Published on 21.12.16 in Vol 18, No 12 (2016): December
Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/6555, first published Aug 26, 2016.
Increasing Consumer Engagement by Tailoring a Public Reporting Website on the Quality of Diabetes Care: A Qualitative Study
Background: The majority of health care utilization decisions in the United States are made by persons with multiple chronic conditions. Existing public reports of health system quality do not distinguish care for these persons and are often not used by the consumers they aim to reach.
Objective: Our goal was to determine if tailoring quality reports to persons with diabetes mellitus and co-occurring chronic conditions would increase user engagement with a website that publicly reports the quality of diabetes care.
Methods: We adapted an existing consumer-focused public reporting website using adult learning theory to display diabetes quality reports tailored to the user’s chronic condition profile. We conducted in-depth cognitive interviews with 20 individuals who either had diabetes and/or cared for someone with diabetes to assess the website. Interviews were audiotaped and transcribed, then analyzed using thematic content analysis.
Results: Three themes emerged that suggested increased engagement from tailoring the site to a user’s chronic conditions: ability to interact, relevance, and feeling empowered to act.
Conclusions: We conclude that tailoring can be used to improve public reporting sites for individuals with chronic conditions, ultimately allowing consumers to make more informed health care decisions.
J Med Internet Res 2016;18(12):e332
In spite of evidence that consumers want more information on health care provider performance, there is limited use of current reports to make informed health care decisions [, ] because only 12% of US adults have consulted online rankings or reviews of clinicians or other physicians [ ]. Public reporting on health care performance has been available in the United States for more than two decades and was further enhanced with the Affordable Care Act’s [ ] creation of a “national strategy for quality improvement through publicly reporting quality performance” [ ]. Consequently, health care information transparency initiatives are rapidly increasing. For example, the recently formed Center for Healthcare Transparency has a goal of making information on the relative cost and quality of health care services available to 50% of the US population by 2020 [ ]. Yet, studies suggest that consumers do not seek out this information, understand it, trust it, or know how to use it [ , ]. Promising strategies to increase consumer engagement in public reports are to improve the design [ , ], include patient narrative [ - ], and to tailor metrics to reflect the concerns and preferences of individual consumers [ ]. It has been shown that the absence of tailoring in public reports makes them unlikely to succeed [ , ] and that consumers are deterred by the content and design of current reports that lack tailoring to their individual needs [ ]. Tailoring, or personalizing health information, means creating communicative information about a given individual to determine what specific content they will receive, the contexts or frames surrounding the content, by whom it will be presented, and the channels through which it will be delivered [ ].
Consumers with multiple chronic conditions are a priority population for tailoring public reports because they have a continuing need to know how to best manage their health conditions to avoid complications and improve their health . It is increasingly recognized that existing reporting initiatives do not support decision making for these consumers even though persons with chronic conditions may be the population most interested in public reports [ , ]. Those with diabetes mellitus are particularly representative of this group because more than 90% have multiple chronic conditions (diabetes plus at least one more condition) [ ]. Additionally, persons with diabetes may be more receptive to publicly reported information on quality [ ] because of their emotional connection to their disease, awareness of symptoms and consequences, and information-seeking behaviors.
We examined whether tailoring existing public reports on health care quality to persons with diabetes and co-occurring chronic conditions would increase their engagement with the reports. Using four principles of adult learning , we adapted a consumer-focused website that publicly reports the quality of diabetes care using a hypothetical patient narrative [ ] by tailoring the information presented more specifically to each person’s co-occurring chronic conditions. We shared the original and revised websites with consumers and conducted semistructured interviews to obtain feedback on the changes. We expected that greater customization of content tailored to the individual’s conditions would increase engagement with this public reporting website [ ].
