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Journal of Medical Internet Research

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


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 globally, 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 complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal we are read by clinicians, allied health professionals, informal caregivers 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).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (e.g. in grant proposals), and for open peer-review purposes. We also invite patients to participate, e.g. as peer-reviewers, and have patient representatives on editorial boards.

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


Recent Articles:

  • Pregnant woman and her partner sharing decision on prenatal testing for Down syndrome using the decision aid with their family physician. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Psychosocial Factors of Health Professionals’ Intention to Use a Decision Aid for Down Syndrome Screening: Cross-Sectional Quantitative Study


    Background: Decisions about prenatal screening for Down syndrome are difficult for women, as they entail risk, potential loss, and regret. Shared decision making increases women’s knowledge of their choices and better aligns decisions with their values. Patient decision aids foster shared decision making but are rarely used in this context. Objective: One of the most promising strategies for implementing shared decision making is distribution of decision aids by health professionals. We aimed to identify factors influencing their intention to use a DA during prenatal visit for decisions about Down syndrome screening. Methods: We conducted a cross-sectional quantitative study. Using a Web panel, we conducted a theory-based survey of health professionals in Quebec province (Canada). Eligibility criteria were as follows: (1) family physicians, midwives, obstetrician-gynecologists, or trainees in these professions; (2) involved in prenatal care; and (3) working in Quebec province. Participants watched a video depicting a health professional using a decision aid during a prenatal consultation with a woman and her partner, and then answered a questionnaire based on an extended version of the theory of planned behavior, including some of the constructs of the theoretical domains framework. The questionnaire assessed 8 psychosocial constructs (attitude, anticipated regret, subjective norm, self-identity, moral norm, descriptive norm, self-efficacy, and perceived control), 7 related sets of behavioral beliefs (advantages, disadvantages, emotions, sources of encouragement or discouragement, incentives, facilitators, and barriers), and sociodemographic data. We performed descriptive, bivariate, and multiple linear regression analyses to identify factors influencing health professionals’ intention to use a decision aid. Results: Among 330 health professionals who completed the survey, 310 met the inclusion criteria: family physicians, 55.2% (171/310); obstetrician-gynecologists, 33.8% (105/310); and midwives, 11.0% (34/310). Of these, 80.9% were female (251/310). Mean age was 39.6 (SD 11.5) years. Less than half were aware of any decision aids at all. In decreasing order of importance, factors influencing their intention to use a decision aid for Down syndrome prenatal screening were as follows: self-identity (beta=.325, P<.001), attitude (beta=.297, P<.001), moral norm (beta=.288, P<.001), descriptive norm (beta=.166, P<.001), and anticipated regret (beta=.099, P=.003). Underlying behavioral beliefs significantly related to intention were that the use of a decision aid would promote decision making (beta=.117, 95% CI 0.043-0.190), would reassure health professionals (beta=.100, 95% CI 0.024-0.175), and might require more time than planned for the consultation (beta=−.077, 95% CI −0.124 to −0.031). Conclusions: We identified psychosocial factors that could influence health professionals’ intention to use a decision aid about Down syndrome screening. Strategies should remind them of the following: (1) using a decision aid for this purpose should be a common practice, (2) it would be expected of someone in their societal role, (3) the experience of using it will be satisfying and reassuring, and (4) it is likely to be compatible with their moral values.

  • Source: Cloud DX, Incorporated; Copyright: Cloud DX, Incorporated; URL:; License: Licensed by the authors.

    A Comparison and Calibration of a Wrist-Worn Blood Pressure Monitor for Patient Management: Assessing the Reliability of Innovative Blood Pressure Devices


    Background: Clinical guidelines recommend monitoring of blood pressure at home using an automatic blood pressure device for the management of hypertension. Devices are not often calibrated against direct blood pressure measures, leaving health care providers and patients with less reliable information than is possible with current technology. Rigorous assessments of medical devices are necessary for establishing clinical utility. Objective: The purpose of our study was 2-fold: (1) to assess the validity and perform iterative calibration of indirect blood pressure measurements by a noninvasive wrist cuff blood pressure device in direct comparison with simultaneously recorded peripheral and central intra-arterial blood pressure measurements and (2) to assess the validity of the measurements thereafter of the noninvasive wrist cuff blood pressure device in comparison with measurements by a noninvasive upper arm blood pressure device to the Canadian hypertension guidelines. Methods: The cloud-based blood pressure algorithms for an oscillometric wrist cuff device were iteratively calibrated to direct pressure measures in 20 consented patient participants. We then assessed measurement validity of the device, using Bland-Altman analysis during routine cardiovascular catheterization. Results: The precalibrated absolute mean difference between direct intra-arterial to wrist cuff pressure measurements were 10.8 (SD 9.7) for systolic and 16.1 (SD 6.3) for diastolic. The postcalibrated absolute mean difference was 7.2 (SD 5.1) for systolic and 4.3 (SD 3.3) for diastolic pressures. This is an improvement in accuracy of 33% systolic and 73% diastolic with a 48% reduction in the variability for both measures. Furthermore, the wrist cuff device demonstrated similar sensitivity in measuring high blood pressure compared with the direct intra-arterial method. The device, when calibrated to direct aortic pressures, demonstrated the potential to reduce a treatment gap in high blood pressure measurements. Conclusions: The systolic pressure measurements of the wrist cuff have been iteratively calibrated using gold standard central (ascending aortic) pressure. This improves the accuracy of the indirect measures and potentially reduces the treatment gap. Devices that undergo auscultatory (indirect) calibration for licensing can be greatly improved by additional iterative calibration via intra-arterial (direct) measures of blood pressure. Further clinical trials with repeated use of the device over time are needed to assess the reliability of the device in accordance with current and evolving guidelines for informed decision making in the management of hypertension. Trial Registration: NCT03015363; (Archived by WebCite at

