JMIR Publications

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 4.5 for 2015

Recent Articles:

  • Image Source: Getty images, royalty free image.

    Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization


    Background: Expansion of virtual health care—real-time video consultation with a physician via the Internet—will continue as use of mobile devices and patient demand for immediate, convenient access to care grow. Objective: The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions. Methods: A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy. Results: A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs. Conclusions: Virtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.

  • Image created by the authors, based on images licensed from

    Demographic and Indication-Specific Characteristics Have Limited Association With Social Network Engagement: Evidence From 24,954 Members of Four Health Care...


    Background: Digital health social networks (DHSNs) are widespread, and the consensus is that they contribute to wellness by offering social support and knowledge sharing. The success of a DHSN is based on the number of participants and their consistent creation of externalities through the generation of new content. To promote network growth, it would be helpful to identify characteristics of superusers or actors who create value by generating positive network externalities. Objective: The aim of the study was to investigate the feasibility of developing predictive models that identify potential superusers in real time. This study examined associations between posting behavior, 4 demographic variables, and 20 indication-specific variables. Methods: Data were extracted from the custom structured query language (SQL) databases of 4 digital health behavior change interventions with DHSNs. Of these, 2 were designed to assist in the treatment of addictions (problem drinking and smoking cessation), and 2 for mental health (depressive disorder, panic disorder). To analyze posting behavior, 10 models were developed, and negative binomial regressions were conducted to examine associations between number of posts, and demographic and indication-specific variables. Results: The DHSNs varied in number of days active (3658-5210), number of registrants (5049-52,396), number of actors (1085-8452), and number of posts (16,231-521,997). In the sample, all 10 models had low R2 values (.013-.086) with limited statistically significant demographic and indication-specific variables. Conclusions: Very few variables were associated with social network engagement. Although some variables were statistically significant, they did not appear to be practically significant. Based on the large number of study participants, variation in DHSN theme, and extensive time-period, we did not find strong evidence that demographic characteristics or indication severity sufficiently explain the variability in number of posts per actor. Researchers should investigate alternative models that identify superusers or other individuals who create social network externalities.

  • Web- and Computer-Based Interventions for Stress. Image source: Author: Hannah Wei. Copyright: CC0.

    The Benefit of Web- and Computer-Based Interventions for Stress: A Systematic Review and Meta-Analysis


    Background: Stress has been identified as one of the major public health issues in this century. New technologies offer opportunities to provide effective psychological interventions on a large scale. Objective: The aim of this study is to investigate the efficacy of Web- and computer-based stress-management interventions in adults relative to a control group. Methods: A meta-analysis was performed, including 26 comparisons (n=4226). Cohen d was calculated for the primary outcome level of stress to determine the difference between the intervention and control groups at posttest. Analyses of the effect on depression, anxiety, and stress in the following subgroups were also conducted: risk of bias, theoretical basis, guidance, and length of the intervention. Available follow-up data (1-3 months, 4-6 months) were assessed for the primary outcome stress. Results: The overall mean effect size for stress at posttest was Cohen d=0.43 (95% CI 0.31-0.54). Significant, small effects were found for depression (Cohen d=0.34, 95% CI 0.21-0.48) and anxiety (Cohen d=0.32, 95% CI 0.17-0.47). Subgroup analyses revealed that guided interventions (Cohen d=0.64, 95% CI 0.50-0.79) were more effective than unguided interventions (Cohen d=0.33, 95% CI 0.20-0.46; P=.002). With regard to the length of the intervention, short interventions (≤4 weeks) showed a small effect size (Cohen d=0.33, 95% CI 0.22-0.44) and medium-long interventions (5-8 weeks) were moderately effective (Cohen d=0.59; 95% CI 0.45-0.74), whereas long interventions (≥9 weeks) produced a nonsignificant effect (Cohen d=0.21, 95% CI –0.05 to 0.47; P=.006). In terms of treatment type, interventions based on cognitive behavioral therapy (CBT) and third-wave CBT (TWC) showed small-to-moderate effect sizes (CBT: Cohen d=0.40, 95% CI 0.19-0.61; TWC: Cohen d=0.53, 95% CI 0.35-0.71), and alternative interventions produced a small effect size (Cohen d=0.24, 95% CI 0.12-0.36; P=.03). Early evidence on follow-up data indicates that Web- and computer-based stress-management interventions can sustain their effects in terms of stress reduction in a small-to-moderate range up to 6 months. Conclusions: These results provide evidence that Web- and computer-based stress-management interventions can be effective and have the potential to reduce stress-related mental health problems on a large scale.

