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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  • Clinicians using OpenMRS-Ebola in full personal protective equipment. Source: Image created by the authors; Copyright: The authors; URL: http://www.jmir.org/2017/8/e294/; License: Creative Commons Attribution (CC-BY).

    Development and Deployment of the OpenMRS-Ebola Electronic Health Record System for an Ebola Treatment Center in Sierra Leone

    Abstract:

    Background: Stringent infection control requirements at Ebola treatment centers (ETCs), which are specialized facilities for isolating and treating Ebola patients, create substantial challenges for recording and reviewing patient information. During the 2014-2016 West African Ebola epidemic, paper-based data collection systems at ETCs compromised the quality, quantity, and confidentiality of patient data. Electronic health record (EHR) systems have the potential to address such problems, with benefits for patient care, surveillance, and research. However, no suitable software was available for deployment when large-scale ETCs opened as the epidemic escalated in 2014. Objective: We present our work on rapidly developing and deploying OpenMRS-Ebola, an EHR system for the Kerry Town ETC in Sierra Leone. We describe our experience, lessons learned, and recommendations for future health emergencies. Methods: We used the OpenMRS platform and Agile software development approaches to build OpenMRS-Ebola. Key features of our work included daily communications between the development team and ground-based operations team, iterative processes, and phased development and implementation. We made design decisions based on the restrictions of the ETC environment and regular user feedback. To evaluate the system, we conducted predeployment user questionnaires and compared the EHR records with duplicate paper records. Results: We successfully built OpenMRS-Ebola, a modular stand-alone EHR system with a tablet-based application for infectious patient wards and a desktop-based application for noninfectious areas. OpenMRS-Ebola supports patient tracking (registration, bed allocation, and discharge); recording of vital signs and symptoms; medication and intravenous fluid ordering and monitoring; laboratory results; clinician notes; and data export. It displays relevant patient information to clinicians in infectious and noninfectious zones. We implemented phase 1 (patient tracking; drug ordering and monitoring) after 2.5 months of full-time development. OpenMRS-Ebola was used for 112 patient registrations, 569 prescription orders, and 971 medication administration recordings. We were unable to fully implement phases 2 and 3 as the ETC closed because of a decrease in new Ebola cases. The phase 1 evaluation suggested that OpenMRS-Ebola worked well in the context of the rollout, and the user feedback was positive. Conclusions: To our knowledge, OpenMRS-Ebola is the most comprehensive adaptable clinical EHR built for a low-resource setting health emergency. It is designed to address the main challenges of data collection in highly infectious environments that require robust infection prevention and control measures and it is interoperable with other electronic health systems. Although we built and deployed OpenMRS-Ebola more rapidly than typical software, our work highlights the challenges of having to develop an appropriate system during an emergency rather than being able to rapidly adapt an existing one. Lessons learned from this and previous emergencies should be used to ensure that a set of well-designed, easy-to-use, pretested health software is ready for quick deployment in future.

  • Source: Image created by the authors; Copyright: Nicholas Gordon; URL: https://ibb.co/c2kpxk; License: Creative Commons Attribution (CC-BY).

    Validation Relaxation: A Quality Assurance Strategy for Electronic Data Collection

    Abstract:

    Background: The use of mobile devices for data collection in developing world settings is becoming increasingly common and may offer advantages in data collection quality and efficiency relative to paper-based methods. However, mobile data collection systems can hamper many standard quality assurance techniques due to the lack of a hardcopy backup of data. Consequently, mobile health data collection platforms have the potential to generate datasets that appear valid, but are susceptible to unidentified database design flaws, areas of miscomprehension by enumerators, and data recording errors. Objective: We describe the design and evaluation of a strategy for estimating data error rates and assessing enumerator performance during electronic data collection, which we term “validation relaxation.” Validation relaxation involves the intentional omission of data validation features for select questions to allow for data recording errors to be committed, detected, and monitored. Methods: We analyzed data collected during a cluster sample population survey in rural Liberia using an electronic data collection system (Open Data Kit). We first developed a classification scheme for types of detectable errors and validation alterations required to detect them. We then implemented the following validation relaxation techniques to enable data error conduct and detection: intentional redundancy, removal of “required” constraint, and illogical response combinations. This allowed for up to 11 identifiable errors to be made per survey. The error rate was defined as the total number of errors committed divided by the number of potential errors. We summarized crude error rates and estimated changes in error rates over time for both individuals and the entire program using logistic regression. Results: The aggregate error rate was 1.60% (125/7817). Error rates did not differ significantly between enumerators (P=.51), but decreased for the cohort with increasing days of application use, from 2.3% at survey start (95% CI 1.8%-2.8%) to 0.6% at day 45 (95% CI 0.3%-0.9%; OR=0.969; P<.001). The highest error rate (84/618, 13.6%) occurred for an intentional redundancy question for a birthdate field, which was repeated in separate sections of the survey. We found low error rates (0.0% to 3.1%) for all other possible errors. Conclusions: A strategy of removing validation rules on electronic data capture platforms can be used to create a set of detectable data errors, which can subsequently be used to assess group and individual enumerator error rates, their trends over time, and categories of data collection that require further training or additional quality control measures. This strategy may be particularly useful for identifying individual enumerators or systematic data errors that are responsive to enumerator training and is best applied to questions for which errors cannot be prevented through training or software design alone. Validation relaxation should be considered as a component of a holistic data quality assurance strategy.

