cardiac patients. Methods: This multicenter randomized controlled trial consisted of 140 cardiac rehabilitation patients randomized (1:1) to a 24-week telerehabilitation program in combination with conventional cardiac rehabilitation (intervention group; n=70) or to conventional cardiac rehabilitation alone (control group; n=70). In the telerehabilitation program, initiated 6 weeks after the start of ambulatory rehabilitation, patients were stimulated to increase physical activity levels. Based on registered activity data, they received semiautomatic telecoaching via email and SMS text message encouraging them to gradually achieve predefined exercise training goals. Patient-specific dietary and/or smoking cessation advice was also provided as part of the telecoaching. The primary endpoint was peak aerobic capacity (VO2 peak). Secondary endpoints included accelerometer-recorded daily step counts, self-assessed physical activities by International Physical Activity Questionnaire (IPAQ), and health-related quality of life (HRQL) assessed by the HeartQol questionnaire at baseline and at 6 and 24 weeks. Results: Mean VO2 peak increased significantly in intervention group patients (n=69) from baseline (mean 22.46, SD 0.78 mL/[min*kg]) to 24 weeks (mean 24.46, SD 1.00 mL/[min*kg], P<.01) versus control group patients (n=70), who did not change significantly (baseline: mean 22.72, SD 0.74 mL/[min*kg]; 24 weeks: mean 22.15, SD 0.77 mL/[min*kg], P=.09). Between-group analysis of aerobic capacity confirmed a significant difference between the intervention group and control group in favor of the intervention group (P<.001). At 24 weeks, self-reported physical activity improved more in the intervention group compared to the control group (P=.01) as did the global HRQL score (P=.01). Conclusions: This study showed that an additional 6-month patient-specific, comprehensive telerehabilitation program can lead to a bigger improvement in both physical fitness (VO2 peak) and associated HRQL compared to center-based cardiac rehabilitation alone. These results are supportive in view of possible future implementation in standard cardiac care.

  • This image is from the public domain.

    Online Recruitment Methods for Web-Based and Mobile Health Studies: A Review of the Literature

    Abstract:

    Background: Internet and mobile health (mHealth) apps hold promise for expanding the reach of evidence-based health interventions. Research in this area is rapidly expanding. However, these studies may experience problems with recruitment and retention. Web-based and mHealth studies are in need of a wide-reaching and low-cost method of recruitment that will also effectively retain participants for the duration of the study. Online recruitment may be a low-cost and wide-reaching tool in comparison to traditional recruitment methods, although empirical evidence is limited. Objective: This study aims to review the literature on online recruitment for, and retention in, mHealth studies. Methods: We conducted a review of the literature of studies examining online recruitment methods as a viable means of obtaining mHealth research participants. The data sources used were PubMed, CINAHL, EbscoHost, PyscINFO, and MEDLINE. Studies reporting at least one method of online recruitment were included. A narrative approach enabled the authors to discuss the variability in recruitment results, as well as in recruitment duration and study design. Results: From 550 initial publications, 12 studies were included in this review. The studies reported multiple uses and outcomes for online recruitment methods. Web-based recruitment was the only type of recruitment used in 67% (8/12) of the studies. Online recruitment was used for studies with a variety of health domains: smoking cessation (58%; 7/12) and mental health (17%; 2/12) being the most common. Recruitment duration lasted under a year in 67% (8/12) of the studies, with an average of 5 months spent on recruiting. In those studies that spent over a year (33%; 4/12), an average of 17 months was spent on recruiting. A little less than half (42%; 5/12) of the studies found Facebook ads or newsfeed posts to be an effective method of recruitment, a quarter (25%; 3/12) of the studies found Google ads to be the most effective way to reach participants, and one study showed better outcomes with traditional (eg in-person) methods of recruitment. Only one study recorded retention rates in their results, and half (50%; 6/12) of the studies recorded survey completion rates. Conclusions: Although online methods of recruitment may be promising in experimental research, more empirical evidence is needed to make specific recommendations. Several barriers to using online recruitment were identified, including participant retention. These unique challenges of virtual interventions can affect the generalizability and validity of findings from Web-based and mHealth studies. There is a need for additional research to evaluate the effectiveness of online recruitment methods and participant retention in experimental mHealth studies.