  • Key themes influencing readiness for digital health.

    Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the...


    Background: Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. Objective: The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ‟Delivering Assisted Living Lifestyles at Scale” (dallas) from 2012-2015. Methods: The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem. Results: We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness. Conclusions: Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.

  • A Smoking Prevention Interactive Experience (ASPIRE). Image source: the authors.

    From the Experience of Interactivity and Entertainment to Lower Intention to Smoke: A Randomized Controlled Trial and Path Analysis of a Web-Based Smoking...


    Background: Web-based programs for smoking prevention are being increasingly used with some success among adolescents. However, little is known about the mechanisms that link the experience of such programs to intended nicotine or tobacco control outcomes. Objective: Based on the experiential learning theory and extended elaboration likelihood model, this study aimed to evaluate the impact of a Web-based intervention, A Smoking Prevention Interactive Experience (ASPIRE), on adolescents’ intention to smoke, while considering the experience of interactivity and entertainment as predictors of reduced intention to smoke, under a transitional user experience model. Methods: A total of 101 adolescents were recruited from after-school programs, provided consent, screened, and randomized in a single-blinded format to 1 of 2 conditions: the full ASPIRE program as the experimental condition (n=50) or an online , text-based version of ASPIRE as the control condition (n=51). Data were collected at baseline and immediate follow-up. Repeated-measures mixed-effects models and path analyses were conducted. Results: A total of 82 participants completed the study and were included in the analysis. Participants in the experimental condition were more likely to show a decrease in their intention to smoke than those in the control condition (beta=−0.18, P=.008). Perceived interactivity (beta=−0.27, P=.004) and entertainment (beta=−0.20, P=.04) were each associated with a decrease in intention to smoke independently. Results of path analyses indicated that perceived interactivity and perceived entertainment mediated the relationship between ASPIRE use and emotional involvement. Furthermore, perceived presence mediated the relationship between perceived interactivity and emotional involvement. There was a direct relationship between perceived entertainment and emotional involvement. Emotional involvement predicted a decrease in intention to smoke (beta=−0.16, P=.04). Conclusions: Adolescents’ experience of interactivity and entertainment contributed to the expected outcome of lower intention to smoke. Also, emphasis needs to be placed on the emotional experience during Web-based interventions in order to maximize reductions in smoking intentions. Going beyond mere evaluation of the effectiveness of a Web-based smoking prevention program, this study contributes to the understanding of adolescents’ psychological experience and its effect on their intention to smoke. With the results of this study, researchers can work to (1) enhance the experience of interactivity and entertainment and (2) amplify concepts of media effects (eg, presence and emotional involvement) in order to better reach health behavior outcomes. Trial Registration: NCT02469779; (Archived by WebCite at

  • Woman at a table filling prescriptions. Photo credit: Ministério da Saúde. Image source: Flickr, URL:, licensed under Creative Commons NC SA 2.0.

    Patient Use of Electronic Prescription Refill and Secure Messaging and Its Association With Undetectable HIV Viral Load: A Retrospective Cohort Study