  • Participant performing sensor-guided exercise therapy on the Hinge Health program. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Effects of a 12-Week Digital Care Program for Chronic Knee Pain on Pain, Mobility, and Surgery Risk: Randomized Controlled Trial


    Background: Chronic knee pain, most commonly caused by knee osteoarthritis, is a prevalent condition which in most cases can be effectively treated through conservative, non-surgical care involving exercise therapy, education, psychosocial support, and weight loss. However, most people living with chronic knee pain do not receive adequate care, leading to unnecessary use of opiates and surgical procedures. Objective: Assess the efficacy of a remotely delivered digital care program for chronic knee pain. Methods: We enrolled 162 participants into a randomized controlled trial between January and March 2017. Participants were recruited from participating employers using questionnaires for self-assessment of their knee pain, and randomized into treatment (n=101) and control (n=61) groups. Participants in the treatment group were enrolled in the Hinge Health digital care program for chronic knee pain. This is a remotely delivered, home-based 12-week intervention that includes sensor-guided exercise therapy, education, cognitive behavioral therapy, weight loss, and psychosocial support through a personal coach and team-based interactions. The control group received three education pieces regarding self-care for chronic knee pain. Both groups had access to treatment-as-usual. The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain subscale and KOOS Physical Function Shortform (KOOS-PS). Secondary outcomes were visual analog scales (VAS) for pain and stiffness respectively, surgery intent, and self-reported understanding of the condition and treatment options. Outcome measures were analyzed by intention to treat (excluding 7 control participants who received the digital care program due to administrative error) and per protocol. Results: In an intent-to-treat analysis the digital care program group had a significantly greater reduction in KOOS Pain compared to the control group at the end of the program (greater reduction of 7.7, 95% CI 3.0 to 12.3, P=.002), as well as a significantly greater improvement in physical function (7.2, 95% CI 3.0 to 11.5, P=.001). This was also reflected in the secondary outcomes VAS pain (12.3, 95% CI 5.4 to 19.1, P<.001) and VAS stiffness (13.4, 95% CI 5.6 to 21.1, P=.001). Participants’ self-reported likelihood (from 0% to 100%) of having surgery also reduced more strongly in the digital care program group compared to the control group over the next 1 year (–9.4 percentage points, pp, 95% CI –16.6 to –2.2, P=.01), 2 years (–11.3 pp, 95% CI –20.1 to –2.5, P=.01), and 5 years (–14.6 pp, 95% CI –23.6 to –5.5, P=.002). Interest in surgery (from 0 to 10) also reduced more so in the digital care program compared to control group (–1.0, 95% CI –1.7 to –0.2, P=.01). Participants’ understanding of the condition and treatment options (on a scale from 0 to 4) increased more substantially for participants in the digital care program than those in the control group (0.9, 95% CI 0.6 to 1.3, P<.001). In an analysis on participants that completed the intervention (per protocol analysis) all primary and secondary outcomes remained significant at greater effect magnitudes compared to intention to treat, with those completing the program showing a 61% (95% CI 48 to 74) reduction in VAS pain compared to 21% (95% CI 5 to 38) in the control group (P<.001). Accounting for the cost of administering the program, we estimate net cost savings on surgery alone of US $4340 over 1 year and $7900 over 5 years for those participants completing the digital care program compared to those in the control group receiving treatment-as-usual. In an exploratory subgroup analysis including only participants exhibiting clinical symptoms of osteoarthritis the program proved equally effective. Conclusions: This trial provides strong evidence that a comprehensive 12-week digital care program for chronic knee pain, including osteoarthritis, yields significantly improved outcomes for pain, physical function, stiffness, surgery risk, and understanding of the condition, compared to a control group. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 13307390; (Archived by WebCite at

  • Source: Rawpixel; Copyright: Rawpixel; URL:; License: Licensed by JMIR.

