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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:

  • 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.

  • State cancer incidence rank and Google relative search volume (RSV) rank for common cancers by quartile 2009-2013. States whose rank-based quartile was the same for both cancer incidence and RSV are shown in dark red. Progressively lighter shades indicate greater difference in rank of cancer incidence and RSV (quartile difference ranged from 0-3). States shown in gray had missing data and were excluded. Source: Figure 2 from; Copyright: the authors; License: Creative Commons Attribution (CC-BY).

    Relationship Between State-Level Google Online Search Volume and Cancer Incidence in the United States: Retrospective Study


    Background: In the United States, cancer is common, with high morbidity and mortality; cancer incidence varies between states. Online searches reflect public awareness, which could be driven by the underlying regional cancer epidemiology. Objective: The objective of our study was to characterize the relationship between cancer incidence and online Google search volumes in the United States for 6 common cancers. A secondary objective was to evaluate the association of search activity with cancer-related public events and celebrity news coverage. Methods: We performed a population-based, retrospective study of state-level cancer incidence from 2004 through 2013 reported by the Centers for Disease Control and Prevention for breast, prostate, colon, lung, and uterine cancers and leukemia compared to Google Trends (GT) relative search volume (RSV), a metric designed by Google to allow interest in search topics to be compared between regions. Participants included persons in the United States who searched for cancer terms on Google. The primary measures were the correlation between annual state-level cancer incidence and RSV as determined by Spearman correlation and linear regression with RSV and year as independent variables and cancer incidence as the dependent variable. Temporal associations between search activity and events raising public awareness such as cancer awareness months and cancer-related celebrity news were described. Results: At the state level, RSV was significantly correlated to incidence for breast (r=.18, P=.001), prostate (r=–.27, P<.001), lung (r=.33, P<.001), and uterine cancers (r=.39, P<.001) and leukemia (r=.13, P=.003) but not colon cancer (r=–.02, P=.66). After adjusting for time, state-level RSV was positively correlated to cancer incidence for all cancers: breast (P<.001, 95% CI 0.06 to 0.19), prostate (P=.38, 95% CI –0.08 to 0.22), lung (P<.001, 95% CI 0.33 to 0.46), colon (P<.001, 95% CI 0.11 to 0.17), and uterine cancers (P<.001, 95% CI 0.07 to 0.12) and leukemia (P<.001, 95% CI 0.01 to 0.03). Temporal associations in GT were noted with breast cancer awareness month but not with other cancer awareness months and celebrity events. Conclusions: Cancer incidence is correlated with online search volume at the state level. Search patterns were temporally associated with cancer awareness months and celebrity announcements. Online searches reflect public awareness. Advancing understanding of online search patterns could augment traditional epidemiologic surveillance, provide opportunities for targeted patient engagement, and allow public information campaigns to be evaluated in ways previously unable to be measured.

  • Source: Wikimedia Commons; Copyright: Bill Branson; URL:; License: Public Domain (CC0).

    Evidence From Web-Based Dietary Search Patterns to the Role of B12 Deficiency in Non-Specific Chronic Pain: A Large-Scale Observational Study


    Background: Profound vitamin B12 deficiency is a known cause of disease, but the role of low or intermediate levels of B12 in the development of neuropathy and other neuropsychiatric symptoms, as well as the relationship between eating meat and B12 levels, is unclear. Objective: The objective of our study was to investigate the role of low or intermediate levels of B12 in the development of neuropathy and other neuropsychiatric symptoms. Methods: We used food-related Internet search patterns from a sample of 8.5 million people based in the US as a proxy for B12 intake and correlated these searches with Internet searches related to possible effects of B12 deficiency. Results: Food-related search patterns were highly correlated with known consumption and food-related searches (ρ=.69). Awareness of B12 deficiency was associated with a higher consumption of B12-rich foods and with queries for B12 supplements. Searches for terms related to neurological disorders were correlated with searches for B12-poor foods, in contrast with control terms. Popular medicines, those having fewer indications, and those which are predominantly used to treat pain, were more strongly correlated with the ability to predict neuropathic pain queries using the B12 contents of food. Conclusions: Our findings show that Internet search patterns are a useful way of investigating health questions in large populations, and suggest that low B12 intake may be associated with a broader spectrum of neurological disorders than previously thought.

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  • Matching openEHR specifications and General Data Protection Regulation requirements

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: The concerns about privacy and personal data protection resulted in reforms of the existing legislation in European Union (EU). The General Data Protection Regulation (GDPR) aims to reform...