    Background: Electronic personal health records (PHRs) can support patient self-management of chronic conditions. Managing human immunodeficiency virus (HIV) viral load, through taking antiretroviral therapy (ART) is crucial to long term survival of persons with HIV. Many persons with HIV have difficulty adhering to their ART over long periods of time. PHRs contribute to chronic disease self-care and may help persons with HIV remain adherent to ART. Proportionally veterans with HIV are among the most active users of the US Department of Veterans Affairs (VA) PHR, called My HealtheVet. Little is known about whether the use of the PHR is associated with improved HIV outcomes in this population. Objective: The objective of this study was to investigate whether there are associations between the use of PHR tools (electronic prescription refill and secure messaging [SM] with providers) and HIV viral load in US veterans. Methods: We conducted a retrospective cohort study using data from the VA’s electronic health record (EHR) and the PHR. We identified veterans in VA care from 2009-2012 who had HIV and who used the PHR. We examined which ones had achieved the positive outcome of suppressed HIV viral load, and whether achievement of this outcome was associated with electronic prescription refill or SM. From 18,913 veterans with HIV, there were 3374 who both had a detectable viral load in 2009 and who had had a follow-up viral load test in 2012. To assess relationships between electronic prescription refill and viral control, and SM and viral control, we fit a series of multivariable generalized estimating equation models, accounting for clustering in VA facilities. We adjusted for patient demographic and clinical characteristics associated with portal use. In the initial models, the predictor variables were included in dichotomous format. Subsequently, to evaluate a potential dose-effect, the predictor variables were included as ordinal variables. Results: Among our sample of 3374 veterans with HIV who received VA care from 2009-2012, those who had transitioned from detectable HIV viral load in 2009 to undetectable viral load in 2012 tended to be older (P=.004), more likely to be white (P<.001), and less likely to have a substance use disorder, problem alcohol use, or psychosis (P=.006, P=.03, P=.004, respectively). There was a statistically significant positive association between use of electronic prescription refill and change in HIV viral load status from 2009-2012, from detectable to undetectable (OR 1.36, CI 1.11-1.66). There was a similar association between SM use and viral load status, but without achieving statistical significance (OR 1.28, CI 0.89-1.85). Analyses did not demonstrate a dose-response of prescription refill or SM use for change in viral load. Conclusions: PHR use, specifically use of electronic prescription refill, was associated with greater control of HIV. Additional studies are needed to understand the mechanisms by which this may be occurring.

  • Safeguarding and online sexual health services. Image sourced and copyright owned by authors.

    Screening for Child Sexual Exploitation in Online Sexual Health Services: An Exploratory Study of Expert Views


    Background: Sexual health services routinely screen for child sexual exploitation (CSE). Although sexual health services are increasingly provided online, there has been no research on the translation of the safeguarding function to online services. We studied expert practitioner views on safeguarding in this context. Objective: The aim was to document expert practitioner views on safeguarding in the context of an online sexual health service. Methods: We conducted semistructured interviews with lead professionals purposively sampled from local, regional, or national organizations with a direct influence over CSE protocols, child protection policies, and sexual health services. Interviews were analyzed by three researchers using a matrix-based analytic method. Results: Our respondents described two different approaches to safeguarding. The “information-providing” approach considers that young people experiencing CSE will ask for help when they are ready from someone they trust. The primary function of the service is to provide information, provoke reflection, generate trust, and respond reliably to disclosure. The approach values online services as an anonymous space to test out disclosure without commitment. The “information-gathering” approach considers that young people may withhold information about exploitation. Therefore, services should seek out information to assess risk and initiate disclosure. This approach values face-to-face opportunities for individualized questioning and immediate referral. Conclusions: The information-providing approach is associated with confidential telephone support lines and the information-gathering approach with clinical services. The approach adopted online will depend on ethos and the range of services provided. Effective transition from online to clinic services after disclosure is an essential element of this process and further research is needed to understand and support this transition.

  • Copyright: Jasmin Härkönen, with photographer's permission.

