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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:

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

    Development and Usability Evaluation of an Art and Narrative-Based Knowledge Translation Tool for Parents With a Child With Pediatric Chronic Pain:...


    Background: Chronic pain in childhood is increasingly being recognized as a significant clinical problem for children and their families. Previous research has identified that families want information about the causes of their child’s chronic pain, treatment options, and effective strategies to help their child cope with the pain. Unfortunately, parents have reported that finding this information can be challenging. Objective: The aim of this study was to actively work together with children attending a pediatric chronic pain clinic and their parents to develop, refine, and evaluate the usability of an art and narrative-based electronic book (e-book) for pediatric chronic pain. Methods: A multiphase, multi-method research design employing patient engagement techniques was used to develop, refine, and evaluate the usability of an art and narrative based e-book for pediatric chronic pain management to facilitate knowledge translation for parents with a child with chronic pain. The multiple phases included the following: (1) qualitative interviews to compile parents’ narratives using qualitative interviews; (2) qualitative data analysis; (3) development of an e-book prototype; (4) expert clinician feedback; (5) parent usability evaluation, knowledge change, and confidence in knowledge responses using an electronic survey; (6) e-book refinement; and (7) dissemination of the e-book. Results: A 48-page e-book was developed to characterize the experiences of a family living with a child with chronic pain. The e-book was a composite narrative of the parent interviews and encompassed descriptions of the effects the condition has on each member of the family. This was merged with the best available research evidence on the day-to-day management of pediatric chronic pain. The e-book was vetted for clinical accuracy by expert pediatric pain clinicians. All parents that participated in the usability evaluation (N=14) agreed or strongly agreed the content of the e-book was easy to understand and stated that they would recommend the e-book to other families who have children with chronic pain. Our research identified up to a 21.4% increase in knowledge after using the e-book, and paired t tests demonstrated a statistically significant difference in confidence in answering two of the five knowledge questions (chronic pain is a disease involving changes in the nervous system; the use of ibuprofen is usually effective at controlling chronic pain); t13=0.165, P=.001 and t13=0.336, P=.002, respectively, after being exposed to the e-book. Conclusions: Our results demonstrate that parents positively rated an e-book developed for parents with a child with chronic pain. Our results also identify that overall, parents’ knowledge increased after using the e-book, and confidence in their knowledge about chronic pain and its management increased in two aspects after e-book exposure. These results suggest that art and narrative-based knowledge translation interventions may be useful in transferring complex health information to parents.

  • Source: Wikimedia Commons; Copyright: Jean-Pierre Dalbéra; URL:; License: Creative Commons Attribution (CC-BY).

    Individual Differences in the Relationship Between Attachment and Nomophobia Among College Students: The Mediating Role of Mindfulness


    Background: There is a growing interest in nomophobia, which is defined as the fear of being out of cellular phone contact, or "feelings of discomfort or anxiety experienced by individuals when they are unable to use their mobile phones or utilize the affordances these devices provide”. However, only limited research can be found in terms of its determinants at present. Contemporary literature suggests that the relationships among attachment styles, mindfulness, and nomophobia have not been investigated. Objective: This study aims to investigate the mediating effect of mindfulness on the relationship between attachment and nomophobia. In addition, the study also focuses on gender differences in attachment, mindfulness, and nomophobia. A theory-based structural model was tested to understand the essentials of the associations between the constructs. Methods: The Experiences in Close Relationships Scale, Nomophobia Questionnaire, and Mindful Attention Awareness Scale were used to collect data from undergraduate students (N=450; 70.9% women [319/450]; mean age=21.94 years [SD 3.61]). Two measurement models (ie, attachment and mindfulness) and a structural model were specified, estimated, and evaluated. Results: The structural equation model shows that the positive direct effects of avoidant (.13, P=.03) and anxious attachment (.48, P<.001) on nomophobia were significant. The negative direct effects of avoidant (−.18, P=.01) and anxious attachment (−.33, P<.001) on mindfulness were also significant. Moreover, mindfulness has a significant negative effect on nomophobia for women only (−.13, P=.03). Finally, the Sobel test showed that the indirect effects of avoidant and anxious attachment on nomophobia via mindfulness were significant (P<.001). The direct and indirect effects of anxious attachment, avoidant attachment, and mindfulness altogether accounted for 33% of the total variance in nomophobia. Gender comparison results show that there is a significant difference in attachment based on gender (F2,447=6.97, P=.01, Wilk λ=.97, partial η2=.03). Women (mean 68.46 [SD 16.96]) scored significantly higher than men (mean 63.59 [SD 15.97]) in anxious attachment (F1=7.93, P=.01, partial η2=.02). Gender differences in mindfulness were not significant (F4,448=3.45, P=.69). On the other hand, results do show significant gender differences in nomophobia (F4,445=2.71, P=.03, Wilk λ=.98, partial η2=.02) where women scored significantly higher than men. Conclusions: In general, individuals who are emotionally more dependent and crave more closeness and attention in the relationship tend to display higher levels of fear or discomfort when they have no access to their mobile phones. However, gender has a differential impact on the relationship between avoidant attachment and nomophobia. This study establishes the impact of mindfulness on nomophobia for women; therefore, future studies should test the effectiveness of mindfulness-based therapy approaches and confirm whether they are effective and efficient. On the basis of significant gender difference in nomophobia and attachment, we conclude that gender should be taken into account in mindfulness-based treatments dealing with nomophobia.