    ComprehENotes, an Instrument to Assess Patient Reading Comprehension of Electronic Health Record Notes: Development and Validation


    Background: Patient portals are widely adopted in the United States and allow millions of patients access to their electronic health records (EHRs), including their EHR clinical notes. A patient’s ability to understand the information in the EHR is dependent on their overall health literacy. Although many tests of health literacy exist, none specifically focuses on EHR note comprehension. Objective: The aim of this paper was to develop an instrument to assess patients’ EHR note comprehension. Methods: We identified 6 common diseases or conditions (heart failure, diabetes, cancer, hypertension, chronic obstructive pulmonary disease, and liver failure) and selected 5 representative EHR notes for each disease or condition. One note that did not contain natural language text was removed. Questions were generated from these notes using Sentence Verification Technique and were analyzed using item response theory (IRT) to identify a set of questions that represent a good test of ability for EHR note comprehension. Results: Using Sentence Verification Technique, 154 questions were generated from the 29 EHR notes initially obtained. Of these, 83 were manually selected for inclusion in the Amazon Mechanical Turk crowdsourcing tasks and 55 were ultimately retained following IRT analysis. A follow-up validation with a second Amazon Mechanical Turk task and IRT analysis confirmed that the 55 questions test a latent ability dimension for EHR note comprehension. A short test of 14 items was created along with the 55-item test. Conclusions: We developed ComprehENotes, an instrument for assessing EHR note comprehension from existing EHR notes, gathered responses using crowdsourcing, and used IRT to analyze those responses, thus resulting in a set of questions to measure EHR note comprehension. Crowdsourced responses from Amazon Mechanical Turk can be used to estimate item parameters and select a subset of items for inclusion in the test set using IRT. The final set of questions is the first test of EHR note comprehension.

  • Source: Pixabay; Copyright: Gerd Altmann; URL:; License: Public Domain (CC0).

    Risk Assessment for Parents Who Suspect Their Child Has Autism Spectrum Disorder: Machine Learning Approach


    Background: Parents are likely to seek Web-based communities to verify their suspicions of autism spectrum disorder markers in their child. Automated tools support human decisions in many domains and could therefore potentially support concerned parents. Objective: The objective of this study was to test the feasibility of assessing autism spectrum disorder risk in parental concerns from Web-based sources, using automated text analysis tools and minimal standard questioning. Methods: Participants were 115 parents with concerns regarding their child’s social-communication development. Children were 16- to 30-months old, and 57.4% (66/115) had a family history of autism spectrum disorder. Parents reported their concerns online, and completed an autism spectrum disorder-specific screener, the Modified Checklist for Autism in Toddlers-Revised, with Follow-up (M-CHAT-R/F), and a broad developmental screener, the Ages and Stages Questionnaire (ASQ). An algorithm predicted autism spectrum disorder risk using a combination of the parent's text and a single screening question, selected by the algorithm to enhance prediction accuracy. Results: Screening measures identified 58% (67/115) to 88% (101/115) of children at risk for autism spectrum disorder. Children with a family history of autism spectrum disorder were 3 times more likely to show autism spectrum disorder risk on screening measures. The prediction of a child’s risk on the ASQ or M-CHAT-R was significantly more accurate when predicted from text combined with an M-CHAT-R question selected (automatically) than from the text alone. The frequently automatically selected M-CHAT-R questions that predicted risk were: following a point, make-believe play, and concern about deafness. Conclusions: The internet can be harnessed to prescreen for autism spectrum disorder using parental concerns by administering a few standardized screening questions to augment this process.

  • Source: Freepik; Copyright: Josep M Suria; URL:; License: Licensed by JMIR.

    Perceived Drivers and Barriers to the Adoption of eMental Health by Psychologists: The Construction of the Levels of Adoption of eMental Health Model


    Background: The internet offers major opportunities in supporting mental health care, and a variety of technology-mediated mental and behavioral health services have been developed. Yet, despite growing evidence for the effectiveness of these services, their acceptance and use in clinical practice remains low. So far, the current literature still lacks a structured insight into the experienced drivers and barriers to the adoption of electronic mental health (eMental health) from the perspective of clinical psychologists. Objective: The aim of this study was to gain an in-depth and comprehensive understanding of the drivers and barriers for psychologists in adopting eMental health tools, adding to previous work by also assessing drivers and analyzing relationships among these factors, and subsequently by developing a structured representation of the obtained findings. Methods: The study adopted a qualitative descriptive approach consisting of in-depth semistructured interviews with clinical psychologists working in the Netherlands (N=12). On the basis of the findings, a model was constructed that was then examined through a communicative validation. Results: In general, a key driver for psychologists to adopt eMental health is the belief and experience that it can be beneficial to them or their clients. Perceived advantages that are novel to literature include the acceleration of the treatment process, increased intimacy of the therapeutic relationship, and new treatment possibilities due to eMental health. More importantly, a relation was found between the extent to which psychologists have adopted eMental health and the particular drivers and barriers they experience. This differentiation is incorporated in the Levels of Adoption of eMental Health (LAMH) model that was developed during this study to provide a structured representation of the factors that influence the adoption of eMental health. Conclusions: The study identified both barriers and drivers, several of which are new to the literature and found a relationship between the nature and importance of the various drivers and barriers perceived by psychologists and the extent to which they have adopted eMental health. These findings were structured in a conceptual model to further enhance the current understanding. The LAMH model facilitates further research on the process of adopting eMental health, which will subsequently enable targeted recommendations with respect to technology, training, and clinical practice to ensure that mental health care professionals as well as their clients will benefit optimally from the current (and future) range of available eMental health options.