    Use of Information and Communication Technologies Among Older People With and Without Frailty: A Population-Based Survey


    Background: Use of information and communication technologies (ICT) among seniors is increasing; however, studies on the use of ICT by seniors at the highest risk of health impairment are lacking. Frail and prefrail seniors are a group that would likely benefit from preventive nutrition and exercise interventions, both of which can take advantage of ICT. Objective: The objective of the study was to quantify the differences in ICT use, attitudes, and reasons for nonuse among physically frail, prefrail, and nonfrail home-dwelling seniors. Methods: This was a population-based questionnaire study on people aged 65-98 years living in Northern Finland. A total of 794 eligible individuals responded out of a contacted random sample of 1500. Results: In this study, 29.8% (237/794) of the respondents were classified as frail or prefrail. The ICT use of frail persons was lower than that of the nonfrail ones. In multivariable logistic regression analysis, age and education level were associated with both the use of Internet and advanced mobile ICT such as smartphones or tablets. Controlling for age and education, frailty or prefrailty was independently related to the nonuse of advanced mobile ICT (odds ratio, OR=0.61, P=.01), and frailty with use of the Internet (OR=0.45, P=.03). The frail or prefrail ICT nonusers also held the most negative opinions on the usefulness or usability of mobile ICT. When opinion variables were included in the model, frailty status remained a significant predictor of ICT use. Conclusions: Physical frailty status is associated with older peoples’ ICT use independent of age, education, and opinions on ICT use. This should be taken into consideration when designing preventive and assistive technologies and interventions for older people at risk of health impairment.

  • Conceptual model of barriers to successful, sustainable remote health. Image sourced and copyright owned by authors.

    Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme


    Background: Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption. Objective: The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes. Methods: The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified. Results: A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%). Conclusions: The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.

  • Stressed man talking on the phone. Photo credit: JoePhilipson. Image source: Flickr, URL:, licensed under Creative Commons NC SA 2.0.

    Smartphone-Based Self-Assessment of Stress in Healthy Adult Individuals: A Systematic Review


    Background: Stress is a common experience in today’s society. Smartphone ownership is widespread, and smartphones can be used to monitor health and well-being. Smartphone-based self-assessment of stress can be done in naturalistic settings and may potentially reflect real-time stress level. Objective: The objectives of this systematic review were to evaluate (1) the use of smartphones to measure self-assessed stress in healthy adult individuals, (2) the validity of smartphone-based self-assessed stress compared with validated stress scales, and (3) the association between smartphone-based self-assessed stress and smartphone generated objective data. Methods: A systematic review of the scientific literature was reported and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The scientific databases PubMed, PsycINFO, Embase, IEEE, and ACM were searched and supplemented by a hand search of reference lists. The databases were searched for original studies involving healthy individuals older than 18 years, measuring self-assessed stress using smartphones. Results: A total of 35 published articles comprising 1464 individuals were included for review. According to the objectives, (1) study designs were heterogeneous, and smartphone-based self-assessed stress was measured using various methods (e.g., dichotomized questions on stress, yes or no; Likert scales on stress; and questionnaires); (2) the validity of smartphone-based self-assessed stress compared with validated stress scales was investigated in 3 studies, and of these, only 1 study found a moderate statistically significant positive correlation (r=.4; P<.05); and (3) in exploratory analyses, smartphone-based self-assessed stress was found to correlate with some of the reported smartphone generated objective data, including voice features and data on activity and phone usage. Conclusions: Smartphones are being used to measure self-assessed stress in different contexts. The evidence of the validity of smartphone-based self-assessed stress is limited and should be investigated further. Smartphone generated objective data can potentially be used to monitor, predict, and reduce stress levels.

  • Testing two versions of a dietary online intervention for overweight individuals with type 2 diabetes. Copyright:  demaerre, licensed from: iStockphoto.

    An Online Intervention Comparing a Very Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method Diet in Overweight Individuals...