  • SARAH hand exercise. Source: Image created by authors of the SARAH clinical trial ISRCTN89936343; Copyright: Universities of Warwick and Oxford 2014 (S Lamb, M Williams, E Williamson and P Heine); URL:; License: Licensed by the authors.

    A Web-Based Training Resource for Therapists to Deliver an Evidence-Based Exercise Program for Rheumatoid Arthritis of the Hand (iSARAH): Design,...


    Background: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) is a tailored, progressive exercise program for people having difficulties with wrist and hand function due to rheumatoid arthritis (RA). The program was evaluated in a large-scale clinical trial and was found to improve hand function, was safe to deliver, and was cost-effective. These findings led to the SARAH program being recommended in the UK National Institute for Health and Care Excellence guidelines for the management of adults with RA. To facilitate the uptake of this evidence-based program by clinicians, we proposed a Web-based training program for SARAH (iSARAH) to educate and train physiotherapists and occupational therapists on delivering the SARAH program in their practice. The overall iSARAH implementation project was guided by the 5 phases of the analysis, design, development, implementation, and evaluation (ADDIE) system design model. Objective: The objective of our study was to conduct the first 3 phases of the model in the development of the iSARAH project. Methods: Following publication of the trial, the SARAH program materials were made available to therapists to download from the trial website for use in clinical practice. A total of 35 therapists who downloaded these materials completed an online survey to provide feedback on practice trends in prescribing hand exercises for people with RA, perceived barriers and facilitators to using the SARAH program in clinical practice, and their preferences for the content and Web features of iSARAH. The development and design of iSARAH were further guided by a team of multidisciplinary health professionals (n=17) who took part in a half-day development meeting. We developed the preliminary version of iSARAH and tested it among therapists (n=10) to identify and rectify usability issues and to produce the final version. Results: The major recommendations made by therapists and the multidisciplinary team were having a simple Web design and layout, clear exercise pictures and videos, and compatibility of iSARAH on various browsers and devices. We rectified all usability issues in the preliminary version to develop the final version of iSARAH, which included 4 short modules and additional sections on self-assessment, frequently asked questions, and a resource library. Conclusions: The use of the ADDIE design model and engagement of end users in the development and evaluation phases have rendered iSARAH a convenient, easy-to-use, and effective Web-based learning resource for therapists on how to deliver the SARAH program. There is also huge potential for adapting iSARAH across different cultures and languages, thus opening more opportunities for wider uptake and application of the SARAH program into practice.

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

    Evaluating the Dental Caries-Related Information on Brazilian Websites: Qualitative Study


    Background: Dental caries is the most common chronic oral disease, affecting 2.4 billion people worldwide who on average have 2.11 decayed, missing, or filled teeth. It impacts the quality of life of patients, socially and economically. However, the comprehension of dental caries may be difficult for most people, as it involves a multifactorial etiology with the interplay between the tooth surface, the dental biofilm, dietary fermentable carbohydrates, and genetic and behavioral factors. Therefore, the production of effective materials addressed to the education and counseling of patients for the prevention of dental caries requires a high level of specialization. In this regard, the dental caries-related contents produced by laypersons and their availability on the Internet may be low-quality information. Objective: The aim of this study was to assess the readability and the quality of dental caries-related information on Brazilian websites. Methods: A total of 75 websites were selected through Google, Bing, Yahoo!, and Baidu. The websites were organized in rankings according to their order of appearance in each one of the 4 search engines. Furthermore, 2 independent examiners evaluated the quality of websites using the DISCERN questionnaire and the Journal of American Medical Association (JAMA) benchmark criteria. The readability of the websites was assessed by the Flesch Reading Ease adapted to Brazilian Portuguese (FRE-BP). In addition, the information presented on the websites was categorized as etiology, prevention, and treatment of dental caries. The statistical analysis was performed using Spearman rank correlation coefficient, Mann-Whitney U test, hierarchical clustering analysis by Ward minimum variance method, Kruskal-Wallis test, and post hoc Dunn test. P<.05 was considered significant. Results: The Web contents were considered to be of poor quality by DISCERN (mean 33.48, standard deviation, SD 9.06) and JAMA (mean 1.12, SD 0.97) scores, presenting easy reading levels (FRE-BP: mean 62.93, SD 10.15). The rankings of the websites presented by Google (ρ=−.22, P=.08), Baidu (ρ=−.19, P=.53), Yahoo! (ρ=.22, P=.39), and Bing (ρ=−.36, P=.23) were not correlated with DISCERN scores. Moreover, the quality of websites with health- and nonhealth-related authors was similar (P=.27 for DISCERN and P=.47 for JAMA); however, the pages with a greater variety of dental caries information showed significantly higher quality scores than those with limited contents (P=.009). Conclusions: On the basis of this sample, dental caries-related contents available on Brazilian websites were considered simple, accessible, and of poor quality, independent of their authorship. These findings indicate the need for the development of specific policies focused on the stimulus for the production and publication of Web health information, encouraging dentists to guide their patients in searching for recommended oral health websites.