As recommended in the 2025 vision for public reporting , we engaged consumers in developing and testing public reports as a mechanism to determine what is most useful and meaningful to them. We adapted an existing public reporting website that uses a novel storytelling format to explore the health issues and health care options of “Helen,” who has diabetes [ ]. In its existing format, consumers can follow and learn from Helen’s story, compare the performance of more than 20 health systems on metrics representing the quality of diabetes care within each health system, and find useful tips about being a better health care consumer. For our study, we redesigned the website to tell the story of “Karen,” who has diabetes and other health issues ( Figure A1). The website redesign was interactive and allowed the content to be tailored to each user to reflect health system performance metrics for individuals with similar chronic conditions. Next, to assess the websites, we conducted in-depth cognitive interviews with 20 individuals who either had diabetes and/or cared for someone with diabetes [ ]. During the interviews, we asked participants to navigate through the existing website with Helen’s story and the redesigned website with Karen’s story. Interviews were audiotaped and transcribed, then analyzed using thematic content analysis.
Developing a Website That Tailors Information to the User
To create a website that tailors information for the user, we used four principles of adult learning: (1) adult learners’ experience, (2) involved adult learner, (3) problem-centered, and (4) relevance and impact to learners’ lives . Our adaptations to address these principles included (1) creating a new story about Karen who has other health issues in addition to diabetes, (2) allowing the user to answer four questions about their own chronic conditions, (3) using the four questions to create a chronic condition profile for the user ( Figure A2), and (4) generating a report comparing quality among health systems for that user’s chronic condition profile.
To recruit, flyers advertising the study were posted at local libraries, grocery stores, community centers, senior centers, university buildings, and a local hospital. Additionally, we placed an ad in a local paper. Only individuals who had diabetes and/or cared for an individual with diabetes were eligible. Those interested in participating in the study were screened via telephone by the University of Wisconsin Survey Center. We expected our study population to be older, white, and college educated based on the demographics of the local population. Once we reached 20 participants, we closed enrollment into the study. We based our sample size on the goal of saturation (ie, little new is being learned) [, ]. Each participant received a US $50 stipend on the completion of their interview.
Between April and May 2015, we conducted 20 one-on-one, hour-long, in-depth cognitive interviews. During the interviews, the participants navigated through the existing consumer-focused Web pages with Helen’s story while being asked scripted, open-ended questions related to (1) navigation of content, (2) validity of the content, and (3) understanding of the displays. The participants were then instructed to navigate through the newly adapted Web pages with Karen’s story while being asked the same scripted, open-ended questions plus questions about (4) their understanding of information presented for the chosen chronic condition profile, and (5) perceived value of the health care quality report presented for the user’s chronic condition profile. The interviews were audio recorded and transcribed. Short summary thoughts and notes were drafted after each interview.
We used thematic content analysis to identify, analyze, and report themes within our data. As a guide, we applied Braun and Clarke’s “six phases of analysis” in which coders (1) familiarize themselves with the data, (2) generate codes, (3) search for themes among codes, (4) review themes, (5) define and name themes, and (6) produce the report . Data analysis was performed by two research assistants who independently coded each transcript in full and met regularly to discuss coding and reach interrater reliability. Agreed-on codes were then examined to identify reoccurring themes in our dataset.
Our study population (n=20) was primarily female (n=13) with racial minorities making up 30% (6/20) of our sample (). The median age range of our participants was between 41 and 50 years old. The majority (60%, 12/20) of participants had health insurance either through Medicare (n=4), Medicaid (n=8), or a mix of Medicaid and/or Medicare supplemented with private insurance (n=5). Participants included 8 persons with diabetes, 8 caregivers of persons with diabetes, and 4 participants who were both persons with diabetes and caregivers for persons with diabetes.
The findings from our thematic content analysis support the concept that tailoring a public reporting website to a user’s chronic condition profile can increase consumer engagement. Participants found that the ability to interact (Theme 1) with the website to generate a chronic condition profile personalized their experience, whereas the addition of Karen’s story to the website increased the relevance (Theme 2) of the site because it presented the voice of an individual who has “other health issues” in addition to diabetes (). The presence of these two themes—ability to interact and relevance—led to participants’ feeling empowered to act (Theme 3) to improve their health care and health.
|Participant characteristics||n (%)|
|Age range (years)|
|Black or African American||5 (25)|
|Income (US $)|
|Health insurance status|
|Mix of Medicaid and/or Medicare with Private||5 (25)|
|Highest level of education|
|High school diploma or equivalent||3 (15)|
|Some college||7 (35)|
|Associate’s degree||2 (10)|
|Bachelor’s degree||7 (35)|
|Master’s degree||1 (5)|
Ability to Interact
The process of answering questions about their chronic conditions allowed participants to interact directly with the site to create their chronic condition profile and, based on this profile, display information on which health systems perform best for a “patient like them.”