    Background: Type 2 diabetes is a prevalent, chronic disease for which diet is an integral aspect of treatment. In our previous trial, we found that recommendations to follow a very low-carbohydrate ketogenic diet and to change lifestyle factors (physical activity, sleep, positive affect, mindfulness) helped overweight people with type 2 diabetes or prediabetes improve glycemic control and lose weight. This was an in-person intervention, which could be a barrier for people without the time, flexibility, transportation, social support, and/or financial resources to attend. Objective: The aim was to determine whether an online intervention based on our previous recommendations (an ad libitum very low-carbohydrate ketogenic diet with lifestyle factors; “intervention”) or an online diet program based on the American Diabetes Associations’ “Create Your Plate” diet (“control”) would improve glycemic control and other health outcomes among overweight individuals with type 2 diabetes. Methods: In this pilot feasibility study, we randomized overweight adults (body mass index ≥25) with type 2 diabetes (glycated hemoglobin [HbA1c] 6.5%-9.0%) to a 32-week online intervention based on our previous recommendations (n=12) or an online diet program based around a plate method diet (n=13) to assess the impact of each intervention on glycemic control and other health outcomes. Primary and secondary outcomes were analyzed by mixed-effects linear regression to compare outcomes by group. Results: At 32 weeks, participants in the intervention group reduced their HbA1c levels more (estimated marginal mean [EMM] –0.8%, 95% CI –1.1% to –0.6%) than participants in the control group (EMM –0.3%, 95% CI –0.6% to 0.0%; P=.002). More than half of the participants in the intervention group (6/11, 55%) lowered their HbA1c to less than 6.5% versus 0% (0/8) in the control group (P=.02). Participants in the intervention group lost more weight (EMM –12.7 kg, 95% CI –16.1 to –9.2 kg) than participants in the control group (EMM –3.0 kg, 95% CI –7.3 to 1.3 kg; P<.001). A greater percentage of participants lost at least 5% of their body weight in the intervention (10/11, 90%) versus the control group (2/8, 29%; P=.01). Participants in the intervention group lowered their triglyceride levels (EMM –60.1 mg/dL, 95% CI –91.3 to –28.9 mg/dL) more than participants in the control group (EMM –6.2 mg/dL, 95% CI –46.0 to 33.6 mg/dL; P=.01). Dropout was 8% (1/12) and 46% (6/13) for the intervention and control groups, respectively (P=.07). Conclusions: Individuals with type 2 diabetes improved their glycemic control and lost more weight after being randomized to a very low-carbohydrate ketogenic diet and lifestyle online program rather than a conventional, low-fat diabetes diet online program. Thus, the online delivery of these very low-carbohydrate ketogenic diet and lifestyle recommendations may allow them to have a wider reach in the successful self-management of type 2 diabetes. Trial Registration: NCT01967992; (Archived by WebCite at

  • Man sleeping. Photo credit: David. Image source: Flickr, URL:, licensed under Creative Commons NC SA 2.0.

    Commencing and Persisting With a Web-Based Cognitive Behavioral Intervention for Insomnia: A Qualitative Study of Treatment Completers


    Background: Computerized cognitive behavioral therapy for insomnia (CCBT-I) has a growing evidence base as a stand-alone intervention, but it is less clear what factors may limit its acceptability and feasibility when combined with clinical care. Objective: The purpose of this study was to explore barriers and facilitators to use of an adjunctive CCBT-I program among depressed patients in a psychiatric clinic by using both quantitative and qualitative approaches. Methods: We conducted the qualitative component of the study using face-to-face or telephone interviews with participants who had enrolled in a clinical trial of a CCBT-I program as an adjunctive treatment in a psychiatric clinical setting. In line with the grounded theory approach, we used a semistructured interview guide with new thematic questions being formulated during the transcription and data analysis, as well as being added to the interview schedule. A range of open and closed questions addressing user experience were asked of all study participants who completed the 12-week trial in an online survey. Results: Three themes emerged from the interviews and open questions, consistent with nonadjunctive CCBT-I implementation. Identification with the adjunctive intervention’s target symptom of insomnia and the clinical setting were seen as key reasons to engage initially. Persistence was related to factors to do with the program, its structure, and its content, rather than any nonclinical factors. The survey results showed that only the key active behavioral intervention, sleep restriction, was rated as a major problem by more than 15% of the sample. In this clinical setting, the support of the clinician in completing the unsupported program was highlighted, as was the need for the program and clinical treatment to be coordinated. Conclusions: The use of a normally unsupported CCBT-I program as an adjunctive treatment can be aided by the clinician’s approach. A key behavioral component of the intervention, specific to insomnia treatment, was identified as a major problem for persistence. As such, clinicians need to be aware of when such components are delivered in the program and coordinate their care accordingly, if the use of the program is to be optimized. ClinicalTrial: Australian and New Zealand Clinical Trials Registry ACTRN12612000985886; (Archived by WebCite at

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  • Meeting Patients Where They Are: Development of a Novel Patient Engagement Platform Using Accessible Text Messages and Calls

    Date Submitted: Feb 8, 2017

    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Patient noncompliance with therapy, treatments, and appointments represents a significant barrier to improving health care delivery and reducing the cost of care. Objective: We created a n...

