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Journal of Medical Internet Research

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


Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2016: 5.175, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

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

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


Recent Articles:

  • Source: Unsplash; Copyright: James Sutton; URL:; License: Licensed by the authors.

    Internet and Social Media Access Among Youth Experiencing Homelessness: Mixed-Methods Study


    Background: Youth experiencing homelessness are at a risk for a variety of adverse outcomes. Given the widespread use of the internet and social media, these new technologies may be used to address their needs and for outreach purposes. However, little is known about how this group uses these resources. Objective: This study investigated how homeless adolescents use these technologies for general and health-related purposes, whether the scope of their use changes with housing status, and their interest in a website dedicated to youth experiencing homelessness. Methods: A convenience sample of youth aged 18 to 21 years was recruited from a youth-specific homeless shelter. All participants completed a 47-item survey, with 10 individuals completing a semistructured interview. Descriptive statistics, exact testing, logistic regression, and generalized estimating equation modeling was performed for quantitative data analysis. Interviews were transcribed verbatim, and NVivo 10 (QSR International) was employed to facilitate double coding and thematic analysis. Results: A total of 87 participants completed the survey with a mean age of 19.4 (SD 1.1) years. While experiencing homelessness, 56% (49/87) accessed the internet at least once a day, with 86% (75/87) accessing once a week. Access to a smartphone was associated with a 3.03 greater odds of accessing the internet and was the most frequently used device (66% of participants, 57/87). While experiencing homelessness, subjects reported a 68% decreased odds in internet access frequency (odds ratio [OR] 0.32, P<.001), 75% decreased odds in spending greater amounts of time on the internet (OR 0.25, P<.001), and an 87% decreased odds of social media use (OR 0.13, P=.01). Ten participants completed the semistructured interview. Several themes were identified, including (1) changes in internet behaviors while experiencing homelessness, (2) health status as a major concern and reason for Internet use, and (3) interest in a website dedicated to youth experiencing homelessness. While experiencing homelessness, participants indicated their behaviors were more goal-oriented and less focused on leisure or entertainment activities. Conclusions: While homeless youth experience changes in the frequency, amount of time, and specific uses of the internet and social media, study participants were able to access the internet regularly. The internet was used to search health-related topics. Given the importance of smartphones in accessing the internet, mobile-optimized websites may be an effective method for reaching this group.

  • Interaction with the e-learning program. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    The Effectiveness of a Computer-Tailored E-Learning Program for Practice Nurses to Improve Their Adherence to Smoking Cessation Counseling Guidelines:...


    Background: Improving practice nurses’ (PN) adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence rates. However, support programs to aid PNs in improving their guideline uptake and adherence do not exist yet. Objective: The aim of this study was to assess the effects of a novel computer-tailored electronic learning (e-learning) program on PNs’ smoking cessation guideline adherence. Methods: A Web-based randomized controlled trial (RCT) was conducted in which an intervention group (N=147) with full access to the e-learning program for 6 months was compared with a control group (N=122) without access. Data collection was fully automated at baseline and 6-month follow-up via online questionnaires, assessing PNs’ demographics, work-related factors, potential behavioral predictors based on the I-Change model, and guideline adherence. PNs also completed counseling checklists to retrieve self-reported counseling activities for each consultation with a smoker (N=1175). To assess the program’s effectiveness in improving PNs’ guideline adherence (ie, overall adherence and adherence to individual counseling guideline steps), mixed linear and logistic regression analyses were conducted, thus accommodating for the smokers being nested within PNs. Potential effect moderation by work-related factors and behavioral predictors was also examined. Results: After 6 months, 121 PNs in the intervention group (82.3%, 121/147) and 103 in the control group (84.4%, 103/122) completed the follow-up questionnaire. Mixed linear regression analysis revealed that counseling experience moderated the program’s effect on PNs’ overall guideline adherence (beta=.589; 95% CI 0.111-1.068; PHolm-Bonferroni =.048), indicating a positive program effect on adherence for PNs with a more than average level of counseling experience. Mixed logistic regression analyses regarding adherence to individual guideline steps revealed a trend toward moderating effects of baseline levels of behavioral predictors and counseling experience. More specifically, for PNs with less favorable scores on behavioral predictors (eg, low baseline self-efficacy) and high levels of counseling experience, the program significantly increased adherence. Conclusions: Results from our RCT showed that among PNs with more than average counseling experience, the e-learning program resulted in significantly better smoking cessation guideline adherence. Experienced PNs might have been better able to translate the content of our e-learning program into practically applicable counseling strategies compared with less experienced colleagues. Less favorable baseline levels of behavioral predictors among PNs possibly contributed to this effect, as there was more room for improvement by consulting the tailored content of the e-learning program. To further substantiate the effectiveness of e-learning programs on guideline adherence by health care professionals (HCPs), it is important to assess how to support a wider range of HCPs. Trial Registration: Netherlands Trial Register NTR4436; (Archived by WebCite at

  • Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Evaluation of App-Based Serious Gaming as a Training Method in Teaching Chest Tube Insertion to Medical Students: Randomized Controlled Trial


    Background: The insertion of a chest tube should be as quick and accurate as possible to maximize the benefit and minimize possible complications for the patient. Therefore, comprehensive training and assessment before an emergency situation are essential for proficiency in chest tube insertion. Serious games have become more prevalent in surgical training because they enable students to study and train a procedure independently, and errors made have no effect on patients. However, up-to-date evidence regarding the effect of serious games on performance in procedures in emergency medicine remains scarce. Objective: The aim of this study was to investigate the serious gaming approach in teaching medical students an emergency procedure (chest tube insertion) using the app Touch Surgery and a modified objective structural assessment of technical skills (OSATS). Methods: In a prospective, rater-blinded, randomized controlled trial, medical students were randomized into two groups: intervention group or control group. Touch Surgery has been established as an innovative and cost-free app for mobile devices. The fully automatic software enables users to train medical procedures and afterwards self-assess their training effort. The module chest tube insertion teaches each key step in the insertion of a chest tube and enables users the meticulous application of a chest tube. In contrast, the module “Thoracocentesis” discusses a basic thoracocentesis. All students attended a lecture regarding chest tube insertion (regular curriculum) and afterwards received a Touch Surgery training lesson: intervention group used the module chest tube insertion and the control group used Thoracocentesis as control training. Participants’ performance in chest tube insertion on a porcine model was rated on-site via blinded face-to-face rating and via video recordings using a modified OSATS tool. Afterwards, every participant received an individual questionnaire for self-evaluation. Here, trainees gave information about their individual training level, as well as previous experiences, gender, and hobbies. Primary end point was operative performance during chest tube insertion by direct observance. Results: A total of 183 students enrolled, 116 students participated (63.4%), and 21 were excluded because of previous experiences in chest tube insertion. Students were randomized to the intervention group (49/95, 52%) and control group (46/95, 48%). The intervention group performed significantly better than the control group (Intervention group: 38.0 [I50=7.0] points; control group: 30.5 [I50=8.0] points; P<.001). The intervention group showed significantly improved economy of time and motion (P=.004), needed significantly less help (P<.001), and was more confident in handling of instruments (P<.001) than the control group. Conclusions: The results from this study show that serious games are a valid and effective tool in education of operative performance in chest tube insertion. We believe that serious games should be implemented in the surgical curriculum, as well as residency programs, in addition to traditional learning methods. Trial Registration: German Clinical Trials Register (DRKS) DRKS00009994; (Archived by Webcite at

  • A doctor is explaining the correct way to use inhalers, which are becoming more and more digital by having Bluetooth and/or Wi-Fi connectivity. Source: Wikimedia Commons; Copyright: Jorgejesus4; URL:ón_Médico_Paciente.png; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    The Biopsychosocial-Digital Approach to Health and Disease: Call for a Paradigm Expansion


    Digital health is an advancing phenomenon in modern health care systems. Currently, numerous stakeholders in various countries are evaluating the potential benefits of digital health solutions at the individual, population, and/or organizational levels. Additionally, driving factors are being created from the customer-side of the health care systems to push health care providers, policymakers, or researchers to embrace digital health solutions. However, health care providers may differ in their approach to adopt these solutions. Health care providers are not assumed to be appropriately trained to address the requirements of integrating digital health solutions into daily everyday practices and procedures. To adapt to the changing demands of health care systems, it is necessary to expand relevant paradigms and to train human resources as required. In this article, a more comprehensive paradigm will be proposed, based on the ‘biopsychosocial model’ of assessing health and disease, originally introduced by George L Engel. The “biopsychosocial model” must be leveraged to include a “digital” component, thus suggesting a ‘biopsychosocial-digital’ approach to health and disease. Modifications to the “biopsychosocial” model and transition to the “biopsychosocial-digital” model are explained. Furthermore, the emerging implications of understanding health and disease are clarified pertaining to their relevance in training human resources for health care provision and research.

  • Source: iStock by Getty Images; Copyright: asiseeit; URL:; License: Licensed by the authors.