  • Source: JMIR Publications/; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Using Social Media Data to Understand the Impact of Promotional Information on Laypeople’s Discussions: A Case Study of Lynch Syndrome


    Background: Social media is being used by various stakeholders among pharmaceutical companies, government agencies, health care organizations, professionals, and news media as a way of engaging audiences to raise disease awareness and ultimately to improve public health. Nevertheless, it is unclear what effects this health information has on laypeople. Objective: This study aimed to provide a detailed examination of how promotional health information related to Lynch syndrome impacts laypeople’s discussions on a social media platform (Twitter) in terms of topic awareness and attitudes. Methods: We used topic modeling and sentiment analysis techniques on Lynch syndrome–related tweets to answer the following research questions (RQs): (1) what are the most discussed topics in Lynch syndrome–related tweets?; (2) how promotional Lynch syndrome–related information on Twitter affects laypeople’s discussions?; and (3) what impact do the Lynch syndrome awareness activities in the Colon Cancer Awareness Month and Lynch Syndrome Awareness Day have on laypeople’s discussions and their attitudes? In particular, we used a set of keywords to collect Lynch syndrome–related tweets from October 26, 2016 to August 11, 2017 (289 days) through the Twitter public search application programming interface (API). We experimented with two different classification methods to categorize tweets into the following three classes: (1) irrelevant, (2) promotional health information, and (3) laypeople’s discussions. We applied a topic modeling method to discover the themes in these Lynch syndrome–related tweets and conducted sentiment analysis on each layperson’s tweet to gauge the writer’s attitude (ie, positive, negative, and neutral) toward Lynch syndrome. The topic modeling and sentiment analysis results were elaborated to answer the three RQs. Results: Of all tweets (N=16,667), 87.38% (14,564/16,667) were related to Lynch syndrome. Of the Lynch syndrome–related tweets, 81.43% (11,860/14,564) were classified as promotional and 18.57% (2704/14,564) were classified as laypeople’s discussions. The most discussed themes were treatment (n=4080) and genetic testing (n=3073). We found that the topic distributions in laypeople’s discussions were similar to the distributions in promotional Lynch syndrome–related information. Furthermore, most people had a positive attitude when discussing Lynch syndrome. The proportion of negative tweets was 3.51%. Within each topic, treatment (16.67%) and genetic testing (5.60%) had more negative tweets compared with other topics. When comparing monthly trends, laypeople’s discussions had a strong correlation with promotional Lynch syndrome–related information on awareness (r=.98, P<.001), while there were moderate correlations on screening (r=.602, P=.05), genetic testing (r=.624, P=.04), treatment (r=.69, P=.02), and risk (r=.66, P=.03). We also discovered that the Colon Cancer Awareness Month (March 2017) and the Lynch Syndrome Awareness Day (March 22, 2017) had significant positive impacts on laypeople’s discussions and their attitudes. Conclusions: There is evidence that participative social media platforms, namely Twitter, offer unique opportunities to inform cancer communication surveillance and to explore the mechanisms by which these new communication media affect individual health behavior and population health.

  • fNIRS recording during a virtual reality dental task. Source: Suzanne Perry; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Getting to the Root of Fine Motor Skill Performance in Dentistry: Brain Activity During Dental Tasks in a Virtual Reality Haptic Simulation


    Background: There is little evidence considering the relationship between movement-specific reinvestment (a dimension of personality which refers to the propensity for individuals to consciously monitor and control their movements) and working memory during motor skill performance. Functional near-infrared spectroscopy (fNIRS) measuring oxyhemoglobin demands in the frontal cortex during performance of virtual reality (VR) psychomotor tasks can be used to examine this research gap. Objective: The aim of this study was to determine the potential relationship between the propensity to reinvest and blood flow to the dorsolateral prefrontal cortices of the brain. A secondary aim was to determine the propensity to reinvest and performance during 2 dental tasks carried out using haptic VR simulators. Methods: We used fNIRS to assess oxygen demands in 24 undergraduate dental students during 2 dental tasks (clinical, nonclinical) on a VR haptic simulator. We used the Movement-Specific Reinvestment Scale questionnaire to assess the students’ propensity to reinvest. Results: Students with a high propensity for movement-specific reinvestment displayed significantly greater oxyhemoglobin demands in an area associated with working memory during the nonclinical task (Spearman correlation, rs=.49, P=.03). Conclusions: This small-scale study suggests that neurophysiological differences are evident between high and low reinvesters during a dental VR task in terms of oxyhemoglobin demands in an area associated with working memory.

