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 5.175 for 2016

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  • Source: Flickr; Copyright: Senado Federal; URL:; License: Creative Commons Attribution (CC-BY).

    Development and Use of Health-Related Technologies in Indigenous Communities: Critical Review


    Background: Older Indigenous adults encounter multiple challenges as their age intersects with health inequities. Research suggests that a majority of older Indigenous adults prefer to age in place, and they will need culturally safe assistive technologies to do so. Objective: The aim of this critical review was to examine literature concerning use, adaptation, and development of assistive technologies for health purposes by Indigenous peoples. Methods: Working within Indigenous research methodologies and from a decolonizing approach, searches of peer-reviewed academic and gray literature dated to February 2016 were conducted using keywords related to assistive technology and Indigenous peoples. Sources were reviewed and coded thematically. Results: Of the 34 sources captured, only 2 concerned technology specifically for older Indigenous adults. Studies detailing technology with Indigenous populations of all ages originated primarily from Canada (n=12), Australia (n=10), and the United States (n=9) and were coded to four themes: meaningful user involvement and community-based processes in development, the digital divide, Indigenous innovation in technology, and health technology needs as holistic and interdependent. Conclusions: A key finding is the necessity of meaningful user involvement in technology development, especially in communities struggling with the digital divide. In spite of, or perhaps because of this divide, Indigenous communities are enthusiastically adapting mobile technologies to suit their needs in creative, culturally specific ways. This enthusiasm and creativity, coupled with the extensive experience many Indigenous communities have with telehealth technologies, presents opportunity for meaningful, culturally safe development processes.

  • Source:; Copyright: Vichaya Kiatying-Angsulee; URL:; License: Licensed by the authors.

    Adolescents’ Perspectives on Personalized E-Feedback in the Context of Health Risk Behavior Screening for Primary Care: Qualitative Study


    Background: Electronic health screening tools for primary care present an opportunity to go beyond data collection to provide education and feedback to adolescents in order to motivate behavior change. However, there is limited research to guide feedback message development. Objective: The aim of this study was to explore youth perceptions of and preferences for receiving personalized feedback for multiple health risk behaviors and reinforcement for health promoting behaviors from an electronic health screening tool for primary care settings, using qualitative methodology. Methods: In total, 31 adolescents aged 13-18 years completed the screening tool, received the electronic feedback, and subsequently participated in individual, semistructured, qualitative interviews lasting approximately 60 min. Participants were queried about their overall impressions of the tool, perceptions regarding various types of feedback messages, and additional features that would help motivate health behavior change. Using thematic analysis, interview transcripts were coded to identify common themes expressed across participants. Results: Overall, the tool was well-received by participants who perceived it as a way to enhance—but not replace—their interactions with providers. They appreciated receiving nonjudgmental feedback from the tool and responded positively to information regarding the consequences of behaviors, comparisons with peer norms and health guidelines, tips for behavior change, and reinforcement of healthy choices. A small but noteworthy minority of participants dismissed the peer norms as not real or relevant and national guidelines as not valid or reasonable. When prompted for possible adaptations to the tool, adolescents expressed interest in receiving follow-up information, setting health-related goals, tracking their behaviors over time, and communicating with providers electronically between appointments. Conclusions: Adolescents in this qualitative study desired feedback that validates their healthy behavior choices and supports them as independent decision makers by neutrally presenting health information, facilitating goal setting, and offering ongoing technological supports.

  • Source: The Authors; Copyright: Leanwer; URL:; License: Creative Commons Attribution (CC-BY).

    Social Media Engagement and HIV Testing Among Men Who Have Sex With Men in China: A Nationwide Cross-Sectional Survey