    Increasing Physical Activity in Mothers Using Video Exercise Groups and Exercise Mobile Apps: Randomized Controlled Trial


    Background: Women significantly decrease their activity levels in the transition to motherhood. Digital health technologies are low cost, scalable, and can provide an effective delivery mechanism for behavior change. This is the first study that examines the use of videoconferencing and mobile apps to create exercise groups for mothers. Objective: The aim of the study was to test the feasibility, acceptability, and effectiveness of an individually adaptive and socially supportive physical activity intervention incorporating videoconferencing and mobile apps for mothers. Methods: The Moms Online Video Exercise Study was an 8-week, 2-armed, Web-based randomized trial comparing the effectiveness of a group exercise intervention with a waitlist control. Healthy mothers with at least 1 child under the age of 12 years were recruited through Facebook and email listservs. Intervention participants joined exercise groups using videoconferencing (Google Hangouts) every morning on weekdays and exercised together in real time, guided by exercise mobile apps (eg, Nike+, Sworkit) of their choice. Waitlist control participants had access to recommended mobile apps and an invitation to join an exercise group after the 8-week study period. Main outcomes assessed included changes in self-reported moderate, vigorous, and moderate to vigorous physical activity (MVPA) minutes per week in aggregate and stratified by whether women met Centers for Disease Control and Prevention guidelines for sufficient aerobic activity at baseline. Outcomes were measured through self-assessed Web-based questionnaires at baseline and 8 weeks. Results: The intervention was effective at increasing exercise for inactive women and proved to be feasible and acceptable to all participants. A total of 64 women were randomized, 30 to intervention and 34 to control. Women attended 2.8 sessions per week. There was a strong, but not statistically significant, trend toward increasing moderate, vigorous, and MVPA minutes for all women. As hypothesized, in the prespecified stratum of women who were inactive at baseline (n=51), intervention participants significantly increased their activity by an average of 50 (95% CI 4.0-95.9, P=.03) MVPA minutes per week more than control participants. They had a corresponding statistically significant net increase of 19 (95% CI 3.2-34.8, P=.02) minutes of vigorous activity. Inactive women in the intervention arm also experienced promising reductions in depression, reporting a statistically significant net decrease in their depression score (−3.8, 95% CI −7.0 to −0.6; P=.02). Conclusions: We found that a group exercise intervention using videoconferencing and mobile apps was a feasible and acceptable way to deliver a physical activity intervention to mothers. The intervention increased physical activity in inactive mothers. Further studies are needed to better establish how long these changes in physical activity can be maintained and whether these findings can be reproduced in a more diverse population. Trial Registration: NCT02805140; (Archived by WebCite at

  • Source: Unsplash; Copyright: Christin Hume; URL:; License: Licensed by the authors.

    Alcohol Consumption Reduction Among a Web-Based Supportive Community Using the Hello Sunday Morning Blog Platform: Observational Study


    Background: Alcohol misuse is a major social and public health issue in Australia, with an estimated cost to the community of Aus $30 billion per annum. Until recently, a major barrier in addressing this significant public health issue is the fact that the majority of individuals with alcohol use disorders and alcohol misuse are not receiving treatment. Objective: This study aimed to assess whether alcohol consumption changes are associated with participation in Hello Sunday Morning’s blog platform, an online forum discussing experiences in abstaining from alcohol. Methods: The study reports on Hello Sunday Morning participants who signed up for a 3-month period of abstinence from November 2009 to November 2016. The sample comprised 1917 participants (female: 1227/1917, 64.01%; male: 690/1917, 35.99%). Main outcome measures were Alcohol Use Disorders Identification Test (AUDIT) scores, mood, program engagement metrics, and slip-ups. Results: Individuals who reported hazardous (preprogram AUDIT mean 11.92, SD 2.25) and harmful consumption levels (preprogram AUDIT mean 17.52, SD 1.08) and who engaged in the Hello Sunday Morning program reported a significant decrease in alcohol consumption, moving to lower risk consumption levels (hazardous, mean 7.59, SD 5.70 and harmful, mean 10.38, SD 7.43), 4 months following program commencement (P<.001). Those who reported high-risk or dependent consumption levels experienced the biggest reduction (preprogram mean 25.38, SD 4.20), moving to risky consumption (mean 15.83, SD 11.11), 4 months following program commencement (P<.001). These reductions in risk were maintained by participants in each group, 7 months following program commencement. Furthermore, those who engaged in the program more (as defined by more sign-ins, blogs posted, check-ins completed, and engagement with the community through likes and following) had lower alcohol consumption. Finally, those who experienced more slip-ups had lower alcohol consumption. Conclusions: Participation in an online forum can support long-term behavior change in individuals wishing to change their drinking behavior. Importantly, reductions in AUDIT scores appeared larger for those drinking at high-risk and hazardous levels before program commencement. This has promising implications for future models of alcohol reduction treatment, as online forums are an anonymous, accessible, and cost-effective alternative or adjunct to treatment-as-usual. Further research is needed into the specific mechanisms of change within a Web-based supportive community, as well as the role of specific mood states in predicting risky drinking behavior.

