JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 4.5 for 2015

Recent Articles:

  • Image Source: Getty images, royalty free image.

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


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

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

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


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

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

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


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

  • Key themes influencing readiness for digital health.

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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  • Differentiation strategy in online physician competition: Does specialization matter?

    Date Submitted: Feb 19, 2017

    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: A successful product differentiation strategy leads to competitive advantages and higher profits for firms, and this is also the case for the hospital industry. However, we do not know whe...

    Background: A successful product differentiation strategy leads to competitive advantages and higher profits for firms, and this is also the case for the hospital industry. However, we do not know whether a physician’s specialization differentiation strategy will have any impact on her online income in an e-Consultation market; nor do we know the market conditions under which this strategy will be more effective. Objective: We aim to investigate how a specialization differentiation strategy impacts a physician’s online income and the market conditions under which a specialization differentiation strategy has stronger effects. Methods: We employed secondary data in an econometric analysis of transactions obtained from an e-Consultation website ( for four diseases (infantile pneumonia, diabetes, infertility, and pancreatic cancer) from 2008 to 2015. A total of 1160 physicians were included in the analysis. Results: Specialization, the differentiation strategy, has a significant positive impact on the physician’s online income (β =0.011, p < 0.001). Moreover, specialization will improve a physician’s competitive advantage when market competition is more intense (β =0.116, p < 0.001). Conclusions: Physicians whose expertise is differs from that of the majority have higher online incomes, and this impact will be stronger when market competition is more intense. Our study indicates that e-Consultations may accelerate the specialization trend observed in the health care industry because the online market favors more-specialized physicians, and competition in the online market is stronger than in the offline market. Such an impact may be positive for some very complicated diseases but less positive for some chronic diseases. Policy makers should be careful with the double-edged sword of e-Consultation.

  • Implementation Decisions and Design Trade-offs in Developing an EHR-linked Mobile Application to Reduce Parental Uncertainty Around Childhood Cancer

    Date Submitted: Feb 16, 2017

    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: Parents of children newly diagnosed with cancer are confronted with multiple stressors that place them at risk for significant psychological distress. One strategy that has been shown to...

    Background: Parents of children newly diagnosed with cancer are confronted with multiple stressors that place them at risk for significant psychological distress. One strategy that has been shown to help reduce uncertainty is the provision of basic information. Families of newly diagnosed cancer patients are often bombarded with educational material, however. Technology has the potential to help families manage their informational needs and move towards normalization. Objective: We sought to create a mobile application that pulls together data from both the electronic health record (EHR) and vetted external information resources, in order to provide tailored information to parents of newly diagnosed children as one method to reduce the uncertainty around their child’s illness. This application was developed to be used by families in a National Institutes of Health (NIH)-funded randomized controlled trial (RCT) aimed at decreasing uncertainty and the subsequent psychological distress. Methods: A 2-phase qualitative study was conducted to elicit the features and content of the mobile application based on the needs and experience of parents of children newly diagnosed with cancer and their providers. Example functions include the ability to view laboratory results, look up appointments, and to access educational material. Educational material was obtained from databases maintained by the National Cancer Institute (NCI) and groups like the Children’s Oncology Group (COG) and care teams within Cincinnati Children’s Hospital Medical Center. The use of EHR-based web services was explored to allow data-like laboratory results to be retrieved in real-time. Results: The ethnographic design process resulted in an application framework that divided the content of the mobile application into 4 sections: 1) information about the patient’s current treatment and other information from the EHR; 2) educational background material; 3) a calendar to view upcoming appointments at their medical center; 4) a section where participants in the RCT document the study data. Integration with the NCI databases was straightforward, however, accessing the EHR web services posed a challenge, though the roadblocks were not technical in nature. The lack of a formal, end-to-end institutional process for requesting web service access and a mechanism to shepherd the request through all stages of implementation proved to be the biggest barrier. Conclusions: We successfully deployed a mobile application with a custom user interface that can integrate with the EHR to retrieve laboratory results and appointment information using vendor-provided web services. Developers should expect to face hurdles when integrating with the EHR, but many of them can be addressed with frequent communication and thorough documentation. Executive sponsorship is also a key factor for success. Clinical Trial: NCT02505165

  • Feasibility and Acceptability of an SMS Smoking Cessation Program for Young Adults in Lima: A Pilot Study

    Date Submitted: Feb 19, 2017

    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: We conducted a pilot study Objective: to assess whether an SMS Cognitive Behavioral Smoking Cessation Program is a suitable and acceptable intervention among Young Adults in Lima, Peru. Me...