  • (c) Care Innovations.

    Overcoming Clinical Inertia: A Randomized Clinical Trial of a Telehealth Remote Monitoring Intervention Using Paired Glucose Testing in Adults With Type 2...

    Abstract:

    Background: Type 2 diabetes mellitus is a worldwide challenge. Practice guidelines promote structured self-monitoring of blood glucose (SMBG) for informing health care providers about glycemic control and providing patient feedback to increase knowledge, self-efficacy, and behavior change. Paired glucose testing—pairs of glucose results obtained before and after a meal or physical activity—is a method of structured SMBG. However, frequent access to glucose data to interpret values and recommend actions is challenging. A complete feedback loop—data collection and interpretation combined with feedback to modify treatment—has been associated with improved outcomes, yet there remains limited integration of SMBG feedback in diabetes management. Incorporating telehealth remote monitoring and asynchronous electronic health record (EHR) feedback from certified diabetes educators (CDEs)—specialists in glucose pattern management—employ the complete feedback loop to improve outcomes. Objective: The purpose of this study was to evaluate a telehealth remote monitoring intervention using paired glucose testing and asynchronous data analysis in adults with type 2 diabetes. The primary aim was change in glycated hemoglobin (A1c)—a measure of overall glucose management—between groups after 6 months. The secondary aims were change in self-reported Summary of Diabetes Self-Care Activities (SDSCA), Diabetes Empowerment Scale, and Diabetes Knowledge Test. Methods: A 2-group randomized clinical trial was conducted comparing usual care to telehealth remote monitoring with paired glucose testing and asynchronous virtual visits. Participants were aged 30-70 years, not using insulin with A1c levels between 7.5% and 10.9% (58-96 mmol/mol). The telehealth remote monitoring tablet computer transmitted glucose data and facilitated a complete feedback loop to educate participants, analyze actionable glucose data, and provide feedback. Data from paired glucose testing were analyzed asynchronously using computer-assisted pattern analysis and were shared with patients via the EHR weekly. CDEs called participants monthly to discuss paired glucose testing trends and treatment changes. Separate mixed-effects models were used to analyze data. Results: Participants (N=90) were primarily white (64%, 56/87), mean age 58 (SD 11) years, mean body mass index 34.1 (SD 6.7) kg/m2, with diabetes for mean 8.2 (SD 5.4) years, and a mean A1c of 8.3% (SD 1.1; 67 mmol/mol). Both groups lowered A1c with an estimated average decrease of 0.70 percentage points in usual care group and 1.11 percentage points in the treatment group with a significant difference of 0.41 percentage points at 6 months (SE 0.08, t159=–2.87, P=.005). Change in medication (SE 0.21, t157=–3.37, P=.009) was significantly associated with lower A1c level. The treatment group significantly improved on the SDSCA subscales carbohydrate spacing (P=.04), monitoring glucose (P=.001), and foot care (P=.02). Conclusions: An eHealth model incorporating a complete feedback loop with telehealth remote monitoring and paired glucose testing with asynchronous data analysis significantly improved A1c levels compared to usual care. Trial Registration: Clinicaltrials.gov NCT01715649; https://www.clinicaltrials.gov/ct2/show/NCT01715649 (Archived by WebCite at http://www.webcitation.org/6ZinLl8D0).

  • Source:  Tony Alter, https://www.flickr.com/photos/78428166@N00/3872155588. Licensed under cc-by 2.0.