    Background: Many interventions find that social media engagement with health promotion materials can translate into behavioral changes. However, only a few studies have examined the ways in which specific actions on various social media platforms are correlated with health behaviors. Objective: The objective of this study was to examine the association between social media use and HIV testing behaviors among Chinese men who have sex with men (MSM). Methods: In July 2016, a Web-based survey was conducted to recruit MSM in 8 Chinese cities through Blued (Blue City Holdings Ltd.), the world’s largest gay mobile phone app. Data on sociodemographic variables, social media use platforms and behaviors, sexual behaviors, and HIV testing histories were collected. HIV testing–related social media use was defined as having ever engaged with HIV testing content on social media, which was further divided into observing (ie, receiving), endorsing (eg, liking and sharing), and contributing (eg, posting or commenting on HIV testing materials). Confirmatory factor analysis (CFA) was conducted to determine the best division of HIV testing–related social media use. Univariate and multivariable logistic regressions were used to examine the association between HIV testing–related social media use and HIV testing behaviors. Results: A total of 2105 individuals participated in the survey. Among them, 46.75% (984) were under the age of 24 years, 35.43% (746) had high school education or less, and 47.74% (587) had condomless sex in the last 3 months. More than half of the respondents (58.14%, 1224/2105) reported HIV testing–related social media use. Additionally, HIV testing–related social media use, especially on multifunctional platforms such as WeChat, was found to be associated with recent HIV testing (adjusted odds ratio [aOR] 2.32, 95% CI 1.66-3.24). Contributing on social media was correlated with recent HIV testing (aOR 2.10, 95% CI 1.40-3.16), but neither observing (aOR 0.66, 95% CI 0.38-1.15) nor endorsing (aOR 1.29, 95% CI 0.88-1.90) were correlated. Conclusions: Our data suggest that social media use, particularly on multifunctional platforms such as WeChat and with contributing behaviors, is correlated with HIV testing among MSM in China. Campaigns that promote active participant contribution on social media beyond passive observation and endorsement of promotional materials are needed. This study has implications for the design and implementation of social media interventions to promote HIV testing.

  • Source: Flickr; Copyright: Daniel Horacio Agostini; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Youth Oriented Activity Trackers: Comprehensive Laboratory- and Field-Based Validation


    Background: Commercial activity trackers are growing in popularity among adults and some are beginning to be marketed to children. There is, however, a paucity of independent research examining the validity of these devices to detect physical activity of different intensity levels. Objectives: The purpose of this study was to determine the validity of the output from 3 commercial youth-oriented activity trackers in 3 phases: (1) orbital shaker, (2) structured indoor activities, and (3) 4 days of free-living activity. Methods: Four units of each activity tracker (Movband [MB], Sqord [SQ], and Zamzee [ZZ]) were tested in an orbital shaker for 5-minutes at three frequencies (1.3, 1.9, and 2.5 Hz). Participants for Phase 2 (N=14) and Phase 3 (N=16) were 6-12 year old children (50% male). For Phase 2, participants completed 9 structured activities while wearing each tracker, the ActiGraph GT3X+ (AG) research accelerometer, and a portable indirect calorimetry system to assess energy expenditure (EE). For Phase 3, participants wore all 4 devices for 4 consecutive days. Correlation coefficients, linear models, and non-parametric statistics evaluated the criterion and construct validity of the activity tracker output. Results: Output from all devices was significantly associated with oscillation frequency (r=.92-.99). During Phase 2, MB and ZZ only differentiated sedentary from light intensity (P<.01), whereas the SQ significantly differentiated among all intensity categories (all comparisons P<.01), similar to AG and EE. During Phase 3, AG counts were significantly associated with activity tracker output (r=.76, .86, and .59 for the MB, SQ, and ZZ, respectively). Conclusions: Across study phases, the SQ demonstrated stronger validity than the MB and ZZ. The validity of youth-oriented activity trackers may directly impact their effectiveness as behavior modification tools, demonstrating a need for more research on such devices.

  • Wikipedia pages related to autoimmune disorders (montage). Source: The Authors / Freepik; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Readability of Wikipedia Pages on Autoimmune Disorders: Systematic Quantitative Assessment


    Background: In the era of new information and communication technologies, the Internet is being increasingly accessed for health-related information. Indeed, recently published patient surveys of people with autoimmune disorders confirmed that the Internet was reported as one of the most important health information sources. Wikipedia, a free online encyclopedia launched in 2001, is generally one of the most visited websites worldwide and is often consulted for health-related information. Objective: The main objective of this investigation was to quantitatively assess whether the Wikipedia pages related to autoimmune disorders can be easily accessed by patients and their families, in terms of readability. Methods: We obtained and downloaded a list of autoimmune disorders from the American Autoimmune Related Diseases Association (AARDA) website. We analyzed Wikipedia articles for their overall level of readability with 6 different quantitative readability scales: (1) the Flesch Reading Ease, (2) the Gunning Fog Index, (3) the Coleman-Liau Index, (4) the Flesch-Kincaid Grade Level, (5) the Automated Readability Index (ARI), and (6) the Simple Measure of Gobbledygook (SMOG). Further, we investigated the correlation between readability and clinical, pathological, and epidemiological parameters. Moreover, each Wikipedia analysis was assessed according to its content, breaking down the readability indices by main topic of each part (namely, pathogenesis, treatment, diagnosis, and prognosis plus a section containing paragraphs not falling into any of the previous categories). Results: We retrieved 134 diseases from the AARDA website. The Flesch Reading Ease yielded a mean score of 24.34 (SD 10.73), indicating that the sites were very difficult to read and best understood by university graduates, while mean Gunning Fog Index and ARI scores were 16.87 (SD 2.03) and 14.06 (SD 2.12), respectively. The Coleman-Liau Index and the Flesch-Kincaid Grade Level yielded mean scores of 14.48 (SD 1.57) and 14.86 (1.95), respectively, while the mean SMOG score was 15.38 (SD 1.37). All the readability indices confirmed that the sites were suitable for a university graduate reading level. We found no correlation between readability and clinical, pathological, and epidemiological parameters. Differences among the different sections of the Wikipedia pages were statistically significant. Conclusions: Wikipedia pages related to autoimmune disorders are characterized by a low level of readability. The onus is, therefore, on physicians and health authorities to improve the health literacy skills of patients and their families and to create, together with patients themselves, disease-specific readable sites, disseminating highly accessible health-related online information, in terms of both clarity and conciseness.