Participants saw value in interacting with the site to create a profile based on their conditions. One participant stated that it was nice to be able to select your conditions and receive more “personal” data. In fact, some participants would have liked the ability to interact with the site on an even more personal and comprehensive level via a comment box where they could be more specific about their health and conditions. Another participant suggested having a checklist of all possible conditions for the user to self-select. Our findings suggest that the more a user is allowed to interact on a website that reports on health care quality, the more engaged they may become with website and ultimately the information that the website provides.
Overwhelmingly, participants in the study found the website easy to navigate (90%, 18/20). Because the primary goal of the website was for participants to be able to create a tailored report on health care quality by self-selecting their conditions to create a chronic condition profile, the ease of navigating the website was an integral piece of allowing that interaction to take place.
Karen’s story (multiple chronic conditions in addition to diabetes) was viewed by the participants as being more relevant because Karen faced challenges similar to their own. Adding Karen’s story to the website provided a relatable narrator for the participants in our study. It was easy for them to “see themselves” in Karen’s story because she, like them, lives with diabetes and other chronic conditions. As one participant remarked, “There’s more to the issue of complicated diabetes...I don’t know many diabetics that don’t have other health issues.”
Participants viewed receiving a score on how health systems perform for an individual with diabetes and other health issues similar to theirs, as opposed to a score for all patients with diabetes, as significant to them as an individual. Providing a platform for consumers to identify their conditions, to create a profile, and receive a score on health system performance that is personalized for them allows consumers to “see” themselves in the data. This increased the relevance of the health care quality report being communicated because it was specifically related to the consumer and their chronic condition profile. When asked if the website tailored to their chronic condition profile provided more value compared to the untailored website, 13 of 20 participants said yes, 3 participants did not comment, and 4 found no additional value.
Feeling Empowered to Act
The process of self-selecting their conditions and receiving personalized data on how health systems perform for a “patient like them” created a sense of empowerment for the participants. This feeling of empowerment was stimulated by providing a report that showed which health systems perform best in managing patients with their similar chronic condition profile.
Participants suggested that knowing how health systems perform for individuals similar to themselves may influence where they would seek out care. For example, one participant stated they would be more likely to see a provider if the data showed they were good at treating patients with a similar profile to theirs. Participants also thought they would find this information particularly valuable if they were changing insurance. This highlights the importance of making public reports available to consumers at times when they are most likely to make a decision about their health care including health care insurance coverage (eg, open enrollment periods).
Lastly, Karen’s narrative served as a prescriptive guide for participants on how they should interact with their provider to better manage their health. One participant stated, “If you don’t understand something, you have to be honest. And you have to say (to your provider), you know, ‘I don’t understand.’” Other participants felt empowered by the narrative to initiate conversations with their provider and become more of an active participant in their health.
The development of personalized or customizable report cards has been identified as an important priority to the success of consumer-focused quality reporting , although there has been a dearth of evidence on the consumer perspective on personalization [ ]. By engaging consumers, we found that tailoring a website that publicly reports on health care quality to a consumer’s chronic condition profile increased consumer engagement with the website in specific ways. The themes that emerged from our analysis suggest that consumers value a public reporting website that they can interact with, that they feel is relevant to their situation, and that provides them with a feeling of empowerment to support action. Our findings support that tailoring is indeed a potential strategy for increasing consumer engagement in public reports as suggested by Huckman [ ].