  • Using a direct microblog message to engage a suicide ideation population. Source: Tingshao Zhu, Wenyan Liu, Yameng Wang, Ziying Tan; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Designing Microblog Direct Messages to Engage Social Media Users With Suicide Ideation: Interview and Survey Study on Weibo


    Background: While Web-based interventions can be efficacious, engaging a target population’s attention remains challenging. We argue that strategies to draw such a population’s attention should be tailored to meet its needs. Increasing user engagement in online suicide intervention development requires feedback from this group to prevent people who have suicide ideation from seeking treatment. Objective: The goal of this study was to solicit feedback on the acceptability of the content of messaging from social media users with suicide ideation. To overcome the common concern of lack of engagement in online interventions and to ensure effective learning from the message, this research employs a customized design of both content and length of the message. Methods: In study 1, 17 participants suffering from suicide ideation were recruited. The first (n=8) group conversed with a professional suicide intervention doctor about its attitudes and suggestions for a direct message intervention. To ensure the reliability and consistency of the result, an identical interview was conducted for the second group (n=9). Based on the collected data, questionnaires about this intervention were formed. Study 2 recruited 4222 microblog users with suicide ideation via the Internet. Results: The results of the group interviews in study 1 yielded little difference regarding the interview results; this difference may relate to the 2 groups’ varied perceptions of direct message design. However, most participants reported that they would be most drawn to an intervention where they knew that the account was reliable. Out of 4222 microblog users, we received responses from 725 with completed questionnaires; 78.62% (570/725) participants were not opposed to online suicide intervention and they valued the link for extra suicide intervention information as long as the account appeared to be trustworthy. Their attitudes toward the intervention and the account were similar to those from study 1, and 3 important elements were found pertaining to the direct message: reliability of account name, brevity of the message, and details of the phone numbers of psychological intervention centers and psychological assessment. Conclusions: This paper proposed strategies for engaging target populations in online suicide interventions.

  • mHealth supports young people's chronic NCD self-management. Source: Image created by Authors; Copyright: Helen Slater; URL:; License: Creative Commons Attribution (CC-BY).

    End User and Implementer Experiences of mHealth Technologies for Noncommunicable Chronic Disease Management in Young Adults: Systematic Review


    Background: Chronic noncommunicable diseases (NCDs) such as asthma, diabetes, cancer, and persistent musculoskeletal pain impose an escalating and unsustainable burden on young people, their families, and society. Exploring how mobile health (mHealth) technologies can support management for young people with NCDs is imperative. Objective: The aim of this study was to identify, appraise, and synthesize available qualitative evidence on users’ experiences of mHealth technologies for NCD management in young people. We explored the perspectives of both end users (young people) and implementers (health policy makers, clinicians, and researchers). Methods: A systematic review and meta-synthesis of qualitative studies. Eligibility criteria included full reports published in peer-reviewed journals from January 2007 to December 2016, searched across databases including EMBASE, MEDLINE (PubMed), Scopus, and PsycINFO. All qualitative studies that evaluated the use of mHealth technologies to support young people (in the age range of 15-24 years) in managing their chronic NCDs were considered. Two independent reviewers identified eligible reports and conducted critical appraisal (based on the Joanna Briggs Institute Qualitative Assessment and Review Instrument: JBI-QARI). Three reviewers independently, then collaboratively, synthesized and interpreted data through an inductive and iterative process to derive emergent themes across the included data. External validity checking was undertaken by an expert clinical researcher and for relevant content, a health policy expert. Themes were subsequently subjected to a meta-synthesis, with findings compared and contrasted between user groups and policy and practice recommendations derived. Results: Twelve studies met our inclusion criteria. Among studies of end users (N=7), mHealth technologies supported the management of young people with diabetes, cancer, and asthma. Implementer studies (N=5) covered the management of cognitive and communicative disabilities, asthma, chronic self-harm, and attention deficit hyperactivity disorder. Quality ratings were higher for implementer compared with end user studies. Both complementary and unique user themes emerged. Themes derived for end users of mHealth included (1) Experiences of functionality that supported self-management, (2) Acceptance (technical usability and feasibility), (3) Importance of codesign, and (4) Perceptions of benefit (self-efficacy and empowerment). For implementers, derived themes included (1) Characteristics that supported self-management (functional, technical, and behavior change); (2) Implementation challenges (systems level, service delivery level, and clinical level); (3) Adoption considerations for specific populations (training end users; specific design requirements); and (4) Codesign and tailoring to facilitate uptake and person-centered care. Conclusions: Synthesizing available data revealed both complementary and unique user perspectives on enablers and barriers to designing, developing, and implementing mHealth technologies to support young people’s management of their chronic NCDs. Trial Registration: PROSPERO CRD42017056317; 42017056317 (Archived by WebCite at

  • Source: The Authors; Copyright: Bond University; URL:; License: Licensed by the authors.