  • Social network analysis of the 2016 Stanford Medicine X conference based on hubs and authority score (montage). Source: The Authors / Placeit.net; Copyright: JMIR Publications; URL: http://www.jmir.org/2017/8/e280/; License: Creative Commons Attribution (CC-BY).

    Patient Participation at Health Care Conferences: Engaged Patients Increase Information Flow, Expand Propagation, and Deepen Engagement in the Conversation...

    Abstract:

    Background: Health care conferences present a unique opportunity to network, spark innovation, and disseminate novel information to a large audience, but the dissemination of information typically stays within very specific networks. Social network analysis can be adopted to understand the flow of information between virtual social communities and the role of patients within the network. Objective: The purpose of this study is to examine the impact engaged patients bring to health care conference social media information flow and how they expand dissemination and distribution of tweets compared to other health care conference stakeholders such as physicians and researchers. Methods: From January 2014 through December 2016, 7,644,549 tweets were analyzed from 1672 health care conferences with at least 1000 tweets who had registered in Symplur’s Health Care Hashtag Project from 2014 to 2016. The tweet content was analyzed to create a list of the top 100 influencers by mention from each conference, who were then subsequently categorized by stakeholder group. Multivariate linear regression models were created using stepwise function building to identify factors explaining variability as predictor variables for the model in which conference tweets were taken as the dependent variable. Results: Inclusion of engaged patients in health care conference social media was low compared to that of physicians and has not significantly changed over the last 3 years. When engaged patient voices are included in health care conferences, they greatly increase information flow as measured by total tweet volume (beta=301.6) compared to physicians (beta=137.3, P<.001), expand propagation of information tweeted during a conference as measured by social media impressions created (beta=1,700,000) compared to physicians (beta=270,000, P<.001), and deepen engagement in the tweet conversation as measured by replies to their tweets (beta=24.4) compared to physicians (beta=5.5, P<.001). Social network analysis of hubs and authorities revealed that patients had statistically significant higher hub scores (mean 8.26×10-4, SD 2.96×10-4) compared to other stakeholder groups’ Twitter accounts (mean 7.19×10-4, SD 3.81×10-4; t273.84=4.302, P<.001). Conclusions: Although engaged patients are powerful accelerators of information flow, expanders of tweet propagation, and greatly deepen engagement in conversation of tweets on social media of health care conferences compared to physicians, they represent only 1.4% of the stakeholder mix of the top 100 influencers in the conversation. Health care conferences that fail to engage patients in their proceedings may risk limiting their engagement with the public, disseminating scientific information to a narrow community and slowing flow of information across social media channels.

  • e-VITA interface (montage). Source: The Authors / Placeit.net; Copyright: JMIR Publications; URL: http://www.jmir.org/2017/8/e291/; License: Creative Commons Attribution (CC-BY).

    The Effect of Integration of Self-Management Web Platforms on Health Status in Chronic Obstructive Pulmonary Disease Management in Primary Care (e-Vita...

    Abstract:

    Background: Worldwide nearly 3 million people die from chronic obstructive pulmonary disease (COPD) every year. Integrated disease management (IDM) improves quality of life for COPD patients and can reduce hospitalization. Self-management of COPD through eHealth is an effective method to improve IDM and clinical outcomes. Objectives: The objective of this implementation study was to investigate the effect of 3 chronic obstructive pulmonary disease eHealth programs applied in primary care on health status. The e-Vita COPD study compares different levels of integration of Web-based self-management platforms in IDM in 3 primary care settings. Patient health status is examined using the Clinical COPD Questionnaire (CCQ). Methods: The parallel cohort design includes 3 levels of integration in IDM (groups 1, 2, 3) and randomization of 2 levels of personal assistance for patients (group A, high assistance, group B, low assistance). Interrupted time series (ITS) design was used to collect CCQ data at multiple time points before and after intervention, and multilevel linear regression modeling was used to analyze CCQ data. Results: Of the 702 invited patients, 215 (30.6%) registered to a platform. Of these, 82 participated in group 1 (high integration IDM), 36 in group 1A (high assistance), and 46 in group 1B (low assistance); 96 participated in group 2 (medium integration IDM), 44 in group 2A (high assistance) and 52 in group 2B (low assistance); also, 37 participated in group 3 (no integration IDM). In the total group, no significant difference was found in change in CCQ trend (P=.334) before (–0.47% per month) and after the intervention (–0.084% per month). Also, no significant difference was found in CCQ changes before versus after the intervention between the groups with high versus low personal assistance. In all subgroups, there was no significant change in the CCQ trend before and after the intervention (group 1A, P=.237; 1B, P=.991; 2A, P=.120; 2B, P=.166; 3, P=.945). Conclusions: The e-Vita eHealth-supported COPD programs had no beneficial impact on the health status of COPD patients. Also, no differences were found between the patient groups receiving different levels of personal assistance. Trial Registration: Netherlands Trial Registry NTR4098; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4098 (Archived by WebCite at http://www.webcitation.org/6sbM5PayG)

  • Source: Image created by the authors; Copyright: The authors; URL: http://www.jmir.org/2017/8/e288/; License: Creative Commons Attribution (CC-BY).

    “Am I normal?” The Wishes of Patients With Lymphoma to Compare Their Patient-Reported Outcomes With Those of Their Peers

    Abstract:

    Background: Providing feedback to patients on their patient-reported outcomes (PROs) can help patients in monitoring their functioning and symptoms and may help empower them. Objective: The objective of this study was to investigate whether patients with lymphoma wished to receive PRO feedback, including the option to compare their scores with those of their peers, and how this feedback was evaluated. Methods: We invited 64 patients participating in a lymphoma cohort who were eligible for a follow-up questionnaire and gave them the option to receive PRO feedback. Patients completed questions about health-related quality of life (HRQoL) and symptoms. PRO feedback was provided via bar charts. Results: Of the 64 invited patients, 45 participated (response rate 70%) and 36 of those (80%) wished to receive PRO feedback. The vast majority (34/36, 94%) compared their scores with those of a lymphoma reference cohort, and 64% (23/36) compared their score with those of a normative population without cancer. All patients wished to receive feedback on their HRQoL, and 29 (81%) to 33 (92%) wanted feedback on their functioning, fatigue, neuropathy, anxiety, and depressive symptoms. Of the 36 participants wishing to receive PRO feedback, 35 (97%) viewed it as being useful, with reassurance and knowledge about their own functioning in relation to what is “normal” being the most frequently mentioned reasons. Conclusions: A high number of patients with lymphoma wished to receive PRO feedback. Patients reported the comparison of their scores versus a lymphoma reference cohort as most valuable. Further research should investigate whether PRO feedback could increase empowerment and possibly improve HRQoL.

  • Source: Pixabay; Copyright: Gerd Altmann; URL: https://pixabay.com/de/social-media-icon-hand-halten-2489594/; License: Public Domain (CC0).

    A Collaborative Approach to Identifying Social Media Markers of Schizophrenia by Employing Machine Learning and Clinical Appraisals

    Abstract:

    Background: Linguistic analysis of publicly available Twitter feeds have achieved success in differentiating individuals who self-disclose online as having schizophrenia from healthy controls. To date, limited efforts have included expert input to evaluate the authenticity of diagnostic self-disclosures. Objective: This study aims to move from noisy self-reports of schizophrenia on social media to more accurate identification of diagnoses by exploring a human-machine partnered approach, wherein computational linguistic analysis of shared content is combined with clinical appraisals. Methods: Twitter timeline data, extracted from 671 users with self-disclosed diagnoses of schizophrenia, was appraised for authenticity by expert clinicians. Data from disclosures deemed true were used to build a classifier aiming to distinguish users with schizophrenia from healthy controls. Results from the classifier were compared to expert appraisals on new, unseen Twitter users. Results: Significant linguistic differences were identified in the schizophrenia group including greater use of interpersonal pronouns (P<.001), decreased emphasis on friendship (P<.001), and greater emphasis on biological processes (P<.001). The resulting classifier distinguished users with disclosures of schizophrenia deemed genuine from control users with a mean accuracy of 88% using linguistic data alone. Compared to clinicians on new, unseen users, the classifier’s precision, recall, and accuracy measures were 0.27, 0.77, and 0.59, respectively. Conclusions: These data reinforce the need for ongoing collaborations integrating expertise from multiple fields to strengthen our ability to accurately identify and effectively engage individuals with mental illness online. These collaborations are crucial to overcome some of mental illnesses’ biggest challenges by using digital technology.