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

    Identifying Unmet Treatment Needs for Patients With Osteoporotic Fracture: Feasibility Study for an Electronic Clinical Surveillance System


    Background: Traditional clinical surveillance relied on the results from clinical trials and observational studies of administrative databases. However, these studies not only required many valuable resources but also faced a very long time lag. Objective: This study aimed to illustrate a practical application of the National Taiwan University Hospital Clinical Surveillance System (NCSS) in the identification of patients with an osteoporotic fracture and to provide a high reusability infrastructure for longitudinal clinical data. Methods: The NCSS integrates electronic medical records in the National Taiwan University Hospital (NTUH) with a data warehouse and is equipped with a user-friendly interface. The NCSS was developed using professional insight from multidisciplinary experts, including clinical practitioners, epidemiologists, and biomedical engineers. The practical example identifying the unmet treatment needs for patients encountering major osteoporotic fractures described herein was mainly achieved by adopting the computerized workflow in the NCSS. Results: We developed the infrastructure of the NCSS, including an integrated data warehouse and an automatic surveillance workflow. By applying the NCSS, we efficiently identified 2193 patients who were newly diagnosed with a hip or vertebral fracture between 2010 and 2014 at NTUH. By adopting the filter function, we identified 1808 (1808/2193, 82.44%) patients who continued their follow-up at NTUH, and 464 (464/2193, 21.16%) patients who were prescribed anti-osteoporosis medications, within 3 and 12 months post the index date of their fracture, respectively. Conclusions: The NCSS systems can integrate the workflow of cohort identification to accelerate the survey process of clinically relevant problems and provide decision support in the daily practice of clinical physicians, thereby making the benefit of evidence-based medicine a reality.

  • Clinical trial center staff using CTMS. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Utilization of a Clinical Trial Management System for the Whole Clinical Trial Process as an Integrated Database: System Development


    Background: Clinical trials pose potential risks in both communications and management due to the various stakeholders involved when performing clinical trials. The academic medical center has a responsibility and obligation to conduct and manage clinical trials while maintaining a sufficiently high level of quality, therefore it is necessary to build an information technology system to support standardized clinical trial processes and comply with relevant regulations. Objective: The objective of the study was to address the challenges identified while performing clinical trials at an academic medical center, Asan Medical Center (AMC) in Korea, by developing and utilizing a clinical trial management system (CTMS) that complies with standardized processes from multiple departments or units, controlled vocabularies, security, and privacy regulations. Methods: This study describes the methods, considerations, and recommendations for the development and utilization of the CTMS as a consolidated research database in an academic medical center. A task force was formed to define and standardize the clinical trial performance process at the site level. On the basis of the agreed standardized process, the CTMS was designed and developed as an all-in-one system complying with privacy and security regulations. Results: In this study, the processes and standard mapped vocabularies of a clinical trial were established at the academic medical center. On the basis of these processes and vocabularies, a CTMS was built which interfaces with the existing trial systems such as the electronic institutional review board health information system, enterprise resource planning, and the barcode system. To protect patient data, the CTMS implements data governance and access rules, and excludes 21 personal health identifiers according to the Health Insurance Portability and Accountability Act (HIPAA) privacy rule and Korean privacy laws. Since December 2014, the CTMS has been successfully implemented and used by 881 internal and external users for managing 11,645 studies and 146,943 subjects. Conclusions: The CTMS was introduced in the Asan Medical Center to manage the large amounts of data involved with clinical trial operations. Inter- and intraunit control of data and resources can be easily conducted through the CTMS system. To our knowledge, this is the first CTMS developed in-house at an academic medical center side which can enhance the efficiency of clinical trial management in compliance with privacy and security laws.

  • Source: FreePik; Copyright: bearfotos; URL:; License: Licensed by JMIR.