    Reporting of Telehealth-Delivered Dietary Intervention Trials in Chronic Disease: Systematic Review


    Background: Telehealth-delivered dietary interventions are effective for chronic disease management and are an emerging area of clinical practice. However, to apply interventions from the research setting in clinical practice, health professionals need details of each intervention component. Objective: The aim of this study was to evaluate the completeness of intervention reporting in published dietary chronic disease management trials that used telehealth delivery methods. Methods: Eligible randomized controlled trial publications were identified through a systematic review. The completeness of reporting of experimental and comparison interventions was assessed by two independent assessors using the Template for Intervention Description and Replication (TIDieR) checklist that consists of 12 items including intervention rationale, materials used, procedures, providers, delivery mode, location, when and how much intervention delivered, intervention tailoring, intervention modifications, and fidelity. Where reporting was incomplete, further information was sought from additional published material and through email correspondence with trial authors. Results: Within the 37 eligible trials, there were 49 experimental interventions and 37 comparison interventions. One trial reported every TIDieR item for their experimental intervention. No publications reported every item for the comparison intervention. For the experimental interventions, the most commonly reported items were location (96%), mode of delivery (98%), and rationale for the essential intervention elements (96%). Least reported items for experimental interventions were modifications (2%) and intervention material descriptions (39%) and where to access them (20%). Of the 37 authors, 14 responded with further information, and 8 could not be contacted. Conclusions: Many details of the experimental and comparison interventions in telehealth-delivered dietary chronic disease management trials are incompletely reported. This prevents accurate interpretation of trial results and implementation of effective interventions in clinical practice.

  • Source: Shutterstock; Copyright: Boryana Manzurova; URL:; License: Licensed by the authors.

    Media Consumption and Creation in Attitudes Toward and Knowledge of Inflammatory Bowel Disease: Web-Based Survey


    Background: Inflammatory bowel disease (IBD) is a chronic gastrointestinal condition affecting over 5 million people globally and 1.6 million in the United States but currently lacks a precisely determined cause or cure. The range of symptoms IBD patients experience are often debilitating, and the societal stigmas associated with some such symptoms can further degrade their quality of life. Better understanding the nature of this public reproach then is a critical component for improving awareness campaigns and, ultimately, the experiences of IBD patients. Objective: The objective of this study was to explore and assess the public’s awareness and knowledge of IBD, as well as what relationship, if any, exists between the social stigma surrounding IBD, knowledge of the disease, and various media usage, including social media. Methods: Utilizing a Web-based opt-in platform, we surveyed a nationally representative sample (n=1200) with demographics mirroring those of the US Census figures across baseline parameters. Using constructed indices based on factor analysis, we were able to build reliable measures of personal characteristics, media behaviors, and perceptions and knowledge of IBD. Results: Among the American public, IBD is the most stigmatized of seven diseases, including genital herpes and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Additionally, IBD knowledge is generally low with 11.08% (133/1200) of the sample indicating no familiarity with the disease and 85.50% (1026/1200) of participants inaccurately answering two-thirds of the IBD index questions with which their knowledge was assessed. Increased knowledge of IBD is associated with lower levels of stigma. However, social media use is currently related to lower levels of IBD knowledge (P<.05). Furthermore, findings indicate that participants who most frequently engaged in producing social media content are less knowledgeable about IBD (P<.10), highlighting the potential for a dangerous cycle should they be contributing to a Web-based IBD dialogue. Conclusions: Greater efforts must be taken to stymie IBD misinformation across all media, but especially in social media channels, to increase IBD knowledge and reduce stigma surrounding IBD. These findings pave the way for further research qualitatively examining the pervasiveness of specific IBD messages found in today’s social media landscape and their impact on enacted stigmas so as to better equip providers and patient advocacy organizations with impactful communication solutions.

  • MyHealthKeeper system implementation with mobile phone application and EHR-integrated PHR module interface (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Licensed by the authors.

    Impact of an Electronic Health Record-Integrated Personal Health Record on Patient Participation in Health Care: Development and Randomized Controlled Trial...