    Background: The concerns about privacy and personal data protection resulted in reforms of the existing legislation in European Union (EU). The General Data Protection Regulation (GDPR) aims to reform the existing directive on the topic of personal data protection of the European Union citizens, with a strong emphasis on more control of the citizens over their data and in the establishment of rules for the processing of personal data. OpenEHR is a standard that embodies many principles of interoperable and secure software for electronic health records, and has been advocated as the best approach for the development of HIS. Objective: This work aims to understand to what extent the openEHR standard can help in the compliance to the GDPR requirements. Methods: A list of requirements for a Hospital Information Systems (HIS) to support the compliance with GDPR, and also a list of the openEHR specifications were made. The requirements were categorized and compared with the specifications by specialists on openEHR and GDPR. Results: 53 GDPR requirements, and 8 openEHR specification items were identified. The openEHR specifications matched 32% (n=17) GDPR requirements. All the openEHR specifications were aligned with GDPR requirements. Conclusions: This work reinforces the openEHR initial claim, showing that openEHR has a good fit also when privacy and data protection are incorporated by design in the system development. By using an openEHR based EHR the institutions are closer to becoming compliant with GDPR while safeguarding the medical data.

  • Clinical feasibility of monitoring resting heart rate using a wearable activity tracker in patients with thyrotoxicosis: prospective longitudinal observational study

    Date Submitted: Jan 18, 2018

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

    Background: The symptoms and signs of thyrotoxicosis are non-specific and difficult to assess its clinical status with conventional physical examination and history taking. Palpitation or increased he...

    Background: The symptoms and signs of thyrotoxicosis are non-specific and difficult to assess its clinical status with conventional physical examination and history taking. Palpitation or increased heart rate is one of the key symptom or sign of thyrotoxicosis and easiest parameters to quantify. Objective: We assessed the association of the resting heart rate measured by wearable activity tracker (WD-rHR) with thyroid function and its clinical application in patients with thyrotoxicosis. Methods: Thirty patients with thyrotoxicosis and ten controls who could use the smartphone and applications were included at Seoul National University Bundang Hospital. They were instructed to use the wearable activity tracker during the study period, data on changes in heart rate were collected. The primary outcomes were verification of changes in WD-rHR during the treatment of thyrotoxicosis, and associations between WD-rHR and thyroid function. Odds ratio was computed per one standard deviation (1SD) increase in WD-rHR in relation to risk of thyrotoxicosis. These results were compared with that of conventionally obtained rHR at clinic visits (on-site rHR) or hyperthyroidism symptom scale (HSS). Results: WD-rHR was higher in thyrotoxic patients compared to controls, and decreased in association with improvement of thyrotoxicosis. WD-rHR was associated with serum free thyroxine (T4) concentration (B=1.674, P < .001) and clinical thyroid function status. These associations were superior to on-site rHR (B=1.485, P < .001) and similar to HSS (B=1.717, P < .001). WD-rHR also showed the highest odds ratio for thyrotoxicosis (3.843 [95% CI 2.067 – 7.144]) compared with on-site rHR or HSS (2.114 [1.365 – 3.273] or 3.601 [2.190 – 5.923], respectively). Conclusions: WD-rHR can provide more accurate information about the thyroid function than other clinical parameters, and has potential to improve the management of thyrotoxicosis. Clinical Trial: NCT03009357

  • A Survey of Privacy-Preserving Techniques for Reuse of Distributed Health Data

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: Large amounts of detailed electronic health data are being collected. Reuse of these data has enormous potential for scientific discoveries that enables the improvement of healthcare syste...

    Background: Large amounts of detailed electronic health data are being collected. Reuse of these data has enormous potential for scientific discoveries that enables the improvement of healthcare systems’ effectiveness, efficiency, and quality of care. However, health data reuse should protect the privacy interests of the stakeholders (i.e., patients and healthcare providers) and promote public good through research. This is particularly challenging when the data are distributed across several data custodians. Objective: This paper aims to give an overall overview of existing privacy-preserving techniques for distributed data reuse and their practical applications. Methods: We searched for review papers that are focused on privacy-preserving techniques for different stages of distributed data reuse, such as creating dataset that satisfy a given criteria, analyzing the dataset, and releasing statistical results. We analyzed the identified techniques in terms of privacy, data utility, efficiency, and scalability. Practical uses of the techniques are also discussed when there is actual use. Results: Several privacy-preserving data reuse techniques have been identified. The techniques are developed for different stages of distributed data reuse based on de-identification, secure multi-party computation (SMC), or a combination of these two building blocks. Different combinations of the techniques need to be applied for the whole stages of distributed data reuse. Some of the surveyed techniques protect the privacy of data custodians in addition to individuals. The main challenge for de-identification based data reuse techniques is making a balance between utility and privacy. Whereas, efficiency and scalability are the main challenges for SMC based techniques. Conclusions: Enormous progress has been made towards making privacy-preserving reuse of distributed data possible. However, there are only few practical uses of the available techniques. the problem of distributed data reuse also requires governance, legal, and ethical frameworks, as well as the technical solutions. It is not clear whether consent, data-use agreement, and ethics review are required for practical uses of the techniques.