    Background: We conducted a pilot study Objective: to assess whether an SMS Cognitive Behavioral Smoking Cessation Program is a suitable and acceptable intervention among Young Adults in Lima, Peru. Methods: Recruitment was primarily through a web page promoted by diverse strategies, including internet social media. Inclusion criteria were: age 18-25 yrs, daily tobacco smoking (4+ cigarettes/day), willing to quit, own mobile phone, SMS once in past year, and Lima resident. Focus groups & in-depth interviews (FG&DI), and a community advisory committee (CAC) fostered development of SMS content and programming of automatic messaging for 6 weeks that included a four week active quit phase. A Beta Test and a Technological Trial (TT) followed; with participants who received either Spanish language quit messages or a control with SMS nutritional content messages. Results: Of 639 recruits who completed initial online surveys, only 42 met inclusion criteria. Of these, 35 consented and participated as follows: n=12 for FG&DI, n=8 for CAC, n=15 for TT. Results FG&DI allowed us to adapt the SMS content of the Smoking Cessation SMS Cognitive Behavioral Program to the target population, their practices, knowledge and perceptions such as “other healthy behaviors compensate the health hazards of tobacco smoking”, common knowledge that does not matched evidence based treatment such as e-cigarettes as an alternative to quit smoking, the perceived relevant smoking effects on their health (eg, shortness of breath with physical activity, early wrinkles, yellow teeth, infertility, male sexual dysfunction). Also FG&DI and CAC allowed us to include their use and preferences of content, message tone, time, number of received SMS message. For the TT a 6 week SMS program, the quit outcome was evaluated via SMS self report to this question, repeated on days 2, 7, and 30 after the smoker's quit day: "Have you remained without smoking (not even a puff) since the day you quit?” (6 in control arm, with 1 quit, and 9 in active quit arm, with 5 quits). Of smokers assigned to the intervention arm, 100% (n=9) completed the program and answered the quit outcome questions, as compared to 83% (n=5) of those in the control arm. At this stage, the TT included neither long-term follow up nor bioassay confirmation. All participants reported that they received valuable health information and approved the times scheduled for delivery of the SMS messages. Conclusions: This pilot experience was promising and allowed us to adapt content and provided initial evidence that an SMS Behavioral Cognitive Program to quit smoking has feasibility and is acceptable for Spanish-fluent urban young adults in Peru. This work was an initial step toward formal RCTs to evaluate effectiveness of the SMS approach and assess long-term abstinence outcomes, and to enhance SMS-enhanced quit programs in Peru.

  • Development of a Context-Driven Dynamic XML Ophthalmologic Data Capture Application

    Date Submitted: Feb 7, 2017

    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: The capture and integration of ophthalmologic data into electronic health records (EHRs) has historically been a challenge. However, the importance of this activity for patient care and re...

    Background: The capture and integration of ophthalmologic data into electronic health records (EHRs) has historically been a challenge. However, the importance of this activity for patient care and research is critical. Objective: The purpose of this study was to develop a context-driven dynamic XML ophthalmology data capture application for research and clinical care that could be easily integrated into an electronic health record system. Methods: Stakeholders in the medical, research, and informatics fields were interviewed and surveyed to determine data and system requirements for ophthalmologic data capture. Based on these requirements, an ophthalmology data capture application was developed to collect and store discrete data elements with important graphical information. Results: The context-driven data entry application supports several features including: ink-over drawing capability for documenting eye abnormalities, context-based web controls that guide data entry based on pre-established dependencies, and an adaptable database or XML schema that stores web form specifications and allows for immediate changes in form layout or content. The application utilizes web services to enable data integration with a variety of EHRs for retrieval and storage of patient data. Conclusions: This paper describes the development process used to create a context-driven dynamic XML data capture application for optometry and ophthalmology. The list of ophthalmologic data elements identified as important for care and research can be used as a baseline list for future ophthalmologic data collection activities.

  • A Pilot Study of a Smart Toy to enhance Decision Making Process at Children’s Psychomotor Delays Screening

    Date Submitted: Feb 20, 2017

    Open Peer Review Period: Feb 20, 2017 - Feb 27, 2017

    Background: EDUCERE is an ecosystem for ubiquitous detection, care and early stimulation of children with developmental disorders. The objectives of this Spanish government funded R&D project are to i...