    Background: Patient noncompliance with therapy, treatments, and appointments represents a significant barrier to improving health care delivery and reducing the cost of care. Objective: We created a novel, digital health intervention, “Epharmix”, to engage all patients where they are, enabling health care to reach them regardless of their socioeconomic position. Epharmix utilizes existing SMS and phone infrastructure to help patients reach their clinical goals. Methods: The platform utilizes a series of condition-specific, automated text message or phone calls that are optimized for both clinical utility and patient engagement. The intervention algorithms generate provider alerts and triaged patient rosters so patients receive clinical assistance earlier in their disease process. Results: In total, 28,386 text messages and 24,017 calls were sent to 929 patients over nine months. Patients responded to 80-90% of messages allowing the system to detect 1,164 clinically significant events. Patients reported increased satisfaction and communication with their provider. Epharmix increased the number of patient-provider interactions from less than one to over 10 in any given month. Conclusions: Engaging high risk patients remains a difficult process that may be improved through novel, digital health interventions. The Epharmix platform enables increased patient engagement, with very low risk, to improve clinical outcomes. We demonstrated that engagement and adherence among high risk populations is possible when health care comes conveniently to where they are.


    Date Submitted: Feb 14, 2017

    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Despite the potential benefits described by international organizations, 68–80% of survivors do not meet the described guidelines in terms of diet and physical activity. This concern cou...

    Background: Despite the potential benefits described by international organizations, 68–80% of survivors do not meet the described guidelines in terms of diet and physical activity. This concern could be approached with a user-friendly mobile health (mHealth) application for assessing and monitoring healthy lifestyles in breast cancer survivors (BCS). Objective: The main aim is to investigate the test-retest reliability and concurrent validity against accelerometry and dietary records of a novel mHealth system called BENECA (ENErgy Balance on CAncer). Methods: We conducted a descriptive reliability study (N=20 BCS) who were recruited from the Virgen de las Nieves Hospital of the Andalusian Health Service in Granada (Spain) between December 2015 and April 2016. Test-retest reliability analysis used an overlap of approximately 2 hours between times. During an 8-day period tri-axial accelerometers (ActiGraphGT3X+, Pensacola, Fl., US) were worn by patients for concurrent validity analysis. Alike, at baseline 24-hour dietary recalls (also after 8-day period), sociodemographic questionnaire and daily dietary record questionnaires were recorded. For the inter-rater reliability trials, two-way random effect intra-class correlation coefficients (Rho) and their confidence intervals were calculated. Moreover, the agreement in diet between gold-standard and BENECA m-Health System was evaluated using a method described previously by Hillier. Finally, the accuracy of BENECA m-Health System was assessed using a linear regression analysis to determine the correlation coefficient and a Passing-Bablok regression to evaluate bias. Results: The compliance rates for all assessment methods were very high. All outcome measures showed reliability estimates (α)≥0.90; the lowest reliability was obtained for portions of the FV (α=0.94). The inter-rater reliability (gold standard method versus BENECA mHealth system) was very good (Rho≥0.90). The mean match rate between food items reported using BENECA and those registered by gold-standards was 93.51%, with a phantom rate of 3.35%. There were no substantial differences between the BENECA m-Health system and the gold standard assessment methods. There was no fised bias and mean differences between methods were -0.15 for FAT, -0.01 for fruits and vegetables and -8.89 for minutes of moderate-to-vigorous physical activity. There were not any adverse events. One breast cancer survivor could not use the BENECA m-Health System because she was using a previous version of the Android System with which BENECA was incompatible. Conclusions: The BENECA mHealth system is a simple, quick, reliable and low burden method to assess diet and physical activity in BCS. This novel option has potential implications in the cancer units to examine energy balance-related behaviours. Further research is now required to study the usage of both BENECA mHealth system and objective measurement of physical activity because it could suppose a major advance for a growing cancer population whose energy imbalance increases risk of some of the most prevalent cancer processes.