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

    Exploring Hospitals’ Use of Facebook: Thematic Analysis


    Background: Although health care organizations such as hospitals and clinics have widely embraced social media as a means to educate the community on health topics and increase patient loyalty and satisfaction, little is known about the content these organizations actually share when using social media channels. Objective: This study aimed to explore the types of content US hospitals post on their Facebook pages and how hospitals’ Facebook activities differ with regard to content types. Methods: We collected and thematically analyzed more than 1700 Facebook posts made over a 3-month period by 17 US hospitals. During the first phase, the 2 researchers coded a set of 159 posts and created an initial thematic web of content. During the second phase, the researchers coded the remaining posts and then revised, refined, and validated the initial web of content accordingly. Coding consensus was achieved on 1184 of the 1548 analyzable sampled posts (76.49%). Results: We identified a list of 13 unique health social media post themes and classified those themes into 3 thematic groups that included announcing, sharing, and recognizing activities. The most frequently used theme was sharing health information, which appeared in 35.81% (424/1184) of the posts analyzed. Such posts sought to provide health tips and advice to community members. Recognizing special days and recognizing employees were the second and third most frequently used themes, respectively, with 14.95% (177/1184) and 11.82% (140/1184) of the posts containing those themes. The frequency of these themes was surprising as the content was geared more toward stakeholders internal to the organization, although most previous literature has focused on social media as a tool to connect with external stakeholders. In addition, we found many of the posts involved more than one theme, and selected sets of themes co-occurred frequently. For example, 25.4% (45/177) of the posts recognizing special days also included content to share health information, and approximately 38% (32/85) of the posts announcing research activities also included content to share health information. Finally, we found similarities and differences between the sampled hospitals in terms of the types of content they posted more frequently on their Facebook pages. Conclusions: Hospitals use Facebook as an inexpensive way to educate people on health and wellness topics and to communicate different types of information and news to the public audience. Hospitals and clinics that are expanding their social media activities or are starting to embark on social media strategies can use the results of this study to better formulate their activities on Facebook.

  • Source: Image created by the Authors; Copyright: The University of Sydney; URL:; License: Creative Commons Attribution (CC-BY).

    An eHealth Capabilities Framework for Graduates and Health Professionals: Mixed-Methods Study


    Background: The demand for an eHealth-ready and adaptable workforce is placing increasing pressure on universities to deliver eHealth education. At present, eHealth education is largely focused on components of eHealth rather than considering a curriculum-wide approach. Objective: This study aimed to develop a framework that could be used to guide health curriculum design based on current evidence, and stakeholder perceptions of eHealth capabilities expected of tertiary health graduates. Methods: A 3-phase, mixed-methods approach incorporated the results of a literature review, focus groups, and a Delphi process to develop a framework of eHealth capability statements. Results: Participants (N=39) with expertise or experience in eHealth education, practice, or policy provided feedback on the proposed framework, and following the fourth iteration of this process, consensus was achieved. The final framework consisted of 4 higher-level capability statements that describe the learning outcomes expected of university graduates across the domains of (1) digital health technologies, systems, and policies; (2) clinical practice; (3) data analysis and knowledge creation; and (4) technology implementation and codesign. Across the capability statements are 40 performance cues that provide examples of how these capabilities might be demonstrated. Conclusions: The results of this study inform a cross-faculty eHealth curriculum that aligns with workforce expectations. There is a need for educational curriculum to reinforce existing eHealth capabilities, adapt existing capabilities to make them transferable to novel eHealth contexts, and introduce new learning opportunities for interactions with technologies within education and practice encounters. As such, the capability framework developed may assist in the application of eHealth by emerging and existing health care professionals. Future research needs to explore the potential for integration of findings into workforce development programs.

  • A crowd in Paris. Source: Wikimedia Commons; Copyright: Mbzt; URL:; License: Creative Commons Attribution (CC-BY).