  • Source:; Copyright: blackzheep; URL:; License: Licensed by the authors.

    Ecological Momentary Assessment of Physical Activity: Validation Study


    Background: Ecological momentary assessment (EMA) may elicit physical activity (PA) estimates that are less prone to bias than traditional self-report measures while providing context. Objectives: The objective of this study was to examine the convergent validity of EMA-assessed PA compared with accelerometry. Methods: The participants self-reported their PA using International Physical Activity Questionnaire (IPAQ) and Behavioral Risk Factor Surveillance System (BRFSS) and wore an accelerometer while completing daily EMAs (delivered through the mobile phone) for 7 days. Weekly summary estimates included sedentary time and moderate-, vigorous-, and moderate-to vigorous-intensity physical activity (MVPA). Spearman coefficients and Lin’s concordance correlation coefficients (LCC) examined the linear association and agreement for EMA and the questionnaires as compared with accelerometry. Results: Participants were aged 43.3 (SD 13.1) years, 51.7% (123/238) were African American, 74.8% (178/238) were overweight or obese, and 63.0% (150/238) were low income. The linear associations of EMA and traditional self-reports with accelerometer estimates were statistically significant (P<.05) for sedentary time (EMA: ρ=.16), moderate-intensity PA (EMA: ρ=.29; BRFSS: ρ=.17; IPAQ: ρ=.24), and MVPA (EMA: ρ=.31; BRFSS: ρ=.17; IPAQ: ρ=.20). Only EMA estimates of PA were statistically significant compared with accelerometer for agreement. Conclusions: The mobile EMA showed better correlation and agreement to accelerometer estimates than traditional self-report methods. These findings suggest that mobile EMA may be a practical alternative to accelerometers to assess PA in free-living settings.

  • Doctor with Loop interface on phone (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    My Team of Care Study: A Pilot Randomized Controlled Trial of a Web-Based Communication Tool for Collaborative Care in Patients With Advanced Cancer


    Background: The management of patients with complex care needs requires the expertise of health care providers from multiple settings and specialties. As such, there is a need for cross-setting, cross-disciplinary solutions that address deficits in communication and continuity of care. We have developed a Web-based tool for clinical collaboration, called Loop, which assembles the patient and care team in a virtual space for the purpose of facilitating communication around care management. Objective: The objectives of this pilot study were to evaluate the feasibility of integrating a tool like Loop into current care practices and to capture preliminary measures of the effect of Loop on continuity of care, quality of care, symptom distress, and health care utilization. Methods: We conducted an open-label pilot cluster randomized controlled trial allocating patients with advanced cancer (defined as stage III or IV disease) with ≥3 months prognosis, their participating health care team and caregivers to receive either the Loop intervention or usual care. Outcome data were collected from patients on a monthly basis for 3 months. Trial feasibility was measured with rate of uptake, as well as recruitment and system usage. The Picker Continuity of Care subscale, Palliative care Outcomes Scale, Edmonton Symptom Assessment Scale, and Ambulatory and Home Care Record were patient self-reported measures of continuity of care, quality of care, symptom distress, and health services utilization, respectively. We conducted a content analysis of messages posted on Loop to understand how the system was used. Results: Nineteen physicians (oncologists or palliative care physicians) were randomized to the intervention or control arms. One hundred twenty-seven of their patients with advanced cancer were approached and 48 patients enrolled. Of 24 patients in the intervention arm, 20 (83.3%) registered onto Loop. In the intervention and control arms, 12 and 11 patients completed three months of follow-up, respectively. A mean of 1.2 (range: 0 to 4) additional healthcare providers with an average total of 3 healthcare providers participated per team. An unadjusted between-arm increase of +11.4 was observed on the Picker scale in favor of the intervention arm. Other measures showed negligible changes. Loop was primarily used for medical care management, symptom reporting, and appointment coordination. Conclusions: The results of this study show that implementation of Loop was feasible. It provides useful information for planning future studies further examining effectiveness and team collaboration. Numerically higher scores were observed for the Loop arm relative to the control arm with respect to continuity of care. Future work is required to understand the incentives and barriers to participation so that the implementation of tools like Loop can be optimized. Trial Registration: NCT02372994; (Archived by WebCite at