Our specific approach of tailoring a public reporting website based on the principles of adult learning as a framework represents a useful guide to increase consumer engagement. Multiple different strategies have been proposed to increase consumer engagement in public reporting, such as providing cost data, having patient comments and stories on the sites, better design, and providing information that is more relevant to the user [, ]. However, there has been a lack of an overarching framework to organize and prioritize these multiple strategies. Our framework is consistent with consumer requests to have public reporting websites provide more personally relevant information on health care quality for patients with similar health conditions [ ]. Also supporting our framework, we found that the participants in our study wish to engage further with the website we adapted. For example, participants expressed a desire to enter more detailed information about their health conditions in order to create an even more personalized quality report. This suggests that ensuring the delivery of public reports on health care quality are adequately personalized to the consumer is important to consider because personalization is an important component of effectiveness [ , ]. In other settings, tailoring educational materials to individual consumers increases the chances that the information will be read and remembered, saved and discussed with others, perceived as interesting, and personally relevant [ ].
There are multiple ways to tailor health information, such as matching to race, ethnicity, gender, or age , but we chose to tailor reports for persons with multiple chronic conditions for a variety of reasons. Currently in the United States, the majority of health care utilization decisions are made by the quarter of individuals who have multiple chronic conditions, comprising approximately 66% of health care expenditures in the United States [ ]. Having chronic conditions is a powerful motivator to seek out the best health care available because individuals with chronic conditions have a continuing need to know how to best manage their health conditions to avoid complications or deterioration, minimize symptoms, and improve their health [ ]. In addition, individuals with chronic conditions see multiple providers of potentially differing quality in the face of complex medical needs [ ]. By allowing consumers to tailor the reports to their chronic condition profile, we are delivering content that is relevant to their interests and needs [ ].
Our study has several limitations. First, although building on the design of a preexisting consumer website as a basis for our assessment reduced development time and facilitated real-world testing, it constrained our options in presentation of data. Second, we had an overrepresentation of low-income and racial minorities in our sample compared to the expected population. However, our sample represents a high-priority population as a proposed strategy to reduce health disparities and improve health outcomes by making health information, such as public reports available to racial and ethnic minorities .
Although consumers want more transparency and information on health care provider performance, they do not use existing public websites that provide this information. We found that redesigning a public reporting website using adult learning theory is one way to potentially increase consumer engagement with these sites. Participants in our study valued their ability to interact with the website, felt the information on the site had relevance to them, and felt empowered to act based on the information provided. Our approach provides specific guidance on changing the content and format of public reports to engage and inform consumer decisions. A potential area for future study is how to tailor health system performance metrics to additional consumer attributes that might affect the quality of care (eg, race/ethnicity), to the relevance of diabetes in a person’s perception of health, or to awareness of other comorbidities, and how these might affect diabetes care.
Funding/Financial support: This project was funded by grant R21 HS021899 from the Agency for Healthcare Research and Quality. Additional support was provided by the Health Innovation Program, the UW School of Medicine and Public Health from The Wisconsin Partnership Program, and the Community‐Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR) through the National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. Dr Magnan was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant #UL1 TR001860 and linked award KL2 TR001859.
Role of the funder: The study sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
We would like to thank the Wisconsin Collaborative for Healthcare Quality and the University of Wisconsin Survey Center for their assistance in the study.
Conflicts of Interest
Multimedia Appendix 1
Public reporting website storyboards.PDF File (Adobe PDF File), 414KB
