Latest Submissions Open for Peer Review

JMIR has been a leader in applying openness, participation, collaboration and other "2.0" ideas to scholarly publishing, and since December 2009 offers open peer review articles, allowing JMIR users to sign themselves up as peer reviewers for specific articles currently considered by the Journal (in addition to author- and editor-selected reviewers).

For a complete list of all submissions across all JMIR journals as well as partner journals, see JMIR Preprints

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Improving the usefulness and use of patient survey programmes: Views from the frontline

    Date Submitted: Aug 22, 2017
    Open Peer Review Period: Aug 22, 2017 - Oct 17, 2017

    Background: A growing body of evidence suggests a concerning lag between collection of patient experience survey data and its application in service improvement. Objective: This study aims to identify what staff perceive to be the barriers and facilitators to using patientsurvey data, and showcase successful examples of doing so. It aims to apply a "systems perspective" to suggest methodological and policy improvements that could support efforts to use data on the frontlines. Methods: Design: Qualitative interviews Setting: Eight UK NHS providers selected based on National Inpatient Survey scores Participants: 18 patient experience leads Intervention(s): Interviews about using patient-reported feedback with relevant staff; transcription and thematic analysis Main Outcome Measure(s): Staff-identified barriers and facilitators to using patient experience feedback Results: The most frequently cited barriers to using patient reported feedback had to do with interpreting results (14 mentions), understanding survey methodology (14), presentation of data in both national CQC (13) and contractor reports (12), inability to link data to other sources (7) and organisational structure (7). In terms of a wish list for improved practice, staff desired more intuitive survey methodologies (10), ability to link patient experience data to other sources (6) and more examples of best practice in patient experience improvement (3). Three organisations also provided examples of how they successfully used feedback to improve care. Conclusions: Staff feedback provides a roadmap for policy makers to reconsider how data is collected and whether or not the national regulations on surveys and patient experience data are meeting the quality improvement needs of local organisations. Clinical Trial: N/A

  • Privacy-preserving logistic regression based on homomorphic encryption

    Date Submitted: Aug 22, 2017
    Open Peer Review Period: Aug 22, 2017 - Oct 17, 2017

    Background: Learning a model without accessing raw data has been an intriguing idea to security and machine learning researchers for years. In an ideal setting, we want to encrypt sensitive data to store them on a commercial cloud and run analysis without ever decrypting the data to preserve the privacy. Homomorphic encryption technique is a perfect match for secure data outsourcing but it is a very challenging task to support real-world machine learning tasks. Existing framework can only handle simplified cases with low-degree polynomials such as linear means classifier and linear discriminative analysis. Objective: The aim of this study is to give a practical support to the mainstream learning models (e.g., logistic regression). Methods: We innovated on: (1) a novel homomorphic encryption scheme optimized for real numbers computation, (2) the least squares approximation of the logistic function for accuracy and efficiency (i.e., reduce computation cost), and (3) new packing and parallelization techniques. Results: Using real world datasets, we evaluated the performance of our model and demonstrated its feasibility in speed and memory consumption. For example, it took about 114 minutes to obtain the model parameter from homomorphically encrypted training model of Edinburgh dataset. In addition, it could give quite correct predictions on the testing dataset. Conclusions: We present the first homomorphically encrypted logistic regression model based on the critical observation that a precision loss of classification models is sufficiently small so that the decision plan stays still.

  • Feasibility, Acceptability and Effectiveness of a Remote Collaborative Care Program for Patients with Depression Living in Rural Areas

    Date Submitted: Aug 21, 2017
    Open Peer Review Period: Aug 21, 2017 - Oct 16, 2017