    Mapping of Crowdsourcing in Health: Systematic Review


    Background: Crowdsourcing involves obtaining ideas, needed services, or content by soliciting Web-based contributions from a crowd. The 4 types of crowdsourced tasks (problem solving, data processing, surveillance or monitoring, and surveying) can be applied in the 3 categories of health (promotion, research, and care). Objective: This study aimed to map the different applications of crowdsourcing in health to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers. Methods: MEDLINE, EMBASE, and were searched for available reports from inception to March 30, 2016, with no restriction on language or publication status. Results: We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, of which only one had posted results at Crowdsourcing was used in health promotion (91/202, 45.0%), research (73/202, 36.1%), and care (38/202, 18.8%). The 4 most frequent areas of application were public health (67/202, 33.2%), psychiatry (32/202, 15.8%), surgery (22/202, 10.9%), and oncology (14/202, 6.9%). Half of the reports (99/202, 49.0%) referred to data processing, 34.6% (70/202) referred to surveying, 10.4% (21/202) referred to surveillance or monitoring, and 5.9% (12/202) referred to problem-solving. Labor market platforms (eg, Amazon Mechanical Turk) were used in most studies (190/202, 94%). The crowd workers’ characteristics were poorly reported, and crowdsourcing logistics were missing from two-thirds of the reports. When reported, the median size of the crowd was 424 (first and third quartiles: 167-802); crowd workers’ median age was 34 years (32-36). Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (58.9%, 119/202), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (11.9% of studies; 24/202). For half of the studies, monetary incentives were mentioned, with mainly less than US $1 to perform the task. The time needed to perform the task was mostly less than 10 min (58.9% of studies; 119/202). Data quality validation was used in 54/202 studies (26.7%), mainly by attention check questions or by replicating the task with several crowd workers. Conclusions: The use of crowdsourcing, which allows access to a large pool of participants as well as saving time in data collection, lowering costs, and speeding up innovations, is increasing in health promotion, research, and care. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports and needs to be precisely reported to better interpret the study findings and replicate them.

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

    Too Important to Ignore: Leveraging Digital Technology to Improve Chronic Illness Management Among Black Men


    Health disparities associated with chronic illness experiences of black men demonstrate widespread, systematic failures to meet an urgent need. Well-established social and behavioral determinants that have led to health disparities among black men include racism, discrimination, and stress. While advocacy work that includes community-engagement and tailoring health promotion strategies have shown local impact, evidence shows the gaps are increasing. We suspect that failure to reduce current disparities may be due to conventional public health interventions and programs; therefore, we submit that innovative interventions, ones that embrace digital technologies and their ability to harness naturally occurring social networks within groups, like black men, have particular importance and deserve attention. This commentary characterizes the current literature on chronic illness among black men as well as health interventions that use digital technology, to build a case for expanding research in this area to reduce the overwhelming burden of chronic illness among black men.

  • Searching for abortion facilities in Texas (montage). Source: Google LLC /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Identifying National Availability of Abortion Care and Distance From Major US Cities: Systematic Online Search


    Background: Abortion is a common medical procedure, yet its availability has become more limited across the United States over the past decade. Women who do not know where to go for abortion care may use the internet to find abortion facility information, and there appears to be more online searches for abortion in states with more restrictive abortion laws. While previous studies have examined the distances women must travel to reach an abortion provider, to our knowledge no studies have used a systematic online search to document the geographic locations and services of abortion facilities. Objective: The objective of our study was to describe abortion facilities and services available in the United States from the perspective of a potential patient searching online and to identify US cities where people must travel the farthest to obtain abortion care. Methods: In early 2017, we conducted a systematic online search for abortion facilities in every state and the largest cities in each state. We recorded facility locations, types of abortion services available, and facility gestational limits. We then summarized the frequencies by region and state. If the online information was incomplete or unclear, we called the facility using a mystery shopper method, which simulates the perspective of patients calling for services. We also calculated distance to the closest abortion facility from all US cities with populations of 50,000 or more. Results: We identified 780 facilities through our online search, with the fewest in the Midwest and South. Over 30% (236/780, 30.3%) of all facilities advertised the provision of medication abortion services only; this proportion was close to 40% in the Northeast (89/233, 38.2%) and West (104/262, 39.7%). The lowest gestational limit at which services were provided was 12 weeks in Wyoming; the highest was 28 weeks in New Mexico. People in 27 US cities must travel over 100 miles (160 km) to reach an abortion facility; the state with the largest number of such cities is Texas (n=10). Conclusions: Online searches can provide detailed information about the location of abortion facilities and the types of services they provide. However, these facilities are not evenly distributed geographically, and many large US cities do not have an abortion facility. Long distances can push women to seek abortion in later gestations when care is even more limited.

  • Nurse using patient portal on a tablet. Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    Barriers and Facilitators Affecting Patient Portal Implementation from an Organizational Perspective: Qualitative Study.