  • Source: Pixabay; Copyright: Chuck Underwood; URL: https://pixabay.com/en/child-girl-young-caucasian-1073638/; License: Public Domain (CC0).

    Parent-Mediated Intervention Training Delivered Remotely for Children With Autism Spectrum Disorder Living Outside of Urban Areas: Systematic Review

    Abstract:

    Background: Parent training programs for families living outside of urban areas can be used to improve the social behavior and communication skills in children with autism spectrum disorder (ASD). However, no review has been conducted to investigate these programs. Objective: The aim of this study was to (1) systematically review the existing evidence presented by studies on parent-mediated intervention training, delivered remotely for parents having children with ASD and living outside of urban areas; (2) provide an overview of current parent training interventions used with this population; (3) and provide an overview of the method of delivery of the parent training interventions used with this population. Methods: Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, we conducted a comprehensive review across 5 electronic databases (CINAHL, Embase, ERIC, PsycINFO, and Pubmed) on July 4, 2016, searching for studies investigating parent-mediated intervention training for families living outside of urban centers who have a child diagnosed with ASD. Two independent researchers reviewed the articles for inclusion, and assessment of methodological quality was based on the Kmet appraisal checklist. Results: Seven studies met the eligibility criteria, including 2 prepost cohort studies, 3 multiple baseline studies, and 2 randomized controlled trials (RCTs). Interventions included mostly self-guided websites: with and without therapist assistance (n=6), with training videos, written training manuals, and videoconferencing. Post intervention, studies reported significant improvements (P<.05) in parent knowledge (n=4), parent intervention fidelity (n=6), and improvements in children’s social behavior and communication skills (n=3). A high risk of bias existed within all of the studies because of a range of factors including small sample sizes, limited use of standardized outcome measures, and a lack of control groups to negate confounding factors. Conclusions: There is preliminary evidence that parent-mediated intervention training delivered remotely may improve parent knowledge, increase parent intervention fidelity, and improve the social behavior and communication skills for children with ASD. A low number of RCTs, difficulty in defining the locality of the population, and a paucity of standardized measures limit the generalization of the findings to the target population. Future studies should investigate the appropriateness and feasibility of the interventions, include RCTs to control for bias, and utilize standard outcome measures.

  • The intervention condition. Source: Image created by the authors; Copyright: The authors; URL: http://www.jmir.org/2017/8/e284/; License: Creative Commons Attribution (CC-BY).

    A Peer-Led, Social Media-Delivered, Safer Sex Intervention for Chinese College Students: Randomized Controlled Trial

    Abstract:

    Background: The peer-led, social media-delivered intervention is an emerging method in sexual health promotion. However, no research has yet investigated its effectiveness as compared with other online channels or in an Asian population. Objective: The objective of this study is to compare a peer-led, social media-delivered, safer sex intervention with a sexual health website. Both conditions target Chinese college students in Hong Kong. Methods: A randomized controlled trial was conducted with a peer-led, safer sex Facebook group as the intervention and an existing online sexual health website as the control. The intervention materials were developed with peer input and followed the information-motivation-behavioral skills model; the intervention was moderated by peer educators. The participants filled out the online questionnaires before and after the 6-week intervention period. Outcome evaluations included safer sex attitudes, behavioral skills, and behaviors, while process evaluation focused on online experience, online-visiting frequency, and online engagement. The effect of online-visiting frequency and online engagement on outcome variables was investigated. Results: Of 196 eligible participants—100 in the control group and 96 in the intervention group—who joined the study, 2 (1.0%) control participants joined the Facebook group and 24 of the remaining 194 participants (12.4%) were lost to follow-up. For the process evaluation, participants in the intervention group reported more satisfying online experiences (P<.001) and a higher level of online-visiting frequency (P<.001). They also had more positive comments when compared with the control group. For outcome evaluation, within-group analysis showed significant improvement in condom use attitude (P=.02) and behavioral skills (P<.001) in the intervention group, but not in the control group. No significant between-group difference was found. After adjusting for demographic data, increased online-visiting frequency was associated with better contraceptive use behavioral intention (P=.05), better behavioral skills (P=.02), and more frequent condom use (P=.04). Conclusions: A peer-led, social media-delivered, safer sex intervention was found to be feasible and effective in improving attitudes toward condom use and behavioral skills, but was not significantly more effective than a website. Future research may focus on the long-term effectiveness and cost-effectiveness of this popular method, as well as the potential cultural differences of using social media between different countries. Trial Registration: Chinese Clinical Trial Registry (ChiCTR): ChiCTR-IOR-16009495; http://www.chictr.org.cn/showprojen.aspx?proj=16234 (Archived by WebCite at http://www.webcitation.org/6s0Fc2L9T)

  • Source: Pexels; Copyright: rawpixel.com; URL: https://www.pexels.com/photo/adult-blank-business-company-515171/; License: Public Domain (CC0).