  • Source: The Authors; Copyright: Kenneth Kobak; URL:; License: Creative Commons Attribution (CC-BY).

    Web-Based Therapist Training in Interpersonal Psychotherapy for Depression: Pilot Study


    Background: Training mental health professionals to deliver evidence-based therapy (EBT) is now required by most academic accreditation bodies, and evaluating the effectiveness of such training is imperative. However, shortages of time, money, and trained EBT clinician teachers make these challenges daunting. New technologies may help. The authors have developed the first empirically evaluated comprehensive Internet therapist training program for interpersonal psychotherapy (IPT). Objective: The aim of this study was to examine whether (1) the training protocol would increase clinicians’ knowledge of IPT concepts and skills and (2) clinicians would deem the training feasible as measured by satisfaction and utility ratings. Methods: A total of 26 clinicians enrolled in the training, consisting of (1) a Web-based tutorial on IPT concepts and techniques; (2) live remote training via videoconference, with trainees practicing IPT techniques in a role-play using a case vignette; and (3) a Web-based portal for therapists posttraining use to help facilitate implementation of IPT and maintain adherence over time. Results: Trainees’ knowledge of IPT concepts and skills improved significantly (P<.001). The standardized effect size for the change was large: d=2.53, 95% CI 2.23-2.92. Users found the technical features easy to use, the content useful for helping them treat depressed clients, and felt the applied training component enhanced their professional expertise. Mean rating of applied learning was 3.9 (scale range from 1=very little to 5=a great deal). Overall satisfaction rating was 3.5 (range from 1=very dissatisfied to 4=very satisfied). Conclusions: Results support the efficacy and feasibility of this technology in training clinicians in EBTs and warrant further empirical evaluation.

  • Screenshot from Instagram. Source: Instagram; URL:; License: Fair use/fair dealings.

    Images of Little Cigars and Cigarillos on Instagram Identified by the Hashtag #swisher: Thematic Analysis


    Background: Little cigar and cigarillo use is becoming more prevalent in the United States and elsewhere, with implications for public health. As little cigar and cigarillo use grows in popularity, big social media data (eg, Instagram, Google Web Search, Twitter) can be used to capture and document the context in which individuals use, and are marketed, these tobacco products. Big social media data may allow people to organically demonstrate how and why they use little cigars and cigarillos, unprimed by a researcher, without instrument bias and at low costs. Objective: This study characterized Swisher (the most popular brand of cigars in the United States, controlling over 75% of the market share) little cigar- and cigarillo-related posts on Instagram to inform the design of tobacco education campaigns and the development of future tobacco control efforts, and to demonstrate the utility in using big social media data in understanding health behaviors. Methods: We collected images from Instagram, an image-based social media app allowing users to capture, customize, and post photos on the Internet with over 400 million active users. Inclusion criteria for this study consisted of an Instagram post with the hashtag “#swisher”. We established rules for coding themes of images. Results: Of 1967 images collected, 486 (24.71%) were marijuana related, 348 (17.69%) were of tobacco products or promotional material, 324 (16.47%) showed individuals smoking, 225 (11.44%) were memes, and 584 (29.69%) were classified as other (eg, selfies, food, sexually explicit images). Of the marijuana-related images, 157/486 (32.3%) contained a Swisher wrapper, indicating that a Swisher product was used in blunt making, which involves hollowing out a cigar and refilling it with marijuana. Conclusions: Images from Instagram may be used to complement and extend the study of health behaviors including tobacco use. Images may be as valuable as, or more valuable than, words from other social media platforms alone. Posts on Instagram showing Swisher products, including blunt making, could add to the normalization of little cigar and cigarillo use and is an area of future research. Tobacco control researchers should design social media campaigns to combat smoking imagery found on popular sites such as Instagram.