    Background: Personal health record (PHR)–based health care management systems can improve patient engagement and data-driven medical diagnosis in a clinical setting. Objective: The purpose of this study was (1) to demonstrate the development of an electronic health record (EHR)–tethered PHR app named MyHealthKeeper, which can retrieve data from a wearable device and deliver these data to a hospital EHR system, and (2) to study the effectiveness of a PHR data-driven clinical intervention with clinical trial results. Methods: To improve the conventional EHR-tethered PHR, we ascertained clinicians’ unmet needs regarding PHR functionality and the data frequently used in the field through a cocreation workshop. We incorporated the requirements into the system design and architecture of the MyHealthKeeper PHR module. We constructed the app and validated the effectiveness of the PHR module by conducting a 4-week clinical trial. We used a commercially available activity tracker (Misfit) to collect individual physical activity data, and developed the MyHealthKeeper mobile phone app to record participants’ patterns of daily food intake and activity logs. We randomly assigned 80 participants to either the PHR-based intervention group (n=51) or the control group (n=29). All of the study participants completed a paper-based survey, a laboratory test, a physical examination, and an opinion interview. During the 4-week study period, we collected health-related mobile data, and study participants visited the outpatient clinic twice and received PHR-based clinical diagnosis and recommendations. Results: A total of 68 participants (44 in the intervention group and 24 in the control group) completed the study. The PHR intervention group showed significantly higher weight loss than the control group (mean 1.4 kg, 95% CI 0.9-1.9; P<.001) at the final week (week 4). In addition, triglyceride levels were significantly lower by the end of the study period (mean 2.59 mmol/L, 95% CI 17.6-75.8; P=.002). Conclusions: We developed an innovative EHR-tethered PHR system that allowed clinicians and patients to share lifelog data. This study shows the effectiveness of a patient-managed and clinician-guided health tracker system and its potential to improve patient clinical profiles. Trial Registration: NCT03200119; (Archived by WebCite at

  • Source: JMIR Publications/; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence


    Background: In electronic health (eHealth) evaluations, there is increasing attention for studying the actual usage of a technology in relation to the outcomes found, often by studying the adherence to the technology. On the basis of the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use. However, to date, little is known on how to operationalize the intended usage of and the adherence to different types of eHealth technology. Objective: The study aimed to improve eHealth evaluations by gaining insight into when, how, and by whom the concept of adherence has been used in previous eHealth evaluations and finding a concise way to operationalize adherence to and intended use of different eHealth technologies. Methods: A systematic review of eHealth evaluations was conducted to gain insight into how the use of the technology was measured, how adherence to different types of technologies was operationalized, and if and how the intended use of the technology was justified. Differences in variables between the use of the technology and the operationalization of adherence were calculated using a chi-square test of independence. Results: In total, 62 studies were included in this review. In 34 studies, adherence was operationalized as “the more use, the better,” whereas 28 studies described a threshold for intended use of the technology as well. Out of these 28, only 6 reported a justification for the intended use. The proportion of evaluations of mental health technologies reporting a justified operationalization of intended use is lagging behind compared with evaluations of lifestyle and chronic care technologies. The results indicated that a justification of intended use does not require extra measurements to determine adherence to the technology. Conclusions: The results of this review showed that to date, justifications for intended use are often missing in evaluations of adherence. Evidently, it is not always possible to estimate the intended use of a technology. However, such measures do not meet the definition of adherence and should therefore be referred to as the actual usage of the technology. Therefore, it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature. When defining the intended use of a technology and selecting valid measures for adherence, the goal or the assumed working mechanisms should be leading. Adherence can then be standardized, which will improve the comparison of adherence rates to different technologies with the same goal and will provide insight into how adherence to different elements contributed to the outcomes.

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  • Drug Repositioning for Parkinson’s Disease Based on Adverse Drug Reactions Detected from Social Media

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Due to the high cost and low success rate in new drug development, systematical drug repositioning methods are exploited to find new indications from existing drugs. Objective: We sought t...

    Background: Due to the high cost and low success rate in new drug development, systematical drug repositioning methods are exploited to find new indications from existing drugs. Objective: We sought to propose a new computational drug repositioning method to identify repositioning drugs for Parkinson’s disease (PD). Methods: We developed a novel heterogeneous network mining repositioning method that constructed a three-layer network of disease, drug, and adverse drug reaction (ADR), and involved user-generated data from online health communities, to identify potential candidate drugs for PD. Results: We identified 44 non-Parkinson drugs by using the proposed approach, with data collected from both pharmaceutical databases and online health communities. Based on the further literature analysis, we found literature evidence for 28 drugs. Conclusions: In summary, the proposed heterogeneous network mining repositioning approach is promising for identifying repositioning candidates for PD. It shows that adverse drug reactions (ADRs) are potential intermediaries to reveal relationships between disease and drug.

  • Medicaid becomes the first third-party payer to cover passive remote monitoring for home care: A policy analysis

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 13, 2017 - Dec 23, 2017

    Background: Recent years have seen an influx of location-tracking, activity-monitoring sensors, and web-cameras to remotely monitor the safety of older adults in their homes and to reduce reliance on...