    Evaluation of Internet-Based Interventions on Waist Circumference Reduction: A Meta-Analysis

    Abstract:

    Background: Internet-based interventions are more cost-effective than conventional interventions and can provide immediate, easy-to-access, and individually tailored support for behavior change. Waist circumference is a strong predictor of an increased risk for a host of diseases, such as hypertension, diabetes, and dyslipidemia, independent of body mass index. To date, no study has examined the effect of Internet-based lifestyle interventions on waist circumference change. Objective: This study aimed to systematically review the effect of Internet-based interventions on waist circumference change among adults. Methods: This meta-analysis reviewed randomized controlled trials (N=31 trials and 8442 participants) that used the Internet as a main intervention approach and reported changes in waist circumference. Results: Internet-based interventions showed a significant reduction in waist circumference (mean change –2.99 cm, 95% CI −3.68 to −2.30, I2=93.3%) and significantly better effects on waist circumference loss (mean loss 2.38 cm, 95% CI 1.61-3.25, I2=97.2%) than minimal interventions such as information-only groups. Meta-regression results showed that baseline waist circumference, gender, and the presence of social support in the intervention were significantly associated with waist circumference reduction. Conclusions: Internet-based interventions have a significant and promising effect on waist circumference change. Incorporating social support into an Internet-based intervention appears to be useful in reducing waist circumference. Considerable heterogeneity exists among the effects of Internet-based interventions. The design of an intervention may have a significant impact on the effectiveness of the intervention.

  • EBM library guide. Screenshot of http://guides.lib.monash.edu/c.php?g=219702&p=1452686.

    A Cost-Effectiveness Analysis of Blended Versus Face-to-Face Delivery of Evidence-Based Medicine to Medical Students

    Abstract:

    Background: Blended learning describes a combination of teaching methods, often utilizing digital technologies. Research suggests that learner outcomes can be improved through some blended learning formats. However, the cost-effectiveness of delivering blended learning is unclear. Objective: This study aimed to determine the cost-effectiveness of a face-to-face learning and blended learning approach for evidence-based medicine training within a medical program. Methods: The economic evaluation was conducted as part of a randomized controlled trial (RCT) comparing the evidence-based medicine (EBM) competency of medical students who participated in two different modes of education delivery. In the traditional face-to-face method, students received ten 2-hour classes. In the blended learning approach, students received the same total face-to-face hours but with different activities and additional online and mobile learning. Online activities utilized YouTube and a library guide indexing electronic databases, guides, and books. Mobile learning involved self-directed interactions with patients in their regular clinical placements. The attribution and differentiation of costs between the interventions within the RCT was measured in conjunction with measured outcomes of effectiveness. An incremental cost-effectiveness ratio was calculated comparing the ongoing operation costs of each method with the level of EBM proficiency achieved. Present value analysis was used to calculate the break-even point considering the transition cost and the difference in ongoing operation cost. Results: The incremental cost-effectiveness ratio indicated that it costs 24% less to educate a student to the same level of EBM competency via the blended learning approach used in the study, when excluding transition costs. The sunk cost of approximately AUD $40,000 to transition to the blended model exceeds any savings from using the approach within the first year of its implementation; however, a break-even point is achieved within its third iteration and relative savings in the subsequent years. The sensitivity analysis indicates that approaches with higher transition costs, or staffing requirements over that of a traditional method, are likely to result in negative value propositions. Conclusions: Under the study conditions, a blended learning approach was more cost-effective to operate and resulted in improved value for the institution after the third year iteration, when compared to the traditional face-to-face model. The wider applicability of the findings are dependent on the type of blended learning utilized, staffing expertise, and educational context.

  • Image credit: Dave Di Biase/Freeimages, http://www.freeimages.com/photo/surf-in-style-1544685.

    Characterizing the Processes for Navigating Internet Health Information Using Real-Time Observations: A Mixed-Methods Approach

    Abstract:

    Background: Little is known about the processes people use to find health-related information on the Internet or the individual characteristics that shape selection of information-seeking approaches. Objective: Our aim was to describe the processes by which users navigate the Internet for information about a hypothetical acute illness and to identify individual characteristics predictive of their information-seeking strategies. Methods: Study participants were recruited from public settings and agencies. Interested individuals were screened for eligibility using an online questionnaire. Participants listened to one of two clinical scenarios—consistent with influenza or bacterial meningitis—and then conducted an Internet search. Screen-capture video software captured Internet search mouse clicks and keystrokes. Each step of the search was coded as hypothesis testing (etiology), evidence gathering (symptoms), or action/treatment seeking (behavior). The coded steps were used to form a step-by-step pattern of each participant’s information-seeking process. A total of 78 Internet health information seekers ranging from 21-35 years of age and who experienced barriers to accessing health care services participated. Results: We identified 27 unique patterns of information seeking, which were grouped into four overarching classifications based on the number of steps taken during the search, whether a pattern consisted of developing a hypothesis and exploring symptoms before ending the search or searching an action/treatment, and whether a pattern ended with action/treatment seeking. Applying dual-processing theory, we categorized the four overarching pattern classifications as either System 1 (41%, 32/78), unconscious, rapid, automatic, and high capacity processing; or System 2 (59%, 46/78), conscious, slow, and deliberative processing. Using multivariate regression, we found that System 2 processing was associated with higher education and younger age. Conclusions: We identified and classified two approaches to processing Internet health information. System 2 processing, a methodical approach, most resembles the strategies for information processing that have been found in other studies to be associated with higher-quality decisions. We conclude that the quality of Internet health-information seeking could be improved through consumer education on methodical Internet navigation strategies and the incorporation of decision aids into health information websites.

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  • Unpacking the black box of text messages in mobile health interventions: A formative research approach to the development of theory-driven, evidence-based, and culturally safe messages

    Date Submitted: Jul 31, 2015

    Open Peer Review Period: Aug 2, 2015 - Sep 27, 2015

    Background: Mobile-cellular subscriptions have increased steadily over the past. The accessibility of SMS messages over existing mobile networks is high and has almost universal availability even on o...

    Background: Mobile-cellular subscriptions have increased steadily over the past. The accessibility of SMS messages over existing mobile networks is high and has almost universal availability even on older and unsophisticated mobile phones and in geographic settings where wireless coverage is weak. There is intensive exploration of this inexpensive mobile telecommunication technology to improve health services and promote behaviour change among vulnerable populations. However, a neglected area of research is the documentation and critical analysis of this formative research process required in the development and refinement of effective SMS messages. Objective: We address this gap in the literature by reporting on our formative research project on the development and refinement of SMS messages for an international research project designed to address health inequalities in hypertension called DREAM-GLOBAL. This paper describes our research to develop evidence-based health knowledge in SMS messages, their theoretical grounding in health behaviour theory and the cultural mediators of meaning that had to be considered to ensure optimal effectiveness of the transmission of the content of messages to the target population. Methods: Qualitative research with the target populations was conducted to deconstruct the content and to study the transmission of evidence-based health knowledge contained in DREAM-GLOBAL SMS messages and to develop a grounded theory of the major factors that may impact on the effectiveness of this communication. We also examined how advice in each message impacts on the three essential conditions (capability, opportunity, and motivation) of the behaviour system of the Behavioural Change Wheel and on cultural safety. Results: Four focus groups with 45 participants were conducted. Our grounded theory research involving Indigenous people from Canada and Tanzania revealed how differences develop between the evidence-based message created by researchers and the message received by the recipient in mobile health interventions. These differences were primarily generated by six mediators of meaning in SMS messages: (1) clarity and practicality of content; (2) framing of advocacies (positive or negative); (3) fear or stress inducing content; (4) oppressive or authoritarian content; (5) congruency with cultural and traditional practices and (6) fit with the reality of SDOH and especially diversity of cultures. The six mediators of meaning impact directly on of the necessary conditions of behaviour of the BCW. Conclusions: Our research underscores the urgent need for mobile health interventions to incorporate and evaluate the quality of SMS messages and to examine the mediators of meaning within each cultural and demographic target group, because the quality of text messages impact significantly on the effectiveness of a text message-based health intervention. Reporting the formative research will allow more transparent research in mobile health interventions and allow researchers in the field to move away from the current back box of SMS text message development.

