JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

Recent Articles:

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

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


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

  • e-VITA interface (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

  • Internet surveillance would play a vital role in identifying the Norovirus infection. Source: The Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Identifying Potential Norovirus Epidemics in China via Internet Surveillance


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

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

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


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

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

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


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

  • Source: Flickr; Copyright: Franchise Opportunities; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    An Internet-Based Method for Extracting Nursing Home Resident Sedative Medication Data From Pharmacy Packing Systems: Descriptive Evaluation


    Background: Inappropriate use of sedating medication has been reported in nursing homes for several decades. The Reducing Use of Sedatives (RedUSe) project was designed to address this issue through a combination of audit, feedback, staff education, and medication review. The project significantly reduced sedative use in a controlled trial of 25 Tasmanian nursing homes. To expand the project to 150 nursing homes across Australia, an improved and scalable method of data collection was required. This paper describes and evaluates a method for remotely extracting, transforming, and validating electronic resident and medication data from community pharmacies supplying medications to nursing homes. Objective: The aim of this study was to develop and evaluate an electronic method for extracting and enriching data on psychotropic medication use in nursing homes, on a national scale. Methods: An application uploaded resident details and medication data from computerized medication packing systems in the pharmacies supplying participating nursing homes. The server converted medication codes used by the packing systems to Australian Medicines Terminology coding and subsequently to Anatomical Therapeutic Chemical (ATC) codes for grouping. Medications of interest, in this case antipsychotics and benzodiazepines, were automatically identified and quantified during the upload. This data was then validated on the Web by project staff and a “champion nurse” at the participating home. Results: Of participating nursing homes, 94.6% (142/150) had resident and medication records uploaded. Facilitating an upload for one pharmacy took an average of 15 min. A total of 17,722 resident profiles were extracted, representing 95.6% (17,722/18,537) of the homes’ residents. For these, 546,535 medication records were extracted, of which, 28,053 were identified as antipsychotics or benzodiazepines. Of these, 8.17% (2291/28,053) were modified during validation and verification stages, and 4.75% (1398/29,451) were added. The champion nurse required a mean of 33 min website interaction to verify data, compared with 60 min for manual data entry. Conclusions: The results show that the electronic data collection process is accurate: 95.25% (28,053/29,451) of sedative medications being taken by residents were identified and, of those, 91.83% (25,762/28,053) were correct without any manual intervention. The process worked effectively for nearly all homes. Although the pharmacy packing systems contain some invalid patient records, and data is sometimes incorrectly recorded, validation steps can overcome these problems and provide sufficiently accurate data for the purposes of reporting medication use in individual nursing homes.

  • Source: The Author; Copyright: Taiwan Government; URL:; License: Creative Commons Attribution (CC-BY).

    Web-Based Medical Service: Technology Attractiveness, Medical Creditability, Information Source, and Behavior Intention

    Authors List:


    Background: Web-based medical service (WBMS), a cooperative relationship between medical service and Internet technology, has been called one of the most innovative services of the 21st century. However, its business promotion and implementation in the medical industry have neither been expected nor executed. Few studies have explored this phenomenon from the viewpoint of inexperienced patients. Objective: The primary goal of this study was to explore whether technology attractiveness, medical creditability, and diversified medical information sources could increase users’ behavior intention. Methods: This study explored the effectiveness of web-based medical service by using three situations to manipulate sources of medical information. A total of 150 questionnaires were collected from people who had never used WBMS before. Hierarchical regression was used to examine the mediation and moderated-mediation effects. Results: Perceived ease of use (P=.002) and perceived usefulness (P=.001) significantly enhance behavior intentions. Medical credibility is a mediator (P=.03), but the relationship does not significantly differ under diverse manipulative information channels (P=.39). Conclusions: Medical credibility could explain the extra variation between technology attractiveness and behavior intention, but not significant under different moderating effect of medical information sources.

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  • Case Study: Implementing an Open Source Electronic Health Record (EHR) System in Secondary Care in Kenya

    Date Submitted: Aug 17, 2017

    Open Peer Review Period: Aug 17, 2017 - Oct 12, 2017

    Background: The Kenyan government, working with international partners and local organisations, has developed an e-Health strategy, specified standards and guidelines for EHR adoption in public hospit...

    Background: The Kenyan government, working with international partners and local organisations, has developed an e-Health strategy, specified standards and guidelines for EHR adoption in public hospitals, and implemented two major health IT projects: DHIS2, for collating national healthcare indicators, and HMIS (using KenyaEHR and IQCare), for managing 600 HIV clinics across the country. Following these projects, a modified version of the OpenMRS EHR system was specified and developed to fulfil the clinical and administrative requirements of primary and secondary healthcare facilities operated by devolved counties and to automate the process of collating healthcare indicators and entering them into the DHIS2 system. Objective: To present a case study of the implementation of an open source Electronic Health Record (EHR) system in secondary care facilities in Kenya. Methods: We conducted a landscape review of existing literature concerning e-Health policies and EHR development in Kenya. Following initial discussions with the Ministry of Health, WHO and implementing partners, we conducted a series of visits to implementing sites to conduct semi-structured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation. Results: This case report describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital IT infrastructure, training users and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of socio-technical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya. Conclusions: Implementing EHR systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. We hope this case study will provide some lessons and guidance for other challenging implementations of EHR systems as they continue across Africa.