  • Source: OpenNotes (the authors); Copyright: OpenNotes (the authors); License: Creative Commons Attribution (CC-BY).

    What Patients Value About Reading Visit Notes: A Qualitative Inquiry of Patient Experiences With Their Health Information


    Background: Patients are increasingly asking for their health data. Yet, little is known about what motivates patients to engage with the electronic health record (EHR). Furthermore, quality-focused mechanisms for patients to comment about their records are lacking. Objective: We aimed to learn more about patient experiences with reading and providing feedback on their visit notes. Methods: We developed a patient feedback tool linked to OpenNotes as part of a pilot quality improvement initiative focused on patient engagement. Patients who had appointments with members of 2 primary care teams piloting the program between August 2014-2015 were eligible to participate. We asked patients what they liked about reading notes and about using a feedback tool and analyzed all patient reports submitted during the pilot period. Two researchers coded the qualitative responses (κ=.74). Results: Patients and care partners submitted 260 reports. Among these, 98.5% (256/260) of reports indicated that the reporting tool was valuable, and 68.8% (179/260) highlighted what patients liked about reading notes and the OpenNotes patient reporting tool process. We identified 4 themes describing what patients value about note content: confirm and remember next steps, quicker access and results, positive emotions, and sharing information with care partners; and 4 themes about both patients’ use of notes and the feedback tool: accuracy and correcting mistakes, partnership and engagement, bidirectional communication and enhanced education, and importance of feedback. Conclusions: Patients and care partners who read notes and submitted feedback reported greater engagement and the desire to help clinicians improve note accuracy. Aspects of what patients like about using both notes as well as a feedback tool highlight personal, relational, and safety benefits. Future efforts to engage patients through the EHR may be guided by what patients value, offering opportunities to strengthen care partnerships between patients and clinicians.

  • Tweet encapsulating #FOAMed (montage). Source: Aidan Baron /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Preliminary Evidence for the Emergence of a Health Care Online Community of Practice: Using a Netnographic Framework for Twitter Hashtag Analytics


    Background: Online communities of practice (oCoPs) may emerge from interactions on social media. These communities offer an open digital space and flat role hierarchy for information sharing and provide a strong group identity, rapid flow of information, content curation, and knowledge translation. To date, there is only a small body of evidence in medicine or health care to verify the existence of an oCoP. Objective: We aimed to examine the emergence of an oCoP through the study of social media interactions of the free open access medical education (FOAM) movement. Methods: We examined social media activity in Twitter by analyzing the network centrality metrics of tweets with the #FOAMed hashtag and compared them with previously validated criteria of a community of practice (CoP). Results: The centrality analytics of the FOAM community showed concordance with aspects of a general CoP (in terms of community, domain, and practice), as well as some specific traits of a health care community, including social control, common purpose, flat hierarchy, and network-based and concrete achievement. Conclusions: This study demonstrated preliminary evidence of an oCoP focused on education and based on social media interactions. Further examination of the topology of the network is needed to definitely prove the existence of an oCoP. Given that these communities result in significant knowledge translation and practice change, further research in this area appears warranted.

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

    Short Text Messages to Encourage Adherence to Medication and Follow-up for People With Psychosis (Mobile.Net): Randomized Controlled Trial in Finland


    Background: A text messaging service (short message service [SMS]) has the potential to target large groups of people with long-term illnesses such as serious mental disorders, who may have difficulty with treatment adherence. Robust research on the impact of mobile technology interventions for these patients remains scarce. Objective: The main objective of our study was to investigate the impact of individually tailored short text messages on the rate of psychiatric hospital readmissions, health care service use, and clinical outcomes. In addition, we analyzed treatment costs. Methods: Between September 2011 and November 2012, we randomly assigned 1139 people to a tailored text message intervention (n=569) or usual care (n=570). Participants received semiautomated text messages for up to 12 months or usual care. The primary outcome, based on routinely collected health register data, was patient readmission into a psychiatric hospital during a 12-month follow-up period. Secondary outcomes were related to other service use, coercion, medication, adverse events, satisfaction, social functioning, quality of life, and economic factors (cost analysis). Results: There was 98.24% (1119/1139) follow-up at 12 months. Tailored mobile telephone text messages did not reduce the rate of hospital admissions (242/563, 43.0% of the SMS group vs 216/556, 38.8% of the control group; relative risk 1.11; 95% CI 0.92-1.33; P=.28), time between hospitalizations (mean difference 7.0 days 95% CI –8.0 to 24.0; P=.37), time spent in a psychiatric hospital during the year (mean difference 2.0 days 95% CI –2.0 to 7.0; P=.35), or other service outcomes. People who received text messages were less disabled, based on Global Assessment Scale scores at the time of their readmission, than those who did not receive text messages (odds ratio 0.68; 95% CI 0.47-0.97; P=.04). The costs of treatment were higher for people in the SMS group than in the control group (mean €10,103 vs €9210, respectively, P<.001). Conclusions: High-grade routinely collected data can provide clear outcomes for pragmatic randomized trials. SMS messaging tailored with the input of each individual patient did not decrease the rate of psychiatric hospital visits after the 12 months of follow-up. Although there may have been other, more subtle effects, the results of these were not evident in outcomes of agreed importance to clinicians, policymakers, and patients and their families. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 27704027; (Archived by WebCite at