    Background: The number of patient portals is rising, and although portals can have positive effects, their implementation has major impacts on the providing health care institutions. However, little is known about the organizational factors affecting successful implementation. Knowledge of the specific barriers to and facilitators of various stakeholders is likely to be useful for future implementations. Objective: The objective of this study was to identify the barriers to and facilitators of patient portal implementation facing various stakeholders within hospital organizations in the Netherlands. Methods: Purposive sampling was used to select hospitals of various types. A total of 2 university medical centers, 3 teaching hospitals, and 2 general hospitals were included. For each, 3 stakeholders were interviewed: (1) medical professionals, (2) managers, and (3) information technology employees. In total, 21 semistructured interviews were conducted using the Grol and Wensing model, which describes barriers to and facilitators of change in health care practice at 6 levels: (1) innovation; (2) individual professional; (3) patient; (4) social context; (5) organizational context; and (6) economic and political context. Two researchers independently selected and coded quotes by applying this model using a (deductive) directed content approach. Additional factors related to technical and portal characteristics were added using the model of McGinn et al, developed for implementation of electronic health records. Results: In total, we identified 376 quotes, 26 barriers, and 28 facilitators. Thirteen barriers and 12 facilitators were common for all stakeholder groups. The facilitators’ perceived usefulness (especially less paperwork) was mentioned by all the stakeholders, followed by subjects’ positive attitude. The main barriers were lack of resources (namely, lack of staff and materials), financial difficulties (especially complying with high costs, lack of reimbursements), and guaranteeing privacy and security (eg, strict regulations). Both similarities and differences were found between stakeholder groups and hospital types. For example, managers and information technology employees mainly considered guaranteeing privacy and security as a predominant barrier. Financial difficulties were particularly mentioned by medical professionals and managers. Conclusions: Patient portal implementation is a complex process and is not only a technical process but also affects the organization and its staff. Barriers and facilitators occurred at various levels and differed among hospital types (eg, lack of accessibility) and stakeholder groups (eg, sufficient resources) in terms of several factors. Our findings underscore the importance of involving multiple stakeholders in portal implementations. We identified a set of barriers and facilitators that are likely to be useful in making strategic and efficient implementation plans.

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  • Publicly available, interactive Option GridTM patient decision aid shifts user preferences about the PSA test, increases knowledge and reduces decisional conflict

    Date Submitted: May 21, 2018

    Open Peer Review Period: May 21, 2018 - Jul 16, 2018

    Background: Randomized trials of web-based decision aids for prostate specific antigen (PSA) testing indicate that these interventions improve knowledge and reduce decisional conflict. However, we do...

    Background: Randomized trials of web-based decision aids for prostate specific antigen (PSA) testing indicate that these interventions improve knowledge and reduce decisional conflict. However, we do not know about these tools’ impact on people who spontaneously use a PSA testing patient decision aid on the internet. Objective: 1) Determine the impact of publicly available web-based PSA Option Grid patient decision aids on preference shift, knowledge, and decisional conflict; 2) identify which frequently asked questions (FAQs) are associated with preference shift; 3) explore the possible relationships between these outcomes. Methods: Data were collected between January 1, 2016 and December 30, 2017. Users who accessed the online, interactive PSA Option Grid were provided with three options – have a PSA test, no PSA test, unsure. Users first declared their initial preference, completed five knowledge questions, and a four-item (yes or no) validated decisional conflict scale (SURE). Next, users were presented with ten FAQs and asked to identify their preference for each question based on the information provided. At the end, users declared their final preference and completed the same knowledge and decisional conflict questions. Paired sample t-tests were employed to compare before-and-after knowledge and decisional conflict scores. A multinomial regression analysis was conducted to determine which FAQs were associated with a shift in screening preference. Results: Of the 467 people who accessed the PSA Option Grid, 186 (40%) completed the interactive journey and associated surveys. After excluding 22 female users, we analyzed 164 responses. At completion, users shifted their preference to ‘not having the PSA test’ (26% vs 71%; P <.01), had higher levels of knowledge (68% vs 89%, P < .01), and lower decisional conflict (57% vs 11%, P < .01). Three FAQs were associated with preference shift: What does the test involve? If my PSA level is high, what are the chances that I have prostate cancer? What are the risks? No relationships were present between knowledge, decisional conflict, and preference shift. Conclusions: Unprompted use of the interactive PSA Option Grid leads to preference shift, increased knowledge, and reduced decisional conflict which confirms the ability of these tools to influence decision-making, even when used outside clinical encounters.

  • A novel approach to evaluating mobile smartphone screen time: feasibility and preliminary findings

    Date Submitted: May 20, 2018

    Open Peer Review Period: May 21, 2018 - Jul 16, 2018

    Background: Increasingly high levels of smartphone ownership and use pose the potential for addictive behaviors and negative health outcomes, particularly among younger populations. Previous methodolo...