    Improving the Usefulness and Use of Patient Survey Programs: National Health Service Interview Study


    Background: A growing body of evidence suggests a concerning lag between collection of patient experience data and its application in service improvement. This study aims to identify what health care staff perceive to be the barriers and facilitators to using patient-reported feedback and showcase successful examples of doing so. Objective: This study aimed to apply a systems perspective to suggest policy improvements that could support efforts to use data on the frontlines. Methods: Qualitative interviews were conducted in eight National Health Service provider locations in the United Kingdom, which were selected based on National Inpatient Survey scores. Eighteen patient-experience leads were interviewed about using patient-reported feedback with relevant staff. Interviews were transcribed and underwent thematic analysis. Staff-identified barriers and facilitators to using patient experience feedback were obtained. Results: The most frequently cited barriers to using patient reported feedback pertained to interpreting results, understanding survey methodology, presentation of data in both national Care Quality Commission and contractor reports, inability to link data to other sources, and organizational structure. In terms of a wish list for improved practice, staff desired more intuitive survey methodologies, the ability to link patient experience data to other sources, and more examples of best practice in patient experience improvement. Three organizations also provided examples of how they successfully used feedback to improve care. Conclusions: Staff feedback provides a roadmap for policy makers to reconsider how data is collected and whether or not the national regulations on surveys and patient experience data are meeting the quality improvement needs of local organizations.

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

    Effectiveness of an Internet- and App-Based Intervention for College Students With Elevated Stress: Randomized Controlled Trial


    Background: Mental health problems are highly prevalent among college students. Most students with poor mental health, however, do not receive professional help. Internet-based self-help formats may increase the utilization of treatment. Objective: The aim of this randomized controlled trial was to evaluate the efficacy of an internet-based, app-supported stress management intervention for college students. Methods: College students (n=150) with elevated levels of stress (Perceived Stress Scale 4-item version, PSS-4 ≥8) were randomly assigned to either an internet- and mobile-based stress intervention group with feedback on demand or a waitlist control group. Self-report data were assessed at baseline, posttreatment (7 weeks), and 3-month follow-up. The primary outcome was perceived stress posttreatment (PSS-4). Secondary outcomes included mental health outcomes, modifiable risk and protective factors, and college-related outcomes. Subgroup analyses were conducted in students with clinically relevant symptoms of depression (Center for Epidemiological Studies’ Depression Scale >17). Results: A total of 106 participants (76.8%) indicated that they were first-time help-seekers, and 77.3% (intervention group: 58/75; waitlist control group: 58/75) showed clinically relevant depressive symptoms at baseline. Findings indicated significant effects of the intervention compared with the waitlist control group for stress (d=0.69; 95% CI 0.36-1.02), anxiety (d=0.76; 95% CI 0.43-1.09), depression (d=0.63; 95% CI 0.30-0.96), college-related productivity (d=0.33; 95% CI 0.01-0.65), academic work impairment (d=0.34; 95% CI 0.01-0.66), and other outcomes after 7 weeks (posttreatment). Response rates for stress symptoms were significantly higher for the intervention group (69%, 52/75) compared with the waitlist control group (35%, 26/75, P<.001; number needed to treat=2.89, 95% CI 2.01-5.08) at posttest (7 weeks). Effects were sustained at 3-month follow-up, and similar findings emerged in students with symptoms of depression. Conclusions: Internet- and mobile-based interventions could be an effective and cost-effective approach to reduce consequences of college-related stress and might potentially attract students with clinically relevant depression who would not otherwise seek help. Trial Registration: German Clinical Trial Register DRKS00010212; navigationId=trial.HTML&TRIAL_ID=DRKS00010212 (Archived by WebCite at

  • Patient using Web-based patient education application on iPad at the outpatient clinic 'Orthopedie' (Orthopedics). Image owned by Zimmer Biomet & Delft University of Technology, photo by Rosel van den Berg. Source: Image created by the Authors; Copyright: Zimmer Biomet & Delft University of Technology, photo by Rosel van den Berg; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Web-Based Patient Education in Orthopedics: Systematic Review


    Background: Patients with orthopedic conditions frequently use the internet to find health information. Patient education that is distributed online may form an easily accessible, time- and cost-effective alternative to education delivered through traditional channels such as one-on-one consultations or booklets. However, no systematic evidence for the comparative effectiveness of Web-based educational interventions exists. Objective: The objective of this systematic review was to examine the effects of Web-based patient education interventions for adult orthopedic patients and to compare its effectiveness with generic health information websites and traditional forms of patient education. Methods: CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, PUBMED, ScienceDirect, Scopus, and Web of Science were searched covering the period from 1995 to 2016. Peer-reviewed English and Dutch studies were included if they delivered patient education via the internet to the adult orthopedic population and assessed its effects in a controlled or observational trial. Results: A total of 10 trials reported in 14 studies involving 4172 patients were identified. Nine trials provided evidence for increased patients’ knowledge after Web-based patient education. Seven trials reported increased satisfaction and good evaluations of Web-based patient education. No compelling evidence exists for an effect of Web-based patient education on anxiety, health attitudes and behavior, or clinical outcomes. Conclusions: Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the objective is to improve patients’ knowledge and satisfaction. However, these findings may not be representative for the whole orthopedic patient population as most trials included considerably younger, higher-educated, and internet-savvy participants only.