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  • Use of social network services for communication among health professionals: a systematic review

    Date Submitted: Jul 20, 2017

    Open Peer Review Period: Jul 20, 2017 - Sep 14, 2017

    Background: Social network services (SNSs) are subject to tremendous exploitation in health communication. Although much research has been done investigating the roles of SNSs in linking patients and...

    Background: Social network services (SNSs) are subject to tremendous exploitation in health communication. Although much research has been done investigating the roles of SNSs in linking patients and health professionals, there is a lack of evidence on their uses, benefits and limitations in connecting health professionals. Objective: This review aimed to examine the utilization of SNSs for communication among health professionals in (1) frontline clinical practice, (2) professional networks and (3) education and training, so as to identify areas for future health communication research. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the literature published in the last ten years (1 January 2007–1 March 2017) was performed in March 2017, using the following electronic databases: Medline via OvidSP, Embase, CINAHL Complete and InfoSci Journals. The searches were performed using the following defined search terms: ‘social media’ OR ‘social network’ OR ‘social network site’ OR ‘Facebook’ OR ‘Twitter’ OR ‘Linkedin’ OR ‘Instagram’ OR ‘Weibo’ OR ‘Whatsapp’ OR ‘Telegram’ OR ‘WeChat’ AND ‘health’ OR ‘health profession’. Results: A total of 32 studies were included in this review. They were exploratory in nature, and the majority utilized surveys, interviews and content analysis. The most reported SNSs were Twitter, Facebook, WhatsApp Messenger and LinkedIn. All retrieved studies stated that SNSs enhanced effective communication and information sharing. In clinical practice, SNSs were used for supporting operations, making referrals, and disseminating guidelines. They were beneficial in network building and professional collaboration. SNSs were novel tools to enhance educational interactions among peers, students, instructors and preceptors. Yet, the application of SNSs for professional communication came with restraints in technical knowledge and techniques. Concerns regarding data protection, privacy and liability should be addressed by proper institutional policy and training. Conclusions: SNSs create a new dimension in communication among health professionals. Expanding professional networks, disseminating multimedia information and producing positive learning experiences are the benefits observed. The evolving use of SNSs necessitates that health professionals match the pace of development. Further robust research such as randomized controlled trials is required to explore the full potential and relative effectiveness of SNSs in professional communication.

  • Using a Refined Process Evaluation Model to Assess an Online Organ Donation Educational Intervention

    Date Submitted: Jul 19, 2017

    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public...

    Background: The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public commitment to organ donation through the broad reach of web-based, behavioral interventions. Implementing Internet interventions, however, presents some challenges, including preventing fraudulent respondents and ensuring intervention uptake. While web-based organ donation interventions have increased in recent years, process evaluation models fit for web-based interventions are lacking. Objective: This study outlines a refined process evaluation model adapted for online settings and used to assess the implementation of an online intervention aimed to increase organ donation among African Americans. Methods: We used a randomized pretest-posttest control design to assess the effectiveness of the intervention website, which addressed barriers to organ donation through corresponding videos. Eligible participants were African American adult residents of Georgia who were not registered on the state donor registry. Drawing from previously developed process constructs, we adapted reach (the extent to which the target population was recruited into the study), recruitment (online mechanism used to recruit participants), dose received (intervention uptake) and context (how the online setting influenced study implementation) for Internet settings, and used the adapted model to assess the implementation of our online intervention. Results: Reach: 1,415 individuals completed the eligibility screener; 948 (67.0%) were determined eligible, of which 918 (96.8%) completed the study. After eliminating duplicate entries (n=17), those who did not initiate the post-test (n=21) and those with an invalid ZIP code (n=108), 772 valid entries remained. Per the IP address analysis, only 23 of the 772 valid entries (3.8%) respondents were within Georgia, and only 17 of those were considered unique entries and could be considered for analyses. Recruitment: 517 of the 772 valid entries (67.0%) of participants were recruited from an online recruiter. Dose received: No videos from the intervention website were watched in their entirety, and the average viewing duration was 17 seconds over the minimum. Context: Context analysis provided us with valuable insights into factors in the Internet environment that may have affected study implementation. Although only active for a brief period of time, the advertisement may have contributed the largest volume of fraudulent responses. Conclusions: We determined fraud and low uptake to be serious threats to this study and further confirmed the importance of conducting a process evaluation to identify such threats. We suggest checking participants’ IP addresses prior to study initiation, selecting software that allows for automatic duplicate protection and tightening minimum requirements for intervention uptake. Further research is needed to understand how process evaluation models can be used to monitor implementation of online studies.