  • An eAlert System Between Family Caregivers and Clinicians Reduces Symptom Distress in Patients With Advanced Cancer: A Pooled Analysis of Two Randomized Clinical Trials

    Date Submitted: Feb 8, 2017

    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Symptom distress toward the end of life can change rapidly. Family caregivers have the potential to help manage those symptoms, as well as their own stress, if they are equipped with the p...

    Background: Symptom distress toward the end of life can change rapidly. Family caregivers have the potential to help manage those symptoms, as well as their own stress, if they are equipped with the proper resources. eHealth systems may be able to provide those resources. Very sick patients may not be able to use such systems themselves to report on their symptoms, but family caregivers could. Objective: Assess the effects of an eHealth system that alerts clinicians to significant changes in a cancer patient’s symptom distress, as reported by a family caregiver. Methods: A pooled analysis from two randomized clinical trials (NCT00214162 and NCT00365963) compared outcomes at 12 months for two unblinded groups: a control group (CHESS-Only) that gave caregivers access to an online support system, the Comprehensive Health Enhancement Support System (CHESS), and an experimental group (CHESS+CR [Clinician Report]), which also had CHESS, but with a Clinician Report that automatically alerted clinicians if symptoms exceeded a predetermined threshold. Participants were dyads (n = 235) of patients with advanced lung, breast, or prostate cancer and their family caregivers from five oncology clinics in the United States. The proportion of improved patient threshold symptoms was compared between groups using area-under-the-curve analysis and binomial proportion tests. The proportion of threshold symptoms out of all reported symptoms was also examined. Results: When caregivers in CHESS+CR reported an over-threshold symptom, they were more likely to subsequently report threshold symptom improvement, P < .001, than in the group that did not include CR. Moreover, fewer caregivers in the CHESS+CR group completed symptom reports than in the CHESS-Only group (P < .001). Knowing their reports might be sent to a doctor, they might have been reluctant to “bother” the clinician. Conclusions: This study suggests that a caregiver-focused eHealth system that alerts clinicians to worrisome changes in patient health status may lead to a reduction in patient distress. Clinical Trial: NCT00214162; (Archived by WebCite at NCT00365963; (Archived by WebCite at )

  • Content Analysis of Smartphone Apps for Smoking Cessation in China

    Date Submitted: Feb 16, 2017

    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone applications (apps) for smoking ces...

    Background: With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone applications (apps) for smoking cessation are increasingly used in China to help smokers quit. Objective: This study analyzed and evaluated the contents of all smoking cessation apps (iOS & Android) available in China, applying the China Clinical Smoking Cessation Guideline (CCSSG; identical to the U.S. Clinical Practice Guideline for Treating Tobacco Use and Dependence) as a framework for analysis. Methods: We conducted a content analysis of Chinese Android and iOS smoking cessation apps (N=64) designed to assist users in quitting smoking. Each app was independently coded by two raters for its approach to smoking cessation and adherence to the CCSSG. We also recorded the features of smoking cessation apps (e.g., release date, size, frequency of downloads, user ratings, type, quality scores by raters, and designers). Linear regression was used to test predictors of popularity and user-rated quality. Results: Chinese smoking cessation apps have low levels of adherence, with an average score of 11.1 for Android and 14.6 for iOS apps, on a scale of 0 to 46. There was no significant association between popularity, user rating, and the characteristics of apps. However, there was a positive relationship between popularity, user rating, and adherence score. Conclusions: Chinese apps for smoking cessation have low levels of adherence to standard clinical practice guidelines. New apps need be developed and existing apps be revised following evidence-based principles in China.