  • Mobile digital health intervention app (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Usage of a Digital Health Workplace Intervention Based on Socioeconomic Environment and Race: Retrospective Secondary Cross-Sectional Study


    Background: Digital health tools have been associated with improvement of cardiovascular disease (CVD) risk factors and outcomes; however, the differential use of these technologies among various ethnic and economic classes is not well known. Objective: To identify the effect of socioeconomic environment on usage of a digital health intervention. Methods: A retrospective secondary cross-sectional analysis of a workplace digital health tool use, in association with a change in intermediate markers of CVD, was undertaken over the course of one year in 26,188 participants in a work health program across 81 organizations in 42 American states between 2011 and 2014. Baseline demographic data for participants included age, sex, race, home zip code, weight, height, blood pressure, glucose, lipids, and hemoglobin A1c. Follow-up data was then obtained in 90-day increments for up to one year. Using publicly available data from the American Community Survey, we obtained the median income for each zip code as a marker for socioeconomic status via median household income. Digital health intervention usage was analyzed based on socioeconomic status as well as age, gender, and race. Results: The cohort was found to represent a wide sample of socioeconomic environments from a median income of US $11,000 to $171,000. As a whole, doubling of income was associated with 7.6% increase in log-in frequency. However, there were marked differences between races. Black participants showed a 40.5% increase and Hispanic participants showed a 57.8% increase in use with a doubling of income, compared to 3% for Caucasian participants. Conclusions: The current study demonstrated that socioeconomic data confirms no relevant relationship between socioeconomic environment and digital health intervention usage for Caucasian users. However, a strong relationship is present for black and Hispanic users. Thus, socioeconomic environment plays a prominent role only in minority groups that represent a high-risk group for CVD. This finding identifies a need for digital health apps that are effective in these high-risk groups.

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  • Television advertising and Marketplace consumer engagement: the case of Kentucky

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: Reductions in health insurance enrollment outreach could have negative effects on the individual health insurance market. Specifically, consumers may not be informed about the availability...

    Background: Reductions in health insurance enrollment outreach could have negative effects on the individual health insurance market. Specifically, consumers may not be informed about the availability of coverage and if some healthier consumers fail to enroll, there could be a worse risk pool for insurers. Kentucky created its own Marketplace, known as kynect, and adopted Medicaid expansion under the ACA, which yielded the largest decline in adult uninsured rate in the country from 2013 to 2016. The state sponsored an award-winning media campaign yet declined to renew the advertising contract for kynect and canceled all pending television ads with over a month remaining in the 2016 open enrollment period after the election of a new governor in 2015. Objective: The objective of this study is to examine the stark variation in advertising across multiple open enrollment periods in Kentucky and to use this variation to estimate the dose-response effect of state-sponsored advertising on consumer engagement with the Marketplace. In addition, we assess to what extent private insurers can potentially help fill the void when governments reduce or eliminate television advertising. Methods: We obtained advertising (Kantar Media/CMAG) and Marketplace data (Kentucky Health Benefit Exchange) for the period of October 1, 2013 through January 31, 2016 for Kentucky. Advertising data at the spot level were collapsed to state-week counts by sponsor type. Similarly, a state-week series of Marketplace engagement and enrollment measures were derived from state reports to CMS. We use linear regression models to estimate associations between health insurance advertising volume and measures of information seeking (calls to call center; page views, visits, and unique visitors to website) and enrollment (online and total applications, Marketplace enrollment). Results: We find significant dose-response effects of weekly state-sponsored advertising volume during open enrollment on information-seeking behavior (page views: 7,972.9, visits: 390.2, and unique visitors: 387.5) and enrollment activity (applications, online: 61.4 and total: 55.9). Conclusions: State-sponsored television advertising was associated with nearly 40% of unique visitors and online applications. Insurance company advertising was not a significant driver of engagement, an important consideration if cuts to government-sponsored advertising persist.

  • A Novel Insight into the Challenges of Diagnosing Cervical Spondylotic Myelopathy using Online Symptom Checkers

    Date Submitted: Apr 25, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: Cervical Spondylotic Myelopathy (CSM) is a common debilitating condition resulting from degeneration of the cervical spine. Whilst decompressive surgery can halt disease progression, exist...