    Background: EDUCERE is an ecosystem for ubiquitous detection, care and early stimulation of children with developmental disorders. The objectives of this Spanish government funded R&D project are to investigate, develop and evaluate innovative solutions for society, in order to detect changes in psychomotor development through the natural interaction of children with toys and everyday objects, and perform stimulation and early attention activities in real environments such as home and school. Thirty multidisciplinary professionals and three nursery schools worked in EDUCERE project between 2014 and 2017. Objective: The described research encloses the design, implementation and validation of EDUCERE smart toy aimed to detect delays in psychomotor development in an automatic way. The results from initial tests led to enhance the effectiveness of the original design and deployment. The smart toy, based on stackable cubes, has a data collector module and a smart system for detection of developmental delays, called EDUCERE Developmental Delay Screening System (EDUCERE DDSS). Methods: The pilot study involved 65 toddlers aged between 23 and 37 months (average age=29,02) who built a tower with 5 stackable cubes, designed by following the EDUCERE smart toy model. As toddlers make the tower, sensors in the cubes sent data to a collector module through a wireless connection. All trials were video-recorded for further analysis by child development experts. After watching the videos, experts scored the performance of the trials to compare and fine-tune the interpretation of the data automatically gathered by the toy-embedded sensors Results: Judges were highly reliable in an inter-rater agreement analysis (interval of 0.937 to 0.967 with 95% confidence), suggesting that the process was successful to separate different levels of performance. A factor analysis of collected data showed that three factors, “trembling”, “speed” and “accuracy” account for 76.79% of the total variance but only two of them are predictors of performance in a regression analysis: accuracy (p-value=0,001) and speed (p-value=0,002); the other factor, trembling (p-value=0,789), does not have a significant effect on this dependent variable. Conclusions: EDUCERE DDSS is ready to use the regression equation obtained for the dependent variable "performance" as an algorithm for the automatic detection of psychomotor development delays. The results of the factor analysis are valuable to simplify the design of the smart toy by taking into account only the significant variables in the collector module. The fine-tuning of the toy process module will be carried out by following the specifications resulting from the analysis of the data in order to improve the efficiency and effectiveness of the product.

  • An e-recovery portal in community mental health care: An exploratory study of its use and role in shifting practices towards recovery-oriented care

    Date Submitted: Feb 20, 2017

    Open Peer Review Period: Feb 20, 2017 - Feb 27, 2017

    Background: Mental health care is shifting from a primary focus on symptom reduction towards personal recovery-oriented care, especially for persons with long-term mental health care needs. Web-based...

    Background: Mental health care is shifting from a primary focus on symptom reduction towards personal recovery-oriented care, especially for persons with long-term mental health care needs. Web-based portals may facilitate this shift, but little is known about how such tools are used, or the role they may play in personal recovery. Objective: To illustrate uses and experiences with the e-recovery portal ‘ReConnect’ as an adjunct to ongoing community mental health care and explore its potential role in shifting practices towards recovery. Methods: ReConnect was introduced into two Norwegian mental health care communities and used for six months. The aim was to support personal recovery and service user–health care provider collaboration. Among inclusion criteria for participation were long-term care needs and at least one provider willing to interact with users through ReConnect. The portal augmented ongoing collaboration as each service user–provider dyad found appropriate, and comprised of; a) a toolbox of resources for articulating and working with recovery processes, e.g.; status/goals/activities relative to life domains (e.g. employment, social network, health), medications, network map, and exercises (e.g. sleep hygiene, mindfulness), b) secure messaging with providers who had partial access to toolbox content, c) peer support forum. Quantitative data (system log, questionnaires) were analyzed using descriptive statistics. Qualitative data (e.g. focus groups, forum postings) are presented relative to La Boutillier et al’s four recovery-oriented practice domains; personally defined recovery, promoting rcitizenship, woking relationships, and organizational commitment. Results: Fifty-six participants (29 service users and 27 providers) made up 29 service user-provider dyads. Service users reported having 11 different mental health diagnoses averaging two diagnoses each (range 1-7). The 27 providers represented nine different professional backgrounds. Forum was the most frequently used module with 1870 visits and 542 postings. Service users’ control over toolbox resources (e.g. defining and working towards personal goals), coupled with peer-support, activated service users in their personal recovery processes and in community engagement. Some providers (30%) did not interact with service users through ReConnect. Dyads who used the portal resources, did so in highly diverse ways, and participants reported needing more than six months to discover and adapt optimal uses relative to their individual and collaborative needs. Based on our discussion of findings, hypotheses about e-recovery are proposed relative to La Boutillier et al’s four practice domains. Conclusions: Regardless of providers’ portal use, service users’ control over toolbox resources, coupled with peer-support, offered an empowering common frame of reference that represented an immediate shift towards recovery-oriented practices within communities. While service users’ autonomous use of the portal can eventually influence providers in the direction of recovery practices, a fundamental shift is unlikely without broader organizational commitments aligned with recovery principles, e.g. quantified goals for service user involvement in care plans.