    How do eHealth Programs for Adolescents With Depression Work? A Realist Review of Persuasive System Design Components in Internet-Based Psychological Therapies

    Abstract:

    Background: Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT) have been delivered face-to-face. However, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based CBT and IPT involve therapeutic content, interaction between the user and the system, and different technological features embedded into the online program (eg, multimedia). Studies of Internet-based CBT and IPT for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the treatment conditions that influence therapy outcomes is important to designing and evaluating these novel therapies. Objective: Our aim was to examine the technological and program delivery features of Internet-based CBT and IPT for adolescent depression and to document their potential relation to treatment outcomes and program use. Methods: We performed a realist synthesis. We started with an extensive search of published and gray literature. We included intervention studies that evaluated Internet-based CBT or IPT for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the Mixed-Methods Appraisal Tool to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how Internet-based CBT and IPT, as technology-based systems, influence the attitudes and behaviors of system users. PSD components described for the therapies were linked to reported outcomes using a cross-case comparison method and thematic synthesis. Results: We identified 19 Internet-based CBT programs in 59 documents. Of those, 71% (42/59) were of moderate to high quality. The PSD features surface credibility (competent “look and feel”), dialogue support (online program + in-person support), liking and similarity (esthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction, and adherence, as well as symptom and functional impairments. Conclusions: When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction, and depression-related outcomes. Testing of these features using hypothesis-driven dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness.

  • Internet surveillance would play a vital role in identifying the Norovirus infection. Source: The Authors; Copyright: The Authors; URL: http://www.jmir.org/2017/8/e282; License: Creative Commons Attribution (CC-BY).

    Identifying Potential Norovirus Epidemics in China via Internet Surveillance

    Abstract:

    Background: Norovirus is a common virus that causes acute gastroenteritis worldwide, but a monitoring system for norovirus is unavailable in China. Objective: We aimed to identify norovirus epidemics through Internet surveillance and construct an appropriate model to predict potential norovirus infections. Methods: The norovirus-related data of a selected outbreak in Jiaxing Municipality, Zhejiang Province of China, in 2014 were collected from immediate epidemiological investigation, and the Internet search volume, as indicated by the Baidu Index, was acquired from the Baidu search engine. All correlated search keywords in relation to norovirus were captured, screened, and composited to establish the composite Baidu Index at different time lags by Spearman rank correlation. The optimal model was chosen and possibly predicted maps in Zhejiang Province were presented by ArcGIS software. Results: The combination of two vital keywords at a time lag of 1 day was ultimately identified as optimal (ρ=.924, P<.001). The exponential curve model was constructed to fit the trend of this epidemic, suggesting that a one-unit increase in the mean composite Baidu Index contributed to an increase of norovirus infections by 2.15 times during the outbreak. In addition to Jiaxing Municipality, Hangzhou Municipality might have had some potential epidemics in the study time from the predicted model. Conclusions: Although there are limitations with early warning and unavoidable biases, Internet surveillance may be still useful for the monitoring of norovirus epidemics when a monitoring system is unavailable.

  • Teenager using online chat system for young people going through tough times (montage). Source: Photopin / Placeit; Copyright: The authors; URL: http://www.jmir.org/2017/7/e267/; License: Creative Commons Attribution (CC-BY).

    Application of Synchronous Text-Based Dialogue Systems in Mental Health Interventions: Systematic Review

    Abstract:

    Background: Synchronous written conversations (or “chats”) are becoming increasingly popular as Web-based mental health interventions. Therefore, it is of utmost importance to evaluate and summarize the quality of these interventions. Objective: The aim of this study was to review the current evidence for the feasibility and effectiveness of online one-on-one mental health interventions that use text-based synchronous chat. Methods: A systematic search was conducted of the databases relevant to this area of research (Medical Literature Analysis and Retrieval System Online [MEDLINE], PsycINFO, Central, Scopus, EMBASE, Web of Science, IEEE, and ACM). There were no specific selection criteria relating to the participant group. Studies were included if they reported interventions with individual text-based synchronous conversations (ie, chat or text messaging) and a psychological outcome measure. Results: A total of 24 articles were included in this review. Interventions included a wide range of mental health targets (eg, anxiety, distress, depression, eating disorders, and addiction) and intervention design. Overall, compared with the waitlist (WL) condition, studies showed significant and sustained improvements in mental health outcomes following synchronous text-based intervention, and post treatment improvement equivalent but not superior to treatment as usual (TAU) (eg, face-to-face and telephone counseling). Conclusions: Feasibility studies indicate substantial innovation in this area of mental health intervention with studies utilizing trained volunteers and chatbot technologies to deliver interventions. While studies of efficacy show positive post-intervention gains, further research is needed to determine whether time requirements for this mode of intervention are feasible in clinical practice.

  • Source: iStock by Getty Images; Copyright: shironosov; URL: http://www.istockphoto.com/ca/photo/modern-medical-person-gm500392136-80739539?clarity=false; License: Licensed by the authors.

    Psychiatric Consultation at Your Fingertips: Descriptive Analysis of Electronic Consultation From Primary Care to Psychiatry

    Abstract:

    Background: Mental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation. Objective: Our aim was to describe the implementation of eConsults for psychiatry in a large academic health system. Methods: We performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations. Results: Depression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time. Conclusions: For the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders.

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  • Feasibility, Acceptability and Effectiveness of a Remote Collaborative Care Program for Patients with Depression Living in Rural Areas

    Date Submitted: Aug 21, 2017

    Open Peer Review Period: Aug 21, 2017 - Oct 16, 2017

    Background: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas,...

    Background: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. Objective: To test the feasibility, acceptability and effectiveness of a remote collaborative care program for patients with depression living in rural areas. Methods: Physicians from fifteen community hospitals located in rural areas recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to a remote collaborative care program (Telepsiquiatría; n=111) or to usual care (UC; n=139). Telepsiquiatría introduced a shared electronic clinical record between primary care teams and a specialized mental health team, telephone monitoring of patients, and remote supervision by a psychiatrist through electronic platform and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after assignment based on a blinded telephone assessment. Results: Two hundred and twelve patients (84.8%) completed the assessments to six months. Telepsiquiatría was feasible and acceptable; achieving higher user satisfaction (OR 1.94, 95% CI 1.25 to 3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02 to 3.19) at 6 months, as compared to UC. There were no statically significant differences in depressive symptoms between Telepsiquiatría and UC, although a favorable trend was observed in the intervention arm. Significant differences between groups in favour of Telepsiquiatría were observed at 3 months for mental health-related quality of life (β 3.11, 95% CI 0.19 to 6.02). Conclusions: Telepsiquiatría may help reduce depression treatment gap in rural areas, providing an acceptable and highly satisfactory intervention for depressed adults. Future studies must evaluate treatment process outcomes in a more detailed manner. Clinical Trial: Clinicaltrials.gov NCT02200367.

  • Understanding the Associations of Sleep, Physical Activity, Fruit and Vegetable Intake with Quality of Life and Subjective Health: A Cross-Sectional Web-Based Study

    Date Submitted: Aug 19, 2017

    Open Peer Review Period: Aug 20, 2017 - Oct 15, 2017

    Background: In face of internet and increase sedentary times, the prevention of non-communicable diseases and especially cardiovascular diseases are imperative. Internet studies provide the option to...

    Background: In face of internet and increase sedentary times, the prevention of non-communicable diseases and especially cardiovascular diseases are imperative. Internet studies provide the option to research and identify modifiable health behaviors in different age groups. However, little is known about addressing more than single health behaviors across age groups (i.e., young, middle-aged, and older adults) and possible health outcomes. Assumptions exist based on the Compensatory Carry-Over Action Model, which provides a multiple health behavior approach, which was rarely studied in the past. Better understanding of age-specific differences in clustering of health behaviors and may set the stage for designing interventions, particularly for improving health behaviors. Objective: The aim of this study was to identify the associations of restful sleep, physical activity, fruit and vegetable intake, and their associations with sleep quality and overall quality of life and subjective health in different age groups, with an internet study. Methods: A web-based randomized controlled trial was conducted and 790 participants aged 20 to 85 years from Germany and the Netherlands filled in the web-based baseline questionnaire about their restful sleep, physical activity, fruit and vegetable intake, sleep quality, overall quality of life and subjective health. Descriptive analysis, one-way multivariate analysis of covariance, path analysis, and multi-group analysis were conducted. Results: In correlational findings, main study variables were interrelated, except restful sleep only significantly correlated with sleep quality and overall quality of life and subjective health (P < .05). A proposed path analysis model showed acceptable fit with the data χ2(3) = 4.63, P = .20; χ2/df = 1.54, CFI = .998, TLI = .982, RMSEA = .026. Restful sleep ( = .55, SE = .05, P < .001), physical activity ( = .18, SE = .03, P < .001) and fruit and vegetable intake ( = .07, SE = .03, P = .02) were associated with better sleep quality, which then was associated with increased overall quality of life and subjective health ( = .45, SE = .04, P < .001). There were age-group differences regarding multiple health behaviors and overall quality of life and subjective health (Wilks λ = .95, F(10, 1554) = 3.831, P < .001). Middle-aged adults were the least physically active and consumed the least fruit and vegetables, had the poorest sleep quality and overall quality of life and subjective health, compared to young and older adults. Conclusions: From this web-based study, multiple health behaviors are associated with sleep quality and overall quality of life and subjective health, but vary among different age groups. To enhance the effectiveness of web-based interventions to improve health and well-being, the outcomes of this study contributed more understanding of the age-group differences and the underlying mechanisms of multiple health behaviors. Clinical Trial: A clinical trial registration was conducted with ClinalTrials.gov (NCT01909349).