    Background: Cervical Spondylotic Myelopathy (CSM) is a common debilitating condition resulting from degeneration of the cervical spine. Whilst decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability. Treatment within 6 months improves the likelihood of recovery, yet most patients wait over 2 years for a diagnosis. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of CSM by symptom checkers may contribute to the delay in diagnosis. Objective: The present study sought to investigate whether online symptom checkers are able to recognise relevant symptoms of CSM, to characterise the CSM differential returned, and to evaluate the diagnostic performance of its recognised symptoms. Methods: Textbook CSM symptoms were pooled from leading review articles. These symptoms were entered into the algorithms used by the top 20 symptom checker websites (N=4) (Google Search). The most widely cited symptom checker, WebMD, was used to characterise the differential diagnosis for CSM symptoms. Results: 31 textbook CSM symptoms were identified, of which 14 (45%) listed CSM as a differential and 3 (10%) placed CSM in the top third of the differential. The mean differential rank for motor symptoms was significantly better than for arthritic symptoms (P = .0093) and the average differential rank for all symptoms (P = .048). The symptom checker WebMD performed best at recognising CSM, placing it nearer the top of the differential list (average rank of 5.6) than both Healthline (rank of 12.9, P = .015) and Healthtools.AARP (rank of 15.5, P = .0014). On WebMD, only one combination of symptoms resulted in CSM as the primary differential: neck, shoulder and arm pain with hand weakness. 151 differential diagnoses for CSM symptoms were recorded on WebMD. Multiple sclerosis and peripheral neuropathy were the most common differentials, shortlisted for 52% and 32% of CSM symptoms respectively. Conclusions: CSM symptoms perform poorly in online symptom checkers and lead to a large differential of many other common conditions. Whilst a diagnosis becomes more likely as the number of symptoms increases, this will not support much needed earlier diagnosis. Symptom checkers remain an attractive concept with potential. Further research is required to support their optimisation.

  • Quantifying Impact of Validation and Testing on FHIR Standards Compliance

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: There is wide recognition that the lack of health data interoperability has significant impacts. Traditionally health data standards are complex, and test-driven methods played important r...

    Background: There is wide recognition that the lack of health data interoperability has significant impacts. Traditionally health data standards are complex, and test-driven methods played important roles in achieving interoperability. HL7 FHIR may be a technical solution that aligns with policy, but systems need to be validated and tested. Objective: Our objective is to explore the question of whether or not the regular use of validation and testing tools improves server compliance with the HL7 FHIR specification. Methods: We used two independent validation and testing tools, Crucible and Touchstone, and analyzed the usage and result data to determine their impact on server compliance with the HL7 FHIR specification. Results: The use of validation and testing tools such as Crucible and Touchstone are strongly correlated with increased compliance, and “practice makes perfect.” Additional data analysis reveals trends over time with respect to vendors, use-cases, and FHIR versions. Conclusions: Validation and testing tools can aid in the transition to an interoperable health care infrastructure. Developers that use testing and validation tools tend to produce more compliant FHIR implementations. When it comes to health data interoperability, “practice makes perfect.”

  • Telerehabiliitation for Stroke Survivors: A Systematic Review and Meta-analysis

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: Telemedicine is increasingly evaluated for rehabilitation of stroke survivors. However, little is known about the utility of telerehabilitation in stroke survivors. Objective: To summarize...

    Background: Telemedicine is increasingly evaluated for rehabilitation of stroke survivors. However, little is known about the utility of telerehabilitation in stroke survivors. Objective: To summarize the evidence on the utility of telerehabilitation in stroke survivors. Methods: Eligible randomized controlled trials (RCTs) were selected from Medline, Cochrane Central and Web of Science databases. Continuous data on the outcomes were analyzed using the RevMan software as standardized mean difference (SMD) and 95% confidence interval (95% CI) in a fixed effect meta-analysis model. Results: Fifteen studies, providing data on 1,339 stroke survivors were eligible for inclusion. The combined effect estimate showed that telerehabilitation is as good as usual care as Barthel index (SMD = -0.05, 95% CI [-0.18, 0.08]), Berg Balance Scale (SMD = -0.04, 95% CI [-0.34, 0.26]), Fugl-Meyer Upper Extremity (SMD = 0.50, 95% CI [-0.09, 1.09]) and Stroke Impact Scale [mobility] (SMD = 0.18, 95% CI [-0.13, 0.48]) scores were statistically similar in both groups. Further, quality of life (of the stroke survivor), caregiver strain index and patients' satisfaction with care scores were also similar for both the groups. One study showed that the cost of telerehabilitation was lower than usual care by $654. Conclusions: Telerehabilitation can be a suitable alternative to usual rehabilitation care in post-stroke patients, especially in remote or underserved areas.

  • Health Information Technologies in the Support Systems of Pregnant Women and their Caregivers: A Mixed Methods Study

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

    Background: The quality and quantity of families’ support systems during pregnancy can affect maternal and fetal outcomes. The support systems of expecting families can include many elements, such a...