  • Barriers and facilitators to use eHealth in daily practice, perspectives of patients and professionals in dermatology

    Date Submitted: Feb 15, 2017

    Open Peer Review Period: Feb 18, 2017 - Apr 15, 2017

    Background: The number of eHealth interventions in the management of chronic diseases, such as atopic dermatitis (AD) is growing. Despite promising results, the implementation and use of these interve...

    Background: The number of eHealth interventions in the management of chronic diseases, such as atopic dermatitis (AD) is growing. Despite promising results, the implementation and use of these interventions is limited. Objective: This study aimed to assess opinions of most important stakeholders influencing the implementation and use of eHealth services in daily dermatology practice. Methods: A cross sectional survey based on the eHealth implementation toolkit (eHit) was conducted to explore factors influencing the adoption of eHealth interventions offering the possibility of e-consultations, online monitoring and online self-management training among dermatologists and dermatology nurses. Perspectives of patients with atopic dermatitis (AD) regarding the use of eHealth services were discussed in an online focus group. Results: Healthcare professionals (n=99) and patients (n=9) acknowledged the value of eHealth services and were willing to use these digital tools in daily dermatology practice. Key identified barriers in the implementation and adoption of eHealth interventions included concerns about the availability and allocation of resources; financial aspects; reliability, security and confidentially of the intervention itself and the lack of education and training. Conclusions: Healthcare professionals and patients acknowledge the benefits arising from the implementation and use of eHealth services in daily dermatology practice. However, we identified some important barriers that might be useful in addressing the implementation strategy in order to enhance the implementation success of eHealth interventions in dermatology.

  • ICT for health in the EU: the effect of multimorbidity

    Date Submitted: Feb 10, 2017

    Open Peer Review Period: Feb 18, 2017 - Apr 15, 2017

    Background: Multimorbidity is becoming increasingly common and is a key challenge that societies with ageing populations are now facing. The presence of multimorbidity entails the implication of patie...

    Background: Multimorbidity is becoming increasingly common and is a key challenge that societies with ageing populations are now facing. The presence of multimorbidity entails the implication of patients to coordinate, understand and use the information obtained from different health care professionals, in addition to striving to distinguish the symptoms of different diseases and self manage their sometimes conflicting health problems. Information and communications technology (ICT) tools are an opportunity for health information and education for both patients and health professionals, and hold promise for more efficient and cost-effective care processes. Objective: This study aims to analyze the use of ICT tools, particularly the Internet, for health purposes, taking into account the citizens’ socio-demographic and clinical characteristics, and above all, the presence of multimorbidity. Methods: Cross-sectional and exploratory research using online survey data from July-August 2011 was conducted, including a total of 14,000 citizens from 14 European countries between 16 and 74 years of age, and who had used the Internet in the previous three months. The variables of study were the questionnaire items related to how often the Internet was used for health purposes, the degree of morbidity and the ICT for health gradient. Chi-square tests were conducted to classify participants and examine the relationship between the sociodemographic and clinical variables of participants and the ICT user group. A one-way analysis of variance (Anova) made it possible to compare the ICT for health gradient average between different groups of individuals according to their morbidity level. A two-way between-groups Anova was performed to explore the effects of multimorbidity and age group on the ICT for health gradient. Results: According to the ICT for health gradient, most participants (68.1%; 9,541) were labelled as Rare Users, being the majority of them (55.1%) 25-54 years old, with upper secondary education (50.3%), employed (49.3%) and living in medium-sized cities (40.7%). Results of the one-way Anova showed that the number of health problems significantly affected the use of ICT for health purposes [F (2, 13996) = 11.584; p = .001]. A two-way ANOVA showed there was a statistically significant interaction between the effects of age and number of health problems on the ICT for health gradient, F (4, 11991) = 7.936, p = .001. Conclusions: Although multimorbidity patients can benefit from Internet use for health-related activities, there is a need to consider different strategies to make ICT for health tools more sensitive to the particularities of older people and to reduce digital disadvantages.