    Background: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. Objective: To test the feasibility, acceptability and effectiveness of a remote collaborative care program for patients with depression living in rural areas. Methods: Physicians from fifteen community hospitals located in rural areas recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to a remote collaborative care program (Telepsiquiatría; n=111) or to usual care (UC; n=139). Telepsiquiatría introduced a shared electronic clinical record between primary care teams and a specialized mental health team, telephone monitoring of patients, and remote supervision by a psychiatrist through electronic platform and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after assignment based on a blinded telephone assessment. Results: Two hundred and twelve patients (84.8%) completed the assessments to six months. Telepsiquiatría was feasible and acceptable; achieving higher user satisfaction (OR 1.94, 95% CI 1.25 to 3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02 to 3.19) at 6 months, as compared to UC. There were no statically significant differences in depressive symptoms between Telepsiquiatría and UC, although a favorable trend was observed in the intervention arm. Significant differences between groups in favour of Telepsiquiatría were observed at 3 months for mental health-related quality of life (β 3.11, 95% CI 0.19 to 6.02). Conclusions: Telepsiquiatría may help reduce depression treatment gap in rural areas, providing an acceptable and highly satisfactory intervention for depressed adults. Future studies must evaluate treatment process outcomes in a more detailed manner. Clinical Trial: NCT02200367.

  • Understanding the Associations of Sleep, Physical Activity, Fruit and Vegetable Intake with Quality of Life and Subjective Health: A Cross-Sectional Web-Based Study

    Date Submitted: Aug 19, 2017
    Open Peer Review Period: Aug 20, 2017 - Oct 15, 2017

    Background: In face of internet and increase sedentary times, the prevention of non-communicable diseases and especially cardiovascular diseases are imperative. Internet studies provide the option to research and identify modifiable health behaviors in different age groups. However, little is known about addressing more than single health behaviors across age groups (i.e., young, middle-aged, and older adults) and possible health outcomes. Assumptions exist based on the Compensatory Carry-Over Action Model, which provides a multiple health behavior approach, which was rarely studied in the past. Better understanding of age-specific differences in clustering of health behaviors and may set the stage for designing interventions, particularly for improving health behaviors. Objective: The aim of this study was to identify the associations of restful sleep, physical activity, fruit and vegetable intake, and their associations with sleep quality and overall quality of life and subjective health in different age groups, with an internet study. Methods: A web-based randomized controlled trial was conducted and 790 participants aged 20 to 85 years from Germany and the Netherlands filled in the web-based baseline questionnaire about their restful sleep, physical activity, fruit and vegetable intake, sleep quality, overall quality of life and subjective health. Descriptive analysis, one-way multivariate analysis of covariance, path analysis, and multi-group analysis were conducted. Results: In correlational findings, main study variables were interrelated, except restful sleep only significantly correlated with sleep quality and overall quality of life and subjective health (P < .05). A proposed path analysis model showed acceptable fit with the data χ2(3) = 4.63, P = .20; χ2/df = 1.54, CFI = .998, TLI = .982, RMSEA = .026. Restful sleep ( = .55, SE = .05, P < .001), physical activity ( = .18, SE = .03, P < .001) and fruit and vegetable intake ( = .07, SE = .03, P = .02) were associated with better sleep quality, which then was associated with increased overall quality of life and subjective health ( = .45, SE = .04, P < .001). There were age-group differences regarding multiple health behaviors and overall quality of life and subjective health (Wilks λ = .95, F(10, 1554) = 3.831, P < .001). Middle-aged adults were the least physically active and consumed the least fruit and vegetables, had the poorest sleep quality and overall quality of life and subjective health, compared to young and older adults. Conclusions: From this web-based study, multiple health behaviors are associated with sleep quality and overall quality of life and subjective health, but vary among different age groups. To enhance the effectiveness of web-based interventions to improve health and well-being, the outcomes of this study contributed more understanding of the age-group differences and the underlying mechanisms of multiple health behaviors. Clinical Trial: A clinical trial registration was conducted with (NCT01909349).