- Marshall MN, Shekelle PG, Leatherman S, Brook RH. The public release of performance data: what do we expect to gain? A review of the evidence. JAMA 2000 Apr 12;283(14):1866-1874. [Medline]
- Lagu T, Lindenauer PK. Putting the public back in public reporting of health care quality. JAMA 2010 Oct 20;304(15):1711-1712. [CrossRef] [Medline]
- Fox S. The social life of health information. 2011. URL: http://www.pewinternet.org/files/old-media/Files/Reports/2011/PIP_Social_Life_of_Health_Info.pdf [accessed 2016-08-23] [WebCite Cache]
- Eichner J, Blumenthal D, editors. Medicare in the 21st Century: Building a Better Chronic Care System. Washington, DC: National Academy of Social Insurance; 2003 Jan. URL: https://www.nasi.org/sites/default/files/research/Chronic_Care_Report.pdf [WebCite Cache]
- Health Affairs. Health policy brief: public reporting on quality and costs. 2012 Mar 08. URL: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=65 [accessed 2016-08-23] [WebCite Cache]
- Center for Healthcare Transparency. 2014. URL: http://www.nrhi.org/uploads/center-for-healthcare-transparency-vision-and-principles.pdf [accessed 2016-08-23] [WebCite Cache]
- Marshall MN, Shekelle PG, Davies HT, Smith PC. Public reporting on quality in the United States and the United Kingdom. Health Aff (Millwood) 2003;22(3):134-148 [FREE Full text] [Medline]
- Robinowitz DL, Dudley RA. Public reporting of provider performance: can its impact be made greater? Annu Rev Public Health 2006;27:517-536. [CrossRef] [Medline]
- Damman OC, van den Hengel YK, van Loon AJ, Rademakers J. An international comparison of web-based reporting about health care quality: content analysis. J Med Internet Res 2010;12(2):e8 [FREE Full text] [CrossRef] [Medline]
- Sander U, Emmert M, Dickel J, Meszmer N, Kolb B. Information presentation features and comprehensibility of hospital report cards: design analysis and online survey among users. J Med Internet Res 2015;17(3):e68 [FREE Full text] [CrossRef] [Medline]
- Greaves F, Millett C. Consistently increasing numbers of online ratings of healthcare in England. J Med Internet Res 2012;14(3):e94 [FREE Full text] [CrossRef] [Medline]
- Gao GG, McCullough JS, Agarwal R, Jha AK. A changing landscape of physician quality reporting: analysis of patients' online ratings of their physicians over a 5-year period. J Med Internet Res 2012;14(1):e38 [FREE Full text] [CrossRef] [Medline]
- Emmert M, Sander U, Pisch F. Eight questions about physician-rating websites: a systematic review. J Med Internet Res 2013;15(2):e24 [FREE Full text] [CrossRef] [Medline]
- Bardach NS, Hibbard JH, Greaves F, Dudley RA. Sources of traffic and visitors' preferences regarding online public reports of quality: web analytics and online survey results. J Med Internet Res 2015;17(5):e102 [FREE Full text] [CrossRef] [Medline]
- Huckman RS, Kelley MA. Public reporting, consumerism, and patient empowerment. N Engl J Med 2013 Nov 14;369(20):1875-1877. [CrossRef] [Medline]
- Joseph Christine L M, Peterson E, Havstad S, Johnson CC, Hoerauf S, Stringer S, Asthma in Adolescents Research Team. A web-based, tailored asthma management program for urban African-American high school students. Am J Respir Crit Care Med 2007 May 1;175(9):888-895 [FREE Full text] [CrossRef] [Medline]
- Schneider EC, Epstein AM. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998 May 27;279(20):1638-1642. [Medline]
- Hussey PS, Luft HS, McNamara P. Public reporting of provider performance at a crossroads in the United States: summary of current barriers and recommendations on how to move forward. Med Care Res Rev 2014 Oct;71(5 Suppl):5S-16S. [CrossRef] [Medline]
- Hawkins RP, Kreuter M, Resnicow K, Fishbein M, Dijkstra A. Understanding tailoring in communicating about health. Health Educ Res 2008 Jun;23(3):454-466 [FREE Full text] [CrossRef] [Medline]
- Shaller D, Kanouse DE, Schlesinger M. Context-based strategies for engaging consumers with public reports about health care providers. Med Care Res Rev 2014 Oct;71(5 Suppl):17S-37S. [CrossRef] [Medline]
- Emmert M, Meier F, Pisch F, Sander U. Physician choice making and characteristics associated with using physician-rating websites: cross-sectional study. J Med Internet Res 2013;15(8):e187 [FREE Full text] [CrossRef] [Medline]
- Magnan EM, Palta M, Mahoney JE, Pandhi N, Bolt DM, Fink J, et al. The relationship of individual comorbid chronic conditions to diabetes care quality. BMJ Open Diabetes Res Care 2015;3(1):e000080 [FREE Full text] [CrossRef] [Medline]
- Robert Wood Johnson Foundation. Consumer Decision Points of Health Care Information. Princeton, NJ: Robert Wood Johnson Foundation; 2010 Jul. URL: http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf69380 [accessed 2016-12-12] [WebCite Cache]
- Knowles M. In: Wilton C, editor. Knowles MS. The modern practice of adult education: from pedagogy to andragogy (Rev. and Updated. ed.) [Wilton, Conn.]. Chicago: Association Press; Follett Pub. Co; 1980.