  • Security and Privacy Concerns Regarding Genetic Data in Mobile Health Record Systems: An Empirical Study from Turkey

    Date Submitted: Jul 19, 2017

    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: In today’s health services, it has become a necessity to keep patients’ health data in electronic format. There are many theories and considerable research on the design of electronic...

    Background: In today’s health services, it has become a necessity to keep patients’ health data in electronic format. There are many theories and considerable research on the design of electronic health record applications. As the use of genetic testing, and applications of bioinformatics is increasing in healthcare, genetic and genomic information needs to be included within these systems. Objective: In this study, we carried out a descriptive survey with 174 participants to acquire their views on the privacy and the security of mobile health record systems and inclusion of their genetic data in these systems. Methods: An online survey and an on-site survey in the two genetic diagnostic centers were conducted to reach patients or relatives of patients that had undergone genetic testing. Descriptive statistics is used to summarize the data. Results: Nearly half of the participants or their relatives (48.9%) had undergone genetic testing. Doctors are the only profession group that people trust for the privacy of their health and genetic information (61.2%); however, people chose to limit even their doctor’s access to their genetic/medical records (52.5%). Majority of the respondents (94%) prefer to keep full access right option only for themselves. The regulations and security measurements are suggested in the questionnaire are found to be acceptable by the majority of the respondents. A significant amount of participants had bad experiences and prejudices about electronic health records: 9.7 % of respondents’ medical records were used or released without their consents, 15.1 % stated that they had avoided being tested because of violation risks, and 3.5 % asked their doctors to enter a less embarrassing health status into their records. Also our analysis showed that participants attribute special importance to their genetic records, as significantly more participants stated that storing genetic records in a mobile system is more risky compared to other health records (P=.00). Conclusions: People have various negative experiences and there are plenty of information disclosure events in the media; hence people have concerns about the privacy and security of their health and genetic data. The results of our survey showed that people would like to see security measurements and regulations to protect their privacy, before they start to use any application to keep track of their health/genetic data. They also would like to have sole control on these applications. Personal Health Record (PHR) applications offers solutions to the data management problem as an electronic system, since they enable the users to have full control over their records.

  • Clinical Videoconferencing: A Systematic Review and Analysis of eHealth Enacted in User Patterns

    Date Submitted: Jul 19, 2017

    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: Earlier work has described videoconferencing technologies, peripheral equipment, organizational models, human relations, purposes, goals and roles as versatile, multifaceted and used diffe...

    Background: Earlier work has described videoconferencing technologies, peripheral equipment, organizational models, human relations, purposes, goals and roles as versatile, multifaceted and used differently in different clinical practices. Knowledge about benefits and challenges connected to specific characteristics of services are lacking. A 2005 systematic review of published definitions of “eHealth” identified 51 unique definitions and concluded that it had become an accepted neologism despite the lack of clear, precise, agreed-upon definitions. In 2015, the question “What Is eHealth: Time for an Update?” was posed. Objective: Considering videoconferencing as eHealth, the objective of the paper is twofold: to demonstrate and cluster (different) clinical videoconferencing practices and their situated implications and to explore and analyze whether—and how—common features and implications across clusters can contribute to an update of the eHealth concept. Methods: We performed a literature search via the National Center for Biotechnology Information (NCBI), encompassing PubMed and PubMedCentral, for quality reviews and primary studies. This paper reports results for primary studies. We used the terms “videoconferencing” and “clinical practices.” The selection process was based upon clearly defined criteria. We used an electronic proforma to extract data. The analysis was inspired by realist review and “the ten e’s of eHealth”. Results: The search returned 154 reviews and primary studies. This paper considers the primary studies, and eleven were included. We identified three broad clusters; 1) Videoconferencing as singular intstrument within existing organisational frameworks for expert advice, and effectiveness and quality improvement goals; 2) Videoconferencing as multifaceted with novel organisational arrangements, reaching out to homes and family caregivers with the purpose of co-creating improvement; 3) Videoconferencing as an operational instrument for improving administration of triage. The analysis of common features of videoconfeerencing across the clusters that might add to the understanding of eHealth resulted in a proposal to add four d’s to the existing ten e’s. The four d’s are: dynamic, differentiated along services and temporal lines, demanding of fresh resources and (inter) dependent of human and socio economic components. Conclusions: Videoconferencing for clinical work appear as a dynamic of differentiation and adaptation along service and temporal lines, made to work from an ongoing demand for fresh resources. Additionally, videoconferencing is an (inter)dependent assemblage of human, socio economic and technological constituent parts. The four d’s—dynamic, differentiated, demanding and (inter)dependent—can be added as an update of “the ten e’s of eHealth”.