    Background: The quality and quantity of families’ support systems during pregnancy can affect maternal and fetal outcomes. The support systems of expecting families can include many elements, such as family members, friends, and work or community groups. Emerging health information technologies such as social media, Internet websites, and mobile apps provide new resources for pregnant families to augment their support systems and to fill information gaps. Objective: This study sought to determine the number and nature of the components of the support systems of pregnant women and their caregivers, and the role of health information technologies in these support systems. We examined the differences between pregnant women’s support systems and those of their caregivers and the associations between support system composition and stress levels. Methods: We enrolled pregnant women and caregivers from an advanced maternal fetal and group prenatal care clinics. Participants completed surveys assessing sociodemographic characteristics, health literacy, numeracy, and stress levels, and they were asked to draw a picture of their support system. Support system elements were extracted from drawings, categorized by type (i.e., individual persons, groups, technologies, and other), and summarized for pregnant women and caregivers. Participant characteristics and support system elements were compared using Pearson Chi-square test for categorical variables and Wilcoxon ranked sum test for continuous variables. Associations between support system characteristics and stress levels were measured with Spearman correlation coefficient. Results: The study enrolled 100 participants: 71 pregnant women and 29 caregivers. The support systems of pregnant women were significantly larger than those of caregivers, with an average of 7.4 components for pregnant women and 5.4 components for caregivers (P=0.003). For all participants, the most commonly reported support system elements were individual persons (60.3% of support systems), followed by people groups (19.3%), technologies (16.2%), and other resources (4.2%). Pregnant women’s and caregivers’ technology preferences within their support systems differed: pregnant women more often identified informational websites, apps, and social media as parts of their support systems, whereas caregivers more frequently reported general Internet search engines. The size and components of these support systems were not associated with levels of stress. Conclusions: This study is one of the first demonstrating that technologies comprise a substantial portion of the support systems of pregnant women and their caregivers. Pregnant women more frequently reported specific medical information websites as part of their support system, whereas caregivers more often reported general Internet search engines. Although social support is important for maternal and fetal health outcomes, no associations among stress, support system size, and support system components were found in this study. As health information technologies continue to evolve and their adoption increases, their role in patient and caregiver support systems and their effects should be further explored.

  • Image-Based Mobile System for Dietary Management in an American Cardiology Population: Randomized Controlled Trial to Assess the Efficacy of Dietary Coaching Delivered via Smartphone App versus Traditional Counseling

    Date Submitted: Apr 24, 2018

    Open Peer Review Period: Apr 24, 2018 - Jun 19, 2018

    Background: Randomized controlled trials conducted in Mediterranean countries have shown that the Mediterranean diet lowers adverse cardiovascular events. In the American population, diet remains the...

    Background: Randomized controlled trials conducted in Mediterranean countries have shown that the Mediterranean diet lowers adverse cardiovascular events. In the American population, diet remains the biggest uncontrolled risk factor for cardiovascular disease, and patients with cardiovascular disease require more extensive dietary counseling to reduce their risk of myocardial infarction, stroke and hypertension. Objective: Our study tested the hypothesis that asynchronous dietary counseling supplied through a custom smartphone application results in better adherence to a Mediterranean diet in a non-Mediterranean population compared with traditional standard-of-care counseling. Methods: 100 patients presenting to the cardiology clinic of an academic medical center in Washington D.C. were randomized to either the standard-of-care (SOC) or smartphone app-based (EXP) Mediterranean diet intervention after informed consent and 1 hour of individual face-to-face dietary counseling with a registered dietician. Participants in EXP received a custom smartphone application that reinforced the Mediterranean diet while participants in SOC received two additional sessions of in-person dietary counseling with the registered dietician – 30 minutes at 1 month and 30 minutes at 3 months. Pre-existing knowledge of a Mediterranean diet was measured by the validated Mediterranean Diet Score instrument (MDS). Baseline height, weight, blood pressure and laboratory biomarkers were collected. At 1, 3 and 6 months, participants presented for a follow up appointment to assess compliance to the Mediterranean diet using the MDS, as well as a patient satisfaction survey, blood pressure and weight. Repeat laboratory biomarkers were performed at 3 and 6 months. Results: Enrolled participants had a mean age with standard error of 56.6 ± 1.7 for SOC and 57.2 ± 1.8 for EXP; 65.3% of SOC and 56.9% of EXP were male, and 20.4% of SOC and 35.3% of EXP had coronary artery disease. There were no significant differences between EXP and SOC with respect to blood pressure, lipid parameters, HgbA1C, or CRP. Participants in EXP achieved a significantly greater weight loss on average of 3.3 lbs vs. 3.1 lbs for participants in SOC, p=0.04. Adherence to the Mediterranean diet increased significantly over time for both groups (p<0.001), but there was no significant difference between groups (p=0.69). Similarly, there was no significant difference in diet satisfaction between EXP and SOC, although diet satisfaction increased significantly over time for both groups. The proportion of participants with high Mediterranean diet compliance (defined as MDS ≥ 9) increased significantly over time (p<0.001) – from 18.4 to 57.1% for SOC and 27.5 to 64.7% for EXP – however, there was no significant difference between the groups. Conclusions: Both traditional standard-of-care counseling and smartphone-based counseling were effective in getting participants to adhere to a Mediterranean diet in this US-based study of cardiology patients, and these dietary changes persisted even after counseling had ended. However, neither method was more effective than the other. This study demonstrates that the American cardiology patient can change to and maintain a Mediterranean diet with either traditional or smartphone app-based nutrition counseling.