  • “As if neck injuries did not exist”: A qualitative interview study of patients' and relatives' perceptions of online information on whiplash injuries

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: If purposefully designed, patient information can support patients in making well-founded decisions about their care. The study was initiated to improve the online information about whipla...

    Background: If purposefully designed, patient information can support patients in making well-founded decisions about their care. The study was initiated to improve the online information about whiplash injuries at the patient information portal of the Swedish government. Objective: The aim is to describe how patients and relatives perceive the national online information about whiplash injuries. Methods: Five interviews were made with patients (n = 10) who had had a whiplash injury and with relatives (n = 3) of such patients. Interviews were held, until no more categories appeared and we estimated that saturation was reached. The interviews were taped, transcribed verbatim and analysed by means of conventional content analysis. Results: Two themes emerged from the latent content analysis: on the one hand, a confidence and trust in the public health care system (hereinafter health care), and on the other, a disappointment with health care encounters. Conclusions: We found that taking part of the online information had caused distress to most of the study participants because of discrepancy between the sender’s authority and deficient information. The online information on whiplash injuries may greatly impact patients’ care decisions as well as their physical, mental and social wellbeing. We would recommend that patient information about whiplash injuries is made highly informative, with less emphasis on psychology and a patient wide perspective on pathophysiology, prognosis and treatment.

  • Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Despite being an important cardiovascular risk factor, hypertension (HT) has low control levels worldwide. Computerized clinical decision support systems (CDSS) might be effective in reduc...

    Background: Despite being an important cardiovascular risk factor, hypertension (HT) has low control levels worldwide. Computerized clinical decision support systems (CDSS) might be effective in reducing blood pressure, with a potential impact in reducing cardiovascular risk. Objective: To evaluate the feasibility and usability of a CDSS, named TeleHAS, in the care of patients with HT in the context of primary care setting in a middle income country, as well as the physician’s satisfaction with its use. Methods: The TeleHAS application consists of a platform integrating clinical and laboratory data of a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of HT and cardiovascular risk. Ten family physicians of different primary care units in Montes Claros city, Brazil, were randomly selected to use the application for the care of hypertensive patients for 6 months. After 3 months, the feasibility and usability of the CDSS in the routine care of the health teams was evaluated through standardized questionnaire and semi-structured interviews. After 6 months, another questionnaire and semi-structured interviews were applied to test the satisfaction of the physicians with the application. Results: Throughout the study, clinicians registered 535 patients with HT, at an average of 1.24 consultations per patient. Women accounted for 80% of participant doctors, median age 31.5 years (interquartile range 27-59 years). As for feasibility, 100% of medical users claimed it is possible to use the application in the primary care setting and for 80% of them it is easy to incorporate its use in the daily routine and home visits. Nevertheless, 70% of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated the TeleHAS as good (80% of users), with easy filling blanks and friendly interface (100%) and with the potential to improve patients’ treatment (100%). Ninety percent of physicians had access to new knowledge about cardiovascular risk and HT through the application recommendations and found it useful to promote prevention and optimize treatment. Conclusions: In this study, a CDSS developed to assist the management of patients with HT was applicable in the context of primary health care setting in a middle income country, with good user’s satisfaction and potential to improve adherence to evidence-based practices.

  • The Complexity of Mental Health App Privacy Policies: A Potential Barrier to Privacy

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: In 2017, the Indian Supreme Court ruled that privacy is a fundamental right of every citizen. While smartphone apps have the potential to help people with non-communicable diseases, they o...

    Background: In 2017, the Indian Supreme Court ruled that privacy is a fundamental right of every citizen. While smartphone apps have the potential to help people with non-communicable diseases, they often contain complex privacy policies which consumers may not understand. This complexity may impede consumers’ ability to make decisions regarding privacy, a critical issue due to the stigma of mental illness. Objective: Our objective is to determine whether mental health apps have more complex privacy policies than diabetes apps. Methods: The study utilizes privacy policies extracted from apps. Apps pertained to diabetes or mental health, and were of Indian origin. Privacy policy reading complexity was compared between the two types of apps using a series of fifteen readability measures. The universe of applicable apps on the Google Play store, as viewed between May and June 2017, was considered. The measures of readability were compared using Chi-square tests. Results: No significant difference was found between the privacy policy readability of the diabetes apps versus the mental health apps for each of the measures considered. As the mean Flesch-Kincaid Grade Level was 13.9 for diabetes apps and 13.6 for mental health apps, the mean policy was written at a college level. Privacy policies in the 25th percentile of complexity were also written at a college level for both types of apps. Conclusions: Privacy policy complexity may be a barrier for informed decision making. Clinical Trial: NA