    Background: Recent years have seen an influx of location-tracking, activity-monitoring sensors, and web-cameras to remotely monitor the safety of older adults in their homes and to reduce reliance on in-person assistance. The state of research on these monitoring technologies leaves open crucial financial, social, and ethical cost-benefit questions, which have prevented widespread use. Medicaid is now the first large third-party payer in the United States to pay for these technologies, and their use is likely to increase as states transition to Managed Long-Term Services and Supports. Objective: This is the first study to examine how state Medicaid programs are treating passive remote monitoring technologies. This study identifies which states allow location tracking, sensor systems, and cameras; 2) what policies are in place to track their use; 3) what implementation processes and program monitoring mechanisms are in place; and 4) what related insights Medicaid program stakeholders would like to learn from researchers. Methods: Interviews were conducted with forty-three state, federal, and Managed Care Organization Medicaid program stakeholders about how these technologies are used in state waivers serving community-dwelling older adults in fifteen states and what policies are in place to regulate them. The interviews were analyzed by the research team using the framework analysis method for applied policy research. Results: Two-thirds of the states cover location tracking and sensors and one-third cover cameras, but only three states have specific service categories that allow them to track when they are paying for any of these technologies, impeding regulation and understanding of their use at the state and federal level. Consideration of ethical and social risks is limited, and states struggle to understand which circumstances warrant use. They are further challenged by extreme resource restrictions and transitions to Managed Long-term Services and Supports by Managed Care Organizations inexperienced in serving this growing “high-need, high-cost” population. Conclusions: Decisions about Medicaid reimbursement of technologies that have the potential to dramatically alter the way older adults receive supportive services are being made without research on their use, social and ethical implications, or outcomes. At a minimum, new service categories are needed to enable oversight. Participants prioritized three research aims to inform practice: determine cost effectiveness; identify what type of information beneficiaries want generated and whom they want it shared with; and understand how to support ethical decision-making for beneficiaries with cognitive impairment. These findings provide direction for future research and reveal that greater interaction between policy makers and researchers in this field is needed.

  • Online Information Infrastructure Increases Inter-Rater Reliability of Medical Coders: A Quasi-Experimental Study

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 13, 2017 - Feb 7, 2018

    Background: Medical coding is essential for standardized communication and integration of clinical data. The Unified Medical Language System by the National Library of Medicine is the largest clinical...

    Background: Medical coding is essential for standardized communication and integration of clinical data. The Unified Medical Language System by the National Library of Medicine is the largest clinical terminology system for medical coders and natural language processing tools. However, abundance of ambiguous codes leads to low rates of uniform coding among different coders. Objective: To measure uniform coding among different medical experts in terms of inter-rater reliability (IR) and analyze the effect on IR by using an expert-based online code suggestion system. Methods: A quasi-experimental study was conducted. Six medical experts coded 602 medical items from structured quality assurance forms (QA) or free-text eligibility criteria (EC) of 20 different clinical trials. Medical item content was selected based on mortality-leading diseases according to WHO data. The intervention consisted of using a semi-automatic code suggestion tool that is linked to a European information infrastructure providing a large medical text corpus of more than 300,000 medical form items with expert-assigned semantic codes. Krippendorff’s alpha (Kalpha) with bootstrap analysis was used for IR analysis and coding times were measured before and after intervention. Results: The intervention improved IR in structured QA form items (from Kalpha= 0.50, 95%-CI [0.43-0.57] to Kalpha = 0.62 [0.55-0.69]) and free-text eligibility criteria (from Kalpha = 0.19 [0.14-0.24] to Kalpha = 0.43 [0.37-0.50]) while preserving or slightly reducing mean coding time per item for all six coders. Regardless of intervention, pre-coordination and structured items were associated with significant higher IR, but the proportion of items that were pre-coordinated significantly increased after intervention (EC: Odds ratio: 4.92 [2.78 - 8.72]; QA: Odds ratio: 1.96 [1.19-3.25]). Conclusions: Use of an online information infrastructure improved IR towards moderate or even substantial inter coder agreement. Pre-coordination and use of structured vs. free-text data elements are key drivers for higher IR.

  • MISSION COPD: Outcomes from a Multidisciplinary, Vertically Integrated Care Clinic

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 13, 2017 - Feb 7, 2018

    COPD is the second leading cause of death in the UK and accounts for 1.7% of bed days in acute hospitals. An estimated 2/3 patients with COPD remain undiagnosed. MISSION COPD aimed to proactively iden...

    COPD is the second leading cause of death in the UK and accounts for 1.7% of bed days in acute hospitals. An estimated 2/3 patients with COPD remain undiagnosed. MISSION COPD aimed to proactively identify patients from primary care who were undiagnosed or uncontrolled and deliver a comprehensive integrated multidisciplinary clinic to address the needs of this complex group to improve diagnosis, personalise therapy and empower patients to self manage. This clinic was led by a Respiratory Specialist team from Portsmouth Hospitals NHS trust working with five Primary Care surgeries in Wessex. 108 patients were seen, with 98 consenting to be followed up for research. Diagnoses were changed in 14 patients and 32 new diagnoses were made. Reductions were seen across all aspects of unscheduled care compared to each participants use in the 12 months prior: emergency GP visits (3.37-0.79 per patient, p=<0.01), exacerbations (2.64-0.56 per patient, p=0.01), out-of-hours calls (0.16-0.05 per patient, p=0.423), hospital admissions (0.49-0.12 per patient, p=0.48). Improvements were seen in quality of life and symptom scores in addition to patient activation (PAM) and patient reported confidence. This pilot has demonstrated the MISSION model may be an effective way to provide comprehensive gold-standard care that is valued by patients and promotes integration across sectors.