- WCHQ Ambulatory Measure Specification: Diabetes Care Performance Measures. Middleton, WI: Wisconsin Collaborative for Healthcare Quality; 2011.
- Damberg CL, McNamara P. Postscript: research agenda to guide the next generation of public reports for consumers. Med Care Res Rev 2014 Oct;71(5 Suppl):97S-107S. [CrossRef] [Medline]
- My Health Wisconsin. Getting good care. URL: http://www.myhealthwi.org/Resources/GettingGoodCare.aspx [accessed 2016-12-06] [WebCite Cache]
- Bradley CJ, Given CW, Dahman B, Fitzgerald TL. Adjuvant chemotherapy after resection in elderly Medicare and Medicaid patients with colon cancer. Arch Intern Med 2008 Mar 10;168(5):521-529. [CrossRef] [Medline]
- Hibbard J, Sofaer S. Best Practices in Public Reporting No. 1: How To Effectively Present Health Care Performance Data To Consumers. Rockville, MD: Agency for Healthcare Research and Quality; 2010. URL: http://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/pubrptguide1/pubrptguide1.pdf [accessed 2016-08-23] [WebCite Cache]
- Sofaer S, Hibbard J. Best Practices in Public Reporting No. 2: Maximizing Consumer Understanding of Public Comparative Quality Reports: Effective Use of Explanatory Information. Rockville, MD: Agency for Healthcare Research and Quality; 2010. URL: http://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/pubrptguide2/pubrptguide2.pdf [accessed 2016-08-23] [WebCite Cache]
- Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006 Jan;3(2):77-101. [CrossRef]
- Sinaiko AD, Eastman D, Rosenthal MB. How report cards on physicians, physician groups, and hospitals can have greater impact on consumer choices. Health Aff (Millwood) 2012 Mar;31(3):602-611 [FREE Full text] [CrossRef] [Medline]
- Bardach N, Hibbard J, Dudley R. Users of Public Reports of Hospital Quality: Who, What, Why and How? An Aggregate Analysis of 16 Online Public Reporting Web Sites and Users' and Experts' Suggestions for Improvement. Rockville, MD: Agency for Healthcare Research and Quality; 2011. URL: http://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/value/pubreportusers/pubreportusers.pdf [accessed 2016-08-23] [WebCite Cache]
- Marshall MN, Romano PS, Davies HT. How do we maximize the impact of the public reporting of quality of care? Int J Qual Health Care 2004 Apr;16 Suppl 1:i57-i63 [FREE Full text] [CrossRef] [Medline]
- Weymann N, Dirmaier J, von WA, Kriston L, Härter M. Effectiveness of a Web-based tailored interactive health communication application for patients with type 2 diabetes or chronic low back pain: randomized controlled trial. J Med Internet Res 2015;17(3):e53 [FREE Full text] [CrossRef] [Medline]
- Kreuter M, Farrell D, Olevitch L, Brennan L. Tailoring Health Messages: Customizing Communication with Computer Technology. Mahwah, NJ: Lawrence Erlbaum Associates; 2000:270.
- Kreuter MW, Bull FC, Clark EM, Oswald DL. Understanding how people process health information: a comparison of tailored and nontailored weight-loss materials. Health Psychol 1999 Sep;18(5):487-494. [Medline]
- Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 2007 Dec;22 Suppl 3:391-395 [FREE Full text] [CrossRef] [Medline]
- Yonek JC, Mittler JN, Hasnain-Wynia R. Why and how six aligning forces for quality communities have focused on reducing disparities. Med Care Res Rev 2014 Oct;71(5):435-449. [CrossRef] [Medline]
Edited by G Eysenbach; submitted 26.08.16; peer-reviewed by U Sander, M Schlesinger; comments to author 02.11.16; revised version received 14.11.16; accepted 23.11.16; published 21.12.16
©Maureen A Smith, Lauren Bednarz, Peter A Nordby, Jennifer Fink, Robert T Greenlee, Daniel Bolt, Elizabeth M Magnan. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.12.2016.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.