  • How do infant feeding apps in China measure up?

    Date Submitted: Aug 17, 2017

    Open Peer Review Period: Aug 17, 2017 - Oct 12, 2017

    Background: Globally, with the popularization of smartphones, the number of health-related smartphone applications (apps) skyrocketed to 259,000 in 2016. People are changing the way they interact with...

    Background: Globally, with the popularization of smartphones, the number of health-related smartphone applications (apps) skyrocketed to 259,000 in 2016. People are changing the way they interact with health information through their fingertips. In China there are many apps that claim to provide infant feeding and nutrition guidance. However, the quality of information in those apps has not been extensively assessed. Objective: To assess the quality of Chinese infant feeding apps using comprehensive quality assessment criteria and to explore Chinese mothers’ perceptions on apps quality and usability. Methods: We searched for free-to-download Chinese infant feeding apps in the iTunes and Android app stores. A comprehensive assessment of the accountability, scientific basis and accuracy of information relevant to infant feeding, advertising policy, functionality, and a preliminary screening of infant formula advertisements in the apps were carried out. We also carried out exploratory qualitative research through semi-structured interviews with Chinese mothers in Shanghai to elicit their views about the quality of the apps. Results: A total of 4,925 apps were screened, and the 26 apps that met the selection criteria were evaluated. Overall, all 26 apps were developed by commercial entities and the majority of them were rated poorly. The highest total score was 62.2 (out of a possible 100) and the lowest was 16.7. In the four quality domains assessed, none of them fulfilled all the accountability criteria. Only 3 out of 26 apps provided information covering the three practices from the WHO’s infant feeding recommendations. Only one app described its advertising policy in its Terms of Usage. The most common app functionality was a built-in social forum (19/26). Provision of website links was the least common functionality (2/26). 20 of the 26 apps carried infant formula banner advertisements in their homepages. 12 apps included both e-commence stores and featured infant formula advertisements. In total, 21 mothers were interviewed face-to-face. Mothers highly valued immediate access to parenting information and mulita-functionality provided by apps. However, concerns of incredible information and commercial activities in apps, and desire for information and support offered by healthcare professionals were expressed. Conclusions: The findings provide valuable information to the understanding of Chinese infant feeding apps. The results are concerning, particularly with the relative absence of scientific basis and credibility, along with a large amount of commercial advertisements. Apps do seem to be able to provide an opportunity for mothers to access health information and support, but there is a plea for tighter controls on contents and advertisements. Ongoing app research and development should focus on implementation of a standard framework which would drive the development of high-quality apps to support healthy infant feeding, through cooperation among academics, health professionals, app users, app developers and government bodies.

  • Challenges and Opportunities of Implementing a Patient-Reported Measure of Physical Function through an online Electronic Health Record Patient Portal in Routine Rheumatology Practice

    Date Submitted: Aug 15, 2017

    Open Peer Review Period: Aug 16, 2017 - Oct 11, 2017

    Background: Despite significant interest in the collection of patient-reported outcomes (PROs) to make care more patient-centered, few studies have evaluated implementation efforts to collect PROs fro...

    Background: Despite significant interest in the collection of patient-reported outcomes (PROs) to make care more patient-centered, few studies have evaluated implementation efforts to collect PROs from diverse patient populations. Objective: We assessed the collection of PROs from rheumatoid arthritis (RA) patients in an academic rheumatology clinic, using a paper and an online form through the electronic health record (EHR) patient portal. Methods: We identified patients seen between 2012- 2016 with ≥2 face-to-face encounters with a rheumatology provider and ICD codes for RA, ≥30 days apart. In 2013, our clinic implemented a paper version of the Patient Reported Outcome Measurement Information System (PROMIS) physical function (PF) form that was administered to patients upon their check-in at the clinic; in 2015, an online version of the form became available via the EHR patient portal to patients with active portal accounts. We compared the proportion of visits with documented PROMIS scores across age, race/ethnicity, and language, using chi-square, ANOVA tests, and logistic regression model and examined trends over time using a control chart. Results: We included 1,078 patients with RA with 7,049 in-person encounters at the rheumatology clinic over 4 years, with an average of 168 visits/month. 80.4% of patients (867/1078) were female; mean age was 55 (SD 16). Overall PROMIS PF score documentation increased from 60.4% (1081/1791) of visits in 2013 to 74.4% (905/1217) in 2016. Online score documentation increased from 10.0% (148/1473) in 2015 to 19.3% (235/1217) in 2016. African Americans were less likely to have a PROMIS PF recorded (62.5% (55/88) vs. 80.0% (792/990) for other racial/ethnic groups, P<0.001). Compared with Whites, both African American and Hispanics were less likely to have active online EHR portal accounts (50% (44/88) and 57.3% (90/157) respectively, vs. 83.9% (437/521) of Whites; P<0.001) and, once activated, less likely to use the online survey (13.6% (6/44) and 17.8% (16/90) respectively, vs. 30.9% (135/437) of Whites; P=0.02). There was no significant difference in the proportion of any PROMIS PF recorded between non-English vs. English speakers. No significant differences were found across age or gender. Conclusions: PROMIS PF form completion improved overall from 2012-2016, but lagged among racial/ethnic minorities and non-English speaking patients. Future studies should address issues of portal access, enrollment, satisfaction and persistence, and focus on developing PRO implementation strategies that accommodate the needs and preferences of diverse populations.