  • Automatic Health Assessment of Smart Home Residents via Unsupervised Learning from Ambient Sensor Data: An Observational Study

    Date Submitted: Jul 18, 2017

    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: Existing approaches to health assessment for smart home residents mostly rely on the activities recognized by supervised learning methods, which require well-annotated sensor data. Obtaini...

    Background: Existing approaches to health assessment for smart home residents mostly rely on the activities recognized by supervised learning methods, which require well-annotated sensor data. Obtaining such labeled data is not a feasible task, especially for senior adults. Objective: Developing an unsupervised learning method to health assessment for smart home residents without the need of labeled data. Methods: Ambient sensors are deployed in participants’ home to collect activity data. Home resident’s health is assessed via a two-step approach. In the first step, the clusters of sensor data are discovered using K-means or Gaussian Mixture Models (GMM). In the second step, the time spent on each data cluster is used to compute a health score that represents the physical health of the resident. As we could not obtain ground-truth labels, we conduct this project as an observational study. Results: We test the first step of our approach (sensor data clustering) on the Aruba dataset, which was acquired from a testbed occupied by a senior resident for more than a year. In this step, GMM achieves its best performance of 0.75 (𝐹1_score) and 0.79 (Rand_index) and outperforms K-means. Qualitative results obtained on our smart home dataset also demonstrate the correlation between the discovered sensor data clusters with resident’s daily routine. The health score derived in the second step of our approach is highly associated with the health events happened to one of our participants. Conclusions: The experimental results demonstrate that the sensor data clusters discovered by standard clustering methods are highly correlated with the ground-truth activities or daily routine. Between the two tested methods, GMM outperforms K-means in all metrics. The health score derived by our two-step unsupervised approach is highly related to the health events happened to the resident. Clinical Trial: The CSIRO Health and Medical Research Human Research Ethics Committee (#12/17).

  • Reproducibility and Validation of the Qardioarm Application in the Assessment of Blood Pressure and Heart Rate: Reliability and ValidityStudy

    Date Submitted: Jul 13, 2017

    Open Peer Review Period: Jul 17, 2017 - Sep 11, 2017

    Background: Self-measurement of blood pressure is a priority strategy for managing blood pressure. Objective: Following the European Society of Hypertension’s international validation protocol, we e...

    Background: Self-measurement of blood pressure is a priority strategy for managing blood pressure. Objective: Following the European Society of Hypertension’s international validation protocol, we evaluated the reliability and validity of blood pressure and heart rate as measured with the Qardioarm, a fully automatic, non-invasive wireless blood pressure monitor and mobile application. Methods: Test-retest validation study, with two measurement sessions separated by 2-5 days. A single study site with an evaluation room that was maintained at an appropriate temperature and kept free from noises and distractions. 100 healthy volunteers over age 25 from the general population of Ciudad Real, Spain. In each measurement session, 7 systolic blood pressure, diastolic blood pressure, and heart rate assessments were taken, alternating between two devices. The test device was the Qardioarm and the previously validated criterion device was the Omron M3. Results: The Qardioarm displayed very consistent readings both within and across sessions (intraclass correlation coefficients = .80-.95, standard errors of measurement = 2.5-5.4). The Qardioarm measurements corresponded closely to those from the criterion device (Pearson correlations > .96) and mean values for the two devices were nearly identical. The Qardioarm easily passed all validation standards set by the European Society of Hypertension international protocol. Conclusions: The Qardioarm can be recommended for clinical use in individuals with similar characteristics as those who participated in this study. Clinical Trial: IT IS NOT A CLINICAL TRIAL