  • Quality of YouTube TM videos on dental implants

    Date Submitted: Aug 19, 2017
    Open Peer Review Period: Aug 20, 2017 - Oct 15, 2017

    Background: Patients search YouTube for health-care information Objective: To examine what YouTube offers patients seeking information on dental implants, and to evaluate the quality of provided information Methods: A systematic search of YouTube for videos containing information on dental implants was performed. Video demographics and content’s usefulness were analyzed. “Information for patients” available from the American Academy of Implant Dentistry, European Association of Osseointegration, and British Society of Restorative Dentistry were used for benchmarking. Results: A total of 117 videos were analyzed. The most commonly discussed topics were related to procedures involved in dental implantology (76.1%, no=89), and to the indications for dental implants (58.1%, no=78). The mean usefulness score of videos was poor (6.02 ±4.7 [range 0-21]), and misleading content was common (30.1% of videos); mainly in topics related to prognosis and maintenance of dental implants. Most videos (83.1%, n=97) failed to mention the source of information presented in the video or where to find more about dental implants. Conclusions: Information about dental implants on YouTube is limited in quality and quantity. YouTube videos can have a potentially important role in modulating patients’ attitude and treatment decision regarding dental implants Clinical Trial: no

  • Health Information Technology Continues to Show Positive Effect on Medical Outcomes: A Systematic Review of the Literature

    Date Submitted: Aug 20, 2017
    Open Peer Review Period: Aug 20, 2017 - Aug 30, 2017

    Background: The Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized organizations and some providers to adopt the ‘meaningful use’ of a certified Electronic Health Record (EHR), stimulating widespread adoption of HIT across various health care settings. Since the implementation of the HITECH Act, adoption rates of the electronic medical record have shown greater than arithmetic growth, but have patients experienced a commensurate increase in quality as a result of that technology? Objective: The purpose of this review is to analyze the current literature for the impact of HIT on medical outcomes. We hypothesized that there is a positive association between the adoption of HIT and medical outcomes. Methods: We queried CINAHL and Medline by PubMed databases for peer-reviewed publications in the last five years that defined an HIT intervention and an effect on medical outcomes in terms of efficiency or effectiveness. We structured the review from the Primary Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and we conducted the review in accordance with the Assessment for Multiple Systematic Reviews (AMSTAR). Results: We narrowed our search from 3,636 articles to 37 for final analysis. At least one improved medical outcome as a result of HIT adoption was identified in 81% of research studies that met inclusion criteria, strongly supporting our hypothesis. No statistical difference in outcomes was identified as a result of HIT in 19% of included studies. Twelve categories of HIT and three categories of outcomes occurred 38 and 65 times, respectively. Conclusions: A strong majority of the literature shows positive effects of HIT on the effectiveness of medical outcomes, which is excellent news as we all prepare for Stage 3 of Meaningful Use. This aligns with previous reviews in other time frames.

  • Feasibility and Effectiveness of a Web-Based Portal for delivery of care to home dialysis patients.

    Date Submitted: Aug 18, 2017
    Open Peer Review Period: Aug 19, 2017 - Oct 14, 2017

    Background: Background: Quality of life in home dialysis patients is low compared to the general population. Improvement in patient satisfaction through shared decision-making and handling of patient requests through an online interface has been shown to be beneficial in some studies in other disease populations. Such a system may improve patient satisfaction, reduce health service utilization and potentially improve health outcomes. Objective: Objective: To determine the acceptability, practicality, and implementation of an eHealth patient portal in home dialysis patients. Methods: Methods: Prospective feasibility cohort study among patients receiving either home hemodialysis or peritoneal dialysis over a four-month period. Web-based application allowing patients and healthcare workers to communicate through a secure, password protected online portal and permits visualization of the messaging history by patient and provider. Patients and the home dialysis healthcare team had the ability to send messages related to patient care at any time. Messages could be sent between the healthcare team and patient including proposed changes to medication, instructions after a clinic visit, times of new appointments, upcoming investigations or questions about care. Consumer Quality Index (CQI), Quality of Life using the EuroQol Five Dimensions Questionnaire, acceptability and satisfaction using online Acceptability E-scale and Satisfaction questionnaires. Patients were assessed at baseline and at 6 and 12 months of followup. Results: Results: Of the 41 patients who consented to join the web-based portal, 27 (66%) created an online account. Mean CQI for the Nephrology domain was 3.50 (95%CI: 3.33,3.67) and this did not change significantly over the study period. Quality of life using the EQ-index score was 0.80 (IQR: 0.71-0.83) at baseline and this also did not significantly change over the study period. The web-based portal was easy to use with a median response of 4 (IQR: 4-5). Most were satisfied with a mean score of 6.5±0.6 in overall satisfaction. Conclusions: Conclusions: In this study of home dialysis patients, we identified that an online portal for care-delivery was feasible. We did not find a significant improvement in CQI or QOL, but the portal was felt to be beneficial at addressing some domains of patient care. Clinical Trial: Trial Registration: number NCT02128347