  • Using Facebook to recruit young Australian males into a cross-sectional human papillomavirus study

    Date Submitted: Aug 13, 2017

    Open Peer Review Period: Aug 15, 2017 - Oct 10, 2017

    Background: Young males can be difficult to engage in health research using traditional methods of recruitment. Social networking sites (SNS) are increasingly being used to recruit participants into h...

    Background: Young males can be difficult to engage in health research using traditional methods of recruitment. Social networking sites (SNS) are increasingly being used to recruit participants into health research, due to their cost-effectiveness, overall generalisability and wide reach. Objective: The aim of this study was to determine the feasibility of using Facebook to recruit young Australian males into a human papillomavirus (HPV) prevalence study. Methods: Male, permanent residents of Australia, aged 18–35 years were recruited into the HPV in Young Males (HYM) Study through targeted advertising placed on Facebook. Consenting participants completed an online questionnaire and provided a self-collected penile swab for HPV DNA detection and genotyping. Socio-demographic characteristic of the study population were compared to that of the general Australian male population, based on Australian 2011 Census data. Results: Between February 2015 and February 2017, targeted Facebook advertisements reached 1,523,233 males, resulting in 41,811 clicks through to the study website, with 1,072 (2.6%) converting to lodgement of an expression of interest (EOI). Of these, 681 (63.5%) provided written informed consent and 535 (78.6% of recruited participants) completed all the study requirements. Reasons for participating in the study included altruism, past history of HPV, gaining more knowledge about HPV and/or the vaccine, working in the health industry and the monetary compensation. The average advertising cost per completed study participant was AU$48. Compared with the census population, HYM participants were more likely to be Australian born (P<0.001), be from Victoria or the Australian Capital Territory (P=0.003 and 0.004, respectively), reside in a major city (P<0.001) and have completed undergraduate or postgraduate education (P<0.001 for each). HYM participants were less likely to report being a current smoker (P=0.03), but were more likely to identify as bisexual or homosexual (55.6%, P<0.001), than the general population. Conclusions: Facebook is a feasible and efficient strategy for the recruitment of males from across Australia for HPV testing. This method could be utilised for monitoring the impact of HPV vaccination. Additional targeting may achieve a sample that is broadly demographically representative of the Australian population Future research should explore how the sexual risk behaviour characteristics of populations recruited through Facebook compare with traditional recruitment methods.

  • A Dermatologists’ Ammunition in the War Against Smoking

    Date Submitted: Aug 14, 2017

    Open Peer Review Period: Aug 14, 2017 - Aug 23, 2017

    This viewpoint reviews the perspectives for Dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and claim its responsibility due to the superior impact of skin ch...

    This viewpoint reviews the perspectives for Dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and claim its responsibility due to the superior impact of skin changes on a persons’ self-concept and behavior in the design of effective interventions for smoking prevention and cessation.

  • A patient-held smartcard with a unique identifier to improve availability of prenatal test results in rural Nigeria

    Date Submitted: Aug 14, 2017

    Open Peer Review Period: Aug 14, 2017 - Aug 23, 2017

    Background: Community-based strategies to test for HIV, hepatitis B virus (HBV), and sickle cell disease (SCD) have expanded opportunities to increase the proportion of pregnant women who are aware of...

    Background: Community-based strategies to test for HIV, hepatitis B virus (HBV), and sickle cell disease (SCD) have expanded opportunities to increase the proportion of pregnant women who are aware of their diagnosis. In order to use this information to implement evidence-based interventions, these results have to be available to skilled health providers at the point-of-delivery. Most electronic health platforms are dependent on the availability of reliable Internet connectivity and thus, have limited use in many rural and resource-limited settings. Objective: In this study, we explored the possibilities of developing an integrated mobile health (mHealth) platform that is able to capture medical information including test results and encrypt it into a patient-held smartcard that can be read at the point-of-delivery without the need for an Internet connection. Methods: We engaged a team of public health experts and information technology specialists in a focus group and a requirement gathering process to inform the design of a prototype for a platform that utilizes smartcard technology, database deployment, and mobile phone app development. Results: We successfully designed an integrated mHealth platform and deployed it in four health facilities across Benue state, Nigeria. The platform was developed to store test results in a database, securely encrypt the results on a smartcard, and a mobile app was used to read the information on the smartcard, without the need for Internet connectivity. Conclusions: Our findings indicate that it is feasible to develop a patient-held smartcard that contains vital health information that can be read at the point-of-delivery using a mobile phone-based app without Internet connection. Clinical Trial: NCT03027258; (Archived by WebCite at