  • Quality of YouTube TM videos on dental implants

    Date Submitted: Aug 19, 2017

    Open Peer Review Period: Aug 20, 2017 - Oct 15, 2017

    Background: Patients search YouTube for health-care information Objective: To examine what YouTube offers patients seeking information on dental implants, and to evaluate the quality of provided infor...

    Background: Patients search YouTube for health-care information Objective: To examine what YouTube offers patients seeking information on dental implants, and to evaluate the quality of provided information Methods: A systematic search of YouTube for videos containing information on dental implants was performed. Video demographics and content’s usefulness were analyzed. “Information for patients” available from the American Academy of Implant Dentistry, European Association of Osseointegration, and British Society of Restorative Dentistry were used for benchmarking. Results: A total of 117 videos were analyzed. The most commonly discussed topics were related to procedures involved in dental implantology (76.1%, no=89), and to the indications for dental implants (58.1%, no=78). The mean usefulness score of videos was poor (6.02 ±4.7 [range 0-21]), and misleading content was common (30.1% of videos); mainly in topics related to prognosis and maintenance of dental implants. Most videos (83.1%, n=97) failed to mention the source of information presented in the video or where to find more about dental implants. Conclusions: Information about dental implants on YouTube is limited in quality and quantity. YouTube videos can have a potentially important role in modulating patients’ attitude and treatment decision regarding dental implants Clinical Trial: no

  • Health Information Technology Continues to Show Positive Effect on Medical Outcomes: A Systematic Review of the Literature

    Date Submitted: Aug 20, 2017

    Open Peer Review Period: Aug 20, 2017 - Aug 30, 2017

    Background: The Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized organizations and some providers to adopt the ‘meaningful use’ of a certified Electronic He...

    Background: The Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized organizations and some providers to adopt the ‘meaningful use’ of a certified Electronic Health Record (EHR), stimulating widespread adoption of HIT across various health care settings. Since the implementation of the HITECH Act, adoption rates of the electronic medical record have shown greater than arithmetic growth, but have patients experienced a commensurate increase in quality as a result of that technology? Objective: The purpose of this review is to analyze the current literature for the impact of HIT on medical outcomes. We hypothesized that there is a positive association between the adoption of HIT and medical outcomes. Methods: We queried CINAHL and Medline by PubMed databases for peer-reviewed publications in the last five years that defined an HIT intervention and an effect on medical outcomes in terms of efficiency or effectiveness. We structured the review from the Primary Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and we conducted the review in accordance with the Assessment for Multiple Systematic Reviews (AMSTAR). Results: We narrowed our search from 3,636 articles to 37 for final analysis. At least one improved medical outcome as a result of HIT adoption was identified in 81% of research studies that met inclusion criteria, strongly supporting our hypothesis. No statistical difference in outcomes was identified as a result of HIT in 19% of included studies. Twelve categories of HIT and three categories of outcomes occurred 38 and 65 times, respectively. Conclusions: A strong majority of the literature shows positive effects of HIT on the effectiveness of medical outcomes, which is excellent news as we all prepare for Stage 3 of Meaningful Use. This aligns with previous reviews in other time frames.

  • Feasibility and Effectiveness of a Web-Based Portal for delivery of care to home dialysis patients.

    Date Submitted: Aug 18, 2017

    Open Peer Review Period: Aug 19, 2017 - Oct 14, 2017

    Background: Background: Quality of life in home dialysis patients is low compared to the general population. Improvement in patient satisfaction through shared decision-making and handling of patient...