    Background: Increasingly high levels of smartphone ownership and use pose the potential for addictive behaviors and negative health outcomes, particularly among younger populations. Previous methodologies to understand mobile screen time have relied on self-report survey or ecological momentary assessment (EMA). Self-report is subject to bias and unreliability, while EMA can be burdensome to participants. New methodology is needed to advance the understanding of mobile screen time. Objective: The objective of this study was to test the feasibility of a novel methodology to record and evaluate mobile smartphone screen time and use: Battery Use Screenshot (BUS). Methods: The Battery Use Screenshot (BUS) approach, defined for this study as uploading a mobile phone screenshot of a specific page within a smartphone, was utilized within an online cross-sectional survey of adolescents aged 12 to 15 years old through the survey platform Qualtrics. Participants were asked to provide a screenshot of their battery use page, a feature within smartphones, to upload within the online survey. Feasibility was assessed by smartphone ownership and response rate to BUS upload request. Data availability was evaluated as applications (apps) per BUS, completeness of data within screenshot, and five most used applications based on battery use percentage. Results: Among those surveyed, 309 (26.7%) indicated ownership of their smartphone. A total of 105 screenshots were evaluated. For data availability, screenshots contained an average of 10.2 (SD=2.0) apps per screenshot and over half (55%) had complete data available. The most common apps included safari and home/lock screen. Conclusions: Findings describe BUS as a novel approach for real-time data collection focused on mobile smartphone screen time among young adolescents. Though feasibility showed some challenges in upload capacity of young teens, data availability was generally strong across this large data set. This data from screenshots have the potential to provide key insights into precise mobile smartphone screen use and time spent per mobile application. Future studies could explore the use of the BUS methodology to correlate mobile smartphone screen time with health outcomes.

  • How Confidence in Prior Attitudes, Social Tag Popularity, and Source Credibility Shape Confirmation Bias: A Randomized Controlled Web-Based Study about Attitudes towards Antidepressants and Psychotherapy in a Representative German Sample

    Date Submitted: May 18, 2018

    Open Peer Review Period: May 19, 2018 - Jul 14, 2018

    Background: In health-related, web-based information search, people should choose objectively correct information, but they are often misguided by confirmation bias–the tendency to select and evalua...

    Background: In health-related, web-based information search, people should choose objectively correct information, but they are often misguided by confirmation bias–the tendency to select and evaluate information in line with their prior attitudes. They are also misguided by dubious information, not taking source credibility into account properly. Objective: We test whether people are prone to confirmation bias in mental health-related information search, particularly (1) if high confidence worsens confirmation bias, (2) if social tags are an appropriate interface to circumvent the influence of prior attitudes, and (3) if people successfully distinguish high and low source credibility. Moreover, we describe attitudes towards the efficacy of the treatment of depression with antidepressants and psychotherapy. Methods: 520 participants of a representative sample of the German population were recruited on an online platform of a panel company. 250 (48%) completed the fully automated, randomized, controlled web-based study, which was accessible online from November 14th to November 18th 2014, until at least 250 participants completed the survey. Participants provided prior attitudes about antidepressants and psychotherapy. We manipulated (1) confidence by having participants recall situations in which they were confident or doubtful. Next, participants searched for blog posts about the treatment of depression, with social tag clouds differing in (2) tag popularity–either psychotherapy or antidepressant tags were more popular. Finally, we manipulated (3) source credibility with banners indicating high or low expertise of the tagging community, and we measured tag- and blog post selection, and treatment efficacy ratings after navigation. Results: We observed a tendency to rate psychotherapy (mean = 5.24, SD = 1.10) as more effective than antidepressants (mean = 4.61, SD = 1.19; t(225) = 9.71, P < .001, d = .56.). Tag popularity predicted the proportion of selected antidepressant tags (beta = 0.44, SE = .11, P < .001), and blog posts (beta = 0.46, SE = .11, P < .001). We could not replicate the confidence manipulation (t(224) < 1, P = .78). Participants did not attend to source credibility on banners (t(224) = 1.67, P = .10). When confidence was low (-1 SD), participants selected more blog posts consistent with prior attitudes (beta = -0.26, SE = 0.05, P < .001). Moreover, when confidence was low (-1 SD) and source credibility was high (+1 SD), the efficacy ratings of attitude consistent treatments increased (beta = 0.34, SE = 0.13, P = .01). Conclusions: We found correlational support for defense motivation account underlying confirmation bias in the mental health-related search context. That is, participants did not tend to select objectively correct, but information that supported their prior attitudes.

  • Identification of Primary Medication Concerns regarding Thyroid Hormone Replacement Therapy from Online Patient Medication Reviews

    Date Submitted: May 18, 2018

    Open Peer Review Period: May 19, 2018 - Jul 14, 2018

    Background: Patients with hypothyroidism report poor health-related quality of life despite having undergone thyroid hormone replacement therapy (THRT). Understanding patient concerns regarding levoth...