  • A qualitative study exploring parents’ experiences of using an online self-help package designed for individuals supporting those with anorexia nervosa.

    Date Submitted: Jul 28, 2015

    Open Peer Review Period: Jul 30, 2015 - Sep 24, 2015

    Background: Anorexia nervosa (AN) not only impacts the life of the sufferer but also has powerful consequences for those acting as caregivers. Considerable strain is placed on family functioning with...

    Background: Anorexia nervosa (AN) not only impacts the life of the sufferer but also has powerful consequences for those acting as caregivers. Considerable strain is placed on family functioning with carers often reporting distress, burden and psychological morbidity. One way to meet carers’ needs may be through interventions such as the CBT based online package; Overcoming Anorexia Online (OAO). Such packages allow early access to support. Objective: This study explored carers’ experiences of help received prior to and during use of OAO. Methods: Semi-structured interviews were conducted with 10 parents who had a child with AN. Results: Thematic analysis revealed several over-arching themes with parents reporting a distinct lack of support and information, however, all parents found OAO to be an effective form of support and would recommend it to others. Conclusions: This study gives us insight and understanding of the challenges parents face and of the value of OAO as a form of support.

  • India thanks Doctors by trending #ThankYouDoctor on twitter

    Date Submitted: Jul 24, 2015

    Open Peer Review Period: Jul 28, 2015 - Sep 22, 2015

    Twitter trends are said to be one of the important methods to sense the mood of the people in social media. In India, #ThankYouDoctor was trending on Twitter, on July 1st 2015. This is a very signif...

    Twitter trends are said to be one of the important methods to sense the mood of the people in social media. In India, #ThankYouDoctor was trending on Twitter, on July 1st 2015. This is a very significant point to note, as social media is usually flooded with more negativity than positivity on several issues, including medical profession. Negativity about medical profession is usually due to an incident or a particular organization. Positivity about medical profession is usually about a particular doctor or a successful operation. The twitter trend on July 1st 2015, to honour all the doctors, comes as a clear message about the public sentiments. It is noteworthy fact that many a doctors are not using twitter when compared to other professionals. The author has not seen such a trend before, on twitter, thanking other professionals the way doctors were thanked on July 1st. It is indeed heartening. India observes National Doctors' Day on July 1st every year on the birthday of Dr Bidhan Chandra Roy. Dr Roy was honoured with the country's highest civilian award, Bharat Ratna,for being a legendary physician and a popular politician from of West Bengal, India.

  • Translation of Evidence into a mHealth Chronic Disease Platform Supporting Mobile App Design

    Date Submitted: Jul 28, 2015

    Open Peer Review Period: Jul 28, 2015 - Sep 22, 2015

    Background: A design structure, process and tools are important to translate clinical and behavioral evidence, user interface, experience design and technical capabilities into scalable, replicable, e...

    Background: A design structure, process and tools are important to translate clinical and behavioral evidence, user interface, experience design and technical capabilities into scalable, replicable, evidence–based mobile health (mHealth) solutions to drive outcomes. Objective: This paper proposes an approach for systematic design of different types of mHealth apps to facilitate delivery of interventions and evaluation of mobile technologies to answer the questions of when, where and for whom mHealth apps are effective in the real-world. Methods: The process of developing the platform and its frameworks was conducted between June 2012 and June 2014. Informed by clinical guidelines, standards of care, clinical practice recommendations, evidence-based research, best practices and translated by subject matter experts, the mobile strategic framework (mSF) and mobile integrated clinical behavioral framework (mICBF) were developed. Application and refinement of the frameworks across three implementation models allowed for development of the mobile chronic disease platform (mCDP). Results: One platform, its two corresponding frameworks, and its application to seven chronic diseases across three implementation models are described. The platform is the design structure that enables replicable product development. The frameworks allowed for the integration of clinical and behavioral evidence for intervention and feature design. The application to different diseases and implementation models allowed for designing mHealth solutions to support varying levels of chronic disease management. Conclusions: As a result, a comprehensive ontology and associated taxonomies, cataloging the critical components of integrated clinical and behavioral mHealth solution design, was developed to support consistent product development. Implications for policy, practice and research for chronic disease management are discussed.