  • Responding to Unsolicited Medical Requests from Healthcare Professionals (HCP RUR) on Pharmaceutical Industry Social Media Sites

    Date Submitted: Dec 12, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: The use of social media has risen tremendously over the past decade with usage rates spanning from 5% American adults in 2005 up to 69% in 2016. A 2011 survey of 4,033 clinicians found tha...

    Background: The use of social media has risen tremendously over the past decade with usage rates spanning from 5% American adults in 2005 up to 69% in 2016. A 2011 survey of 4,033 clinicians found that 65% physicians use social media for professional purposes. In order to remain relevant in today’s digital society, Medical Information departments must continue to assess new digital channels and evolve their medical information services to meet the changing needs of their customers. Objective: To evaluate the impact and feasibility of using social media as a channel to respond to unsolicited medical requests from Healthcare Professionals (HCP RUR) directed toward the pharmaceutical industry. Methods: Three pilots were conducted from November 2016 to June 2017 during three professional congresses: the 2016 American College of Rheumatology (ACR) Annual Meeting, the 2017 American Society of Clinical Oncology (ASCO) Annual Meeting, and the 2017 American Headache Society (AHS) Annual Scientific Meeting. For each social media account, an identified Community Manager (CM) monitored the incoming account feed for proper triaging of posts. When an unsolicited medical request appeared, the CM routed the question to the Tier One Medical Information Contact Center (MICC) agents to respond. The following metrics were collected: total number of unsolicited requests directed to MICC agents, total number of unsolicited requests that required escalation to Tier Two Medical Information Associates (MIAs), total number of unsolicited requests that were confirmed US HCPs, total number of unsolicited requests received after hours, and total number of unsolicited requests that were redirected to a different channel. Results: Nine unsolicited medical requests were received during the three pilots with request numbers ranging from two to four requests per pilot. One was from a confirmed US HCP that required escalation to the Tier Two MIAs. A majority of requests (seven out of nine) came in after scheduled monitoring hours with many requests appearing to be from potential consumers. Four requests were redirected to the MICC phone number. The Marketing accounts received more unsolicited medical requests than the Corporate accounts (seven versus two, respectively), and the three Twitter accounts saw more overall engagement (ie, medical requests and other general engagement) than the LinkedIn account. Conclusions: A limited number of medical questions were asked by HCPs using social media during the three pilots. New innovative MICC channels often take time to build awareness. Thus, continued channel awareness is needed to fully understand the channel’s true impact. Since consumers currently make up a majority of the engagement, companies should look into creating a combined consumer and HCP RUR strategy to provide better customer experience to all customers.

  • Do Online Health Information Bubbles Exist? An Analysis of Personalized Google Search Results

    Date Submitted: Dec 12, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: There is considerable debate focusing on the consequences of online health information, which is generally related to issues such as information quality and the necessary literacy to ident...

    Background: There is considerable debate focusing on the consequences of online health information, which is generally related to issues such as information quality and the necessary literacy to identify such information. However, the availability of information is a prerequisite to provoke positive outcomes. Search engines inherently prioritize information. In this study, we consider the nature of the health information that is prioritized by Google. Moreover, we consider the potential occurrence of health filter bubbles, due to algorithmic personalization. Such bubbles could restrict the availability of high-quality information, and amplify user self-confirmation. Objective: The aim of this study was to examine the nature of the information sources that are retained as results to a standardized set of health-related Google search queries and to inquire the way in which these search results reflect personalization. Methods: We harvested the personal search results of 380 Google users on 16 standardized health-related search queries. In addition, we conducted a survey measuring socio-demographic and health behavior variables. To define the nature of the collected search results we undertook a content analysis of the collected search queries, coding entries for type of website, revenue model, information authorship, and source materials. Results: An initial Latent Class Analysis (LCA) of the unique search results, based on type of website, revenue model, information authorship, and source materials showed four clusters of information types: commercial health news (33%), health goods and services (30%), user contributions (21%), and health advocacy (16%). To identify personalization, we conducted a subsequent LCA of the entire set of search results per participant. Five patterns emerge, significantly differing for the information they are composed of (i.e., 11 to 41% difference). Still, tests of covariates did not reveal any significant relations (p < .05) with user characteristics (i.e., participants’ gender, age, perception of current health, frequency of searching for online health information, and the age of their Google accounts). Conclusions: The results indicate that the overall majority of health information is commercial in nature, and often lacks proper information on authorship and source materials. Moreover, we find mild evidence for the personalization of health information. However, we were unable to isolate potential grounds for this personalization. Clinical Trial: We received ethical clearance from the Social and Societal Ethics Committee (SMEC) at the KU Leuven ( The clearance is registered as G-2016 01 449.