    Background: Patients with hypothyroidism report poor health-related quality of life despite having undergone thyroid hormone replacement therapy (THRT). Understanding patient concerns regarding levothyroxine can help improve the treatment outcomes of thyroid hormone replacement therapy. Objective: This study aimed to (1) identify the distinctive themes in patient concerns regarding THRT; to (2) determine whether patients have unique primary medication concerns specific to demographics, and to (3) determine the predictability of primary medication concerns on patient treatment satisfaction. Methods: We collected patient reviews from WebMD (1,037 reviews about generic levothyroxine and 1,075 reviews about the brand version) posted between September 1, 2007 and January 30, 2017. We used natural language processing (NLP) to identify the themes of medication concerns. Multiple regression analyses were conducted in order to examine the predictability of the primary medication concerns on patient treatment satisfaction. Results: NLP of the patient reviews of levothyroxine posted on a social networking site produced six distinctive themes of patient medication concerns related to levothyroxine treatment: ‘How to take the drug,’ ‘treatment initiation,’ ‘dose adjustment,’ ‘symptoms of pain,’ ‘generic substitutability’ and ‘appearance.’ Patients had different primary medication concerns unique to their gender, age, and treatment duration. Furthermore, treatment satisfaction on levothyroxine depended on what primary medication concerns the patient had. Conclusions: NLP of text content available on social networks could identify different themes of patient medication concerns that can be incorporated into tailored medication counseling to improve patient treatment satisfaction.

  • Efficacy of smartphone application-based pulmonary rehabilitation in chemotherapy-treated patients with advanced lung cancer: a pilot study

    Date Submitted: May 19, 2018

    Open Peer Review Period: May 19, 2018 - Jul 14, 2018

    Background: Advanced lung cancer patients often have chronic lung disease with reduced exercise capacities and various symptoms leading to altered quality of life (QoL). No studies have assessed pulmo...

    Background: Advanced lung cancer patients often have chronic lung disease with reduced exercise capacities and various symptoms leading to altered quality of life (QoL). No studies have assessed pulmonary rehabilitation (PR) employing a mobile application and an Internet of Things device in advanced lung cancer patients undergoing chemotherapy. Objective: We determined the feasibility and efficacy of a smartphone application-based PR on exercise capacity, symptom management, and QoL in these patients. Methods: A total of 100 patients were recruited in a prospective, single-arm intervention study using smartphone application-based PR program for 12 weeks. Exercise capacity (6-minute walking distance, 6MWD), QoL, symptom scale scores, and distress indexes were investigated. Results: Ninety patients completed the PR program. The most common cause of dropout was hospitalization due to cancer progression. After PR, there was significant improvement in the 6MWD; 380.1 ± 74.1 m at baseline, 429.1 ± 58.6 m at 6-weeks (P < .001), and 448.1 ± 50.0 m at 12-weeks (P < .001). However, the dyspnea scale score showed no significant improvement in the patients overall, but there was a trend for improvement in those with a stable tumor response (P = .065). Role (P = .02), emotional (P < .001), and social functioning (P = .002) scale scores showed significant improvement after PR. Symptom scale scores for fatigue (P < .001), anorexia (P = .047), and diarrhea (P = .01) also showed significant improvement. There was significant improvement in depression (P = .048) and anxiety (P = .01), while there was no significant change in QoL (P = .063) and severity of pain (P = .24). Conclusions: Smartphone application-based PR represents an effective and feasible program to improve exercise capacity, and to manage symptoms and distress in patients with advanced lung cancer, undergoing chemotherapy.

  • Person-Centered, Technology Enhanced Care Model For Managing Chronic Conditions: Development and Implementation

    Date Submitted: May 18, 2018

    Open Peer Review Period: May 19, 2018 - Jul 14, 2018

    Background: Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes...

    Background: Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this current support model unsustainably burdensome on health care systems globally. Mobile health (mHealth) technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being utilized to their full extent within US health care systems. Objective: The purpose of this study was to examine the utilization of staff and costs of a remote monitoring care model in persons with and without a chronic condition. Methods: At Dartmouth-Hitchcock Health, 2,894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a smartphone application that facilitated digital communication with nursing and health behavior change staff. Health data were collected, automatically analyzed, and generated behavioral support communications based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per-capita expenditures. Results: Participants averaged 41 years of age; 73% (n = 2,104) were female and 13% (n = 376) had at least one chronic condition. On average, each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 40% of all staff conversations, with higher per-capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 & 0.19 per-capita conversations, respectively, P<.001). When compared to the same period in the prior year, per-capita healthcare expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls. Conclusions: The technology-based chronic condition management care model was frequently used and demonstrated the potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.