  • Online prediction of the future 6-month healthcare utilization in Maine State: a prospective patient study

    Date Submitted: Jul 24, 2015

    Open Peer Review Period: Jul 24, 2015 - Sep 18, 2015

    Background: The increasing rate of healthcare expenditures in the United States has placed a significant burden on the nation’s economy. Predicting future healthcare utilization of patients can prov...

    Background: The increasing rate of healthcare expenditures in the United States has placed a significant burden on the nation’s economy. Predicting future healthcare utilization of patients can provide useful information to better understand and manage overall healthcare deliveries and clinical resource allocation. Objective: This study developed an EMR-based (electronic-medical-record-based) online risk model predictive of future 6-month resource utilization for patients in Maine, across all payers, all diseases and all demographic groups. Methods: In the HealthInfoNet (HIN), Maine’s Health Information Exchange (HIE), a retrospective cohort of 1,273,114 patients was constructed with the preceding 12-month EMR. Each patient’s future 6-month (between January 1, 2013 and June 30, 2013) healthcare resource utilization was retrospectively scored ranging from 0 to 100, and a decision-tree based predictive model was developed. Our model was later integrated in the Maine HIE population exploration system to allow a prospective validation analysis of 1,358,153 patients by forecasting their future 6-month risks of resource utilization between July 1, 2013 and December 31, 2013. Results: Prospectively predicted risks, on either an individual level or a population (per 1000 patients) level, were consistent with the future 6-month resource utilization distributions as well as the clinical patterns at the population level. A case study demonstrating the strong correlation between its care resource utilization and our risk scores supports the effectiveness of our model. With the online population risk monitoring enterprise dashboards, the effectiveness of the predictive algorithm has been validated by clinicians and care-givers in the State of Maine. Conclusions: The model and associated online applications were designed for tracking the evolving nature of total population risk, in a longitudinal manner, for healthcare resource utilization. It will enable more effective care management strategies driving improved patient outcomes.

  • Personal Health Record Use in the U.S.: Forecasting Future Adoption Levels

    Date Submitted: Jul 23, 2015

    Open Peer Review Period: Jul 24, 2015 - Sep 18, 2015

    Background: PHRs offer a tremendous opportunity to generate consumer support in pursing the triple aim of reducing costs, increasing access, and improving care quality. Moreover, surveys indicate that...

    Background: PHRs offer a tremendous opportunity to generate consumer support in pursing the triple aim of reducing costs, increasing access, and improving care quality. Moreover, surveys indicate that consumers want online access to their medical records. However, concerns that consumers’ low health information literacy levels and physicians’ resistance to sharing notes will limit PHRs utility to a relatively small portion of the population have reduced both the product innovation and policy imperatives. Objective: The purpose of this study is threefold. First, to report on consumers’ current level of Personal Health Record (PHR) activity; second, we describe the imitation and innovation influence factors roles in determining PHR adoption rates, and; third, we forecast future PHR diffusion uptake among U.S. consumers under three scenarios. Methods: Secondary data from the Health Information National Tracking Survey (HINTS: Survey Years: 2008, 2011, and 2013) of U.S. citizens are used. Applying technology diffusion theory and Bass modeling, we evaluate three future PHR adoption scenarios by varying the introduction dates. Results: All models display the characteristic diffusion S-curve indicative that the PHR technology is likely to achieve significant market penetration ahead of MU goals. The best performing model indicates that PHR adoption will exceed 75 percent by 2020. Therefore, the MU program targets for PHR adoption are below the rates likely to occur without an intervention. Conclusions: The promise of improved care quality and cost savings through better consumer engagement prompted the Institute of Medicine to call for universal PHR adoption in 1999. The PHR products available as of 2014 are likely to meet and exceed MU Stage 3 targets prior to 2020 without any incentive. Therefore, more ambitious uptake and functionality availability should be incorporated into future goals. Clinical Trial: N/A