    Background: Background: Quality of life in home dialysis patients is low compared to the general population. Improvement in patient satisfaction through shared decision-making and handling of patient requests through an online interface has been shown to be beneficial in some studies in other disease populations. Such a system may improve patient satisfaction, reduce health service utilization and potentially improve health outcomes. Objective: Objective: To determine the acceptability, practicality, and implementation of an eHealth patient portal in home dialysis patients. Methods: Methods: Prospective feasibility cohort study among patients receiving either home hemodialysis or peritoneal dialysis over a four-month period. Web-based application allowing patients and healthcare workers to communicate through a secure, password protected online portal and permits visualization of the messaging history by patient and provider. Patients and the home dialysis healthcare team had the ability to send messages related to patient care at any time. Messages could be sent between the healthcare team and patient including proposed changes to medication, instructions after a clinic visit, times of new appointments, upcoming investigations or questions about care. Consumer Quality Index (CQI), Quality of Life using the EuroQol Five Dimensions Questionnaire, acceptability and satisfaction using online Acceptability E-scale and Satisfaction questionnaires. Patients were assessed at baseline and at 6 and 12 months of followup. Results: Results: Of the 41 patients who consented to join the web-based portal, 27 (66%) created an online account. Mean CQI for the Nephrology domain was 3.50 (95%CI: 3.33,3.67) and this did not change significantly over the study period. Quality of life using the EQ-index score was 0.80 (IQR: 0.71-0.83) at baseline and this also did not significantly change over the study period. The web-based portal was easy to use with a median response of 4 (IQR: 4-5). Most were satisfied with a mean score of 6.5±0.6 in overall satisfaction. Conclusions: Conclusions: In this study of home dialysis patients, we identified that an online portal for care-delivery was feasible. We did not find a significant improvement in CQI or QOL, but the portal was felt to be beneficial at addressing some domains of patient care. Clinical Trial: Trial Registration: ClinicalTrials.gov number NCT02128347

  • Smartphone apps for quality of life and wellbeing assessment in breast and prostate cancer patients: A systematic review.

    Date Submitted: Aug 19, 2017

    Open Peer Review Period: Aug 19, 2017 - Aug 30, 2017

    Background: Smartphone health applications (apps) are increasingly gaining attention in oncological care as potential tools for supporting cancer patients. However, although the number of publications...

    Background: Smartphone health applications (apps) are increasingly gaining attention in oncological care as potential tools for supporting cancer patients. However, although the number of publications and health apps focusing on cancer is increasing, there are still few specifically designed for the most prevalent cancers diagnosed: breast and prostate cancers. There is a need to review the effect of these apps on breast and prostate cancer patients’ quality of life (QoL) and wellbeing. Objective: The purposes of this study were, firstly, to review the scientific literature on smartphone apps targeting breast or prostate cancer patients, and involving QoL and wellbeing (anxiety and depression symptoms), and secondly, to analyze the clinical and technological characteristics, strengths and weaknesses of these apps, as well as patients’ user experience of them. Methods: We conducted a systematic review of peer-reviewed literature from The Cochrane Library, Embase, PsycINFO, Pubmed, Scopus, and MEDLINE to identify studies involving smartphone apps focused on breast and/or prostate cancer patients and QoL and/or wellbeing, published between January 1st, 2000 and July 12th, 2017. Only trial studies which met the inclusion criteria were selected. The systematic review was completed with a critical analysis of the smartphone apps previously identified in the health literature research that were available in the official application stores. Results: The systematic review of the literature yielded 3,862 articles. After removal of duplicates, 3,229 remained and were evaluated on the basis of title and abstract. Of these, 3,211 were discarded as not meeting the inclusion criteria, and 18 records were selected for full text screening. Finally, 5 citations were included in this review, with a total of 644 patients, mean age 52.16 years. The majority of the studies targeted breast cancer patients and only 1 paper was focused on prostate cancer patients. In three studies an app-related intervention was carried out, and two of them reported an improvement on quality of life, while two of the studies only tracked use of the app, and no effect on quality of life or wellbeing was found. Conclusions: Despite the existence hundreds of studies involving cancer-focused smartphone apps, there is a lack of rigorous trials regarding the QoL and/or wellbeing assessment in breast and/or prostate cancer patients. A strong and collective effort should be made by all health care providers to determine those cancer-focused smartphone apps which effectively represent useful, accurate, and reliable tools for cancer patients’ disease management. Clinical Trial: Registration: PROSPERO (Registered on 26/07/2017, ref. 73069)

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