  • Smartphone apps for quality of life and wellbeing assessment in breast and prostate cancer patients: A systematic review.

    Date Submitted: Aug 19, 2017
    Open Peer Review Period: Aug 19, 2017 - Aug 30, 2017

    Background: Smartphone health applications (apps) are increasingly gaining attention in oncological care as potential tools for supporting cancer patients. However, although the number of publications and health apps focusing on cancer is increasing, there are still few specifically designed for the most prevalent cancers diagnosed: breast and prostate cancers. There is a need to review the effect of these apps on breast and prostate cancer patients’ quality of life (QoL) and wellbeing. Objective: The purposes of this study were, firstly, to review the scientific literature on smartphone apps targeting breast or prostate cancer patients, and involving QoL and wellbeing (anxiety and depression symptoms), and secondly, to analyze the clinical and technological characteristics, strengths and weaknesses of these apps, as well as patients’ user experience of them. Methods: We conducted a systematic review of peer-reviewed literature from The Cochrane Library, Embase, PsycINFO, Pubmed, Scopus, and MEDLINE to identify studies involving smartphone apps focused on breast and/or prostate cancer patients and QoL and/or wellbeing, published between January 1st, 2000 and July 12th, 2017. Only trial studies which met the inclusion criteria were selected. The systematic review was completed with a critical analysis of the smartphone apps previously identified in the health literature research that were available in the official application stores. Results: The systematic review of the literature yielded 3,862 articles. After removal of duplicates, 3,229 remained and were evaluated on the basis of title and abstract. Of these, 3,211 were discarded as not meeting the inclusion criteria, and 18 records were selected for full text screening. Finally, 5 citations were included in this review, with a total of 644 patients, mean age 52.16 years. The majority of the studies targeted breast cancer patients and only 1 paper was focused on prostate cancer patients. In three studies an app-related intervention was carried out, and two of them reported an improvement on quality of life, while two of the studies only tracked use of the app, and no effect on quality of life or wellbeing was found. Conclusions: Despite the existence hundreds of studies involving cancer-focused smartphone apps, there is a lack of rigorous trials regarding the QoL and/or wellbeing assessment in breast and/or prostate cancer patients. A strong and collective effort should be made by all health care providers to determine those cancer-focused smartphone apps which effectively represent useful, accurate, and reliable tools for cancer patients’ disease management. Clinical Trial: Registration: PROSPERO (Registered on 26/07/2017, ref. 73069)

  • 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 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 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 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 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.

  • Title: Two Year Assessment of Nurses’ Experience of Health Information Technology: A Longitudinal Qualitative Study

    Date Submitted: Aug 11, 2017
    Open Peer Review Period: Aug 12, 2017 - Oct 7, 2017

    Background: Nurses are the largest group of HIT users. As such, nurses’ adaptation is critical for HIT implementation success. However, longitudinal approaches to understanding nurses’ perceptions of HIT are underexplored. Previous studies of nurses’ perceptions demonstrate that the progress and timing for acceptance and adaptation varies. Objective: the study aims to explore nurses’ experience regarding implementation of health information technology (HIT) over time. Methods: A phenomenological approach was used for this longitudinal qualitative study to explore nurse perceptions of HIT implementation over time, focusing on three time points (rounds) at 3, 9, and 18 months after the implementation of electronic health records (EHR) and bar code medication administration (BCMA). The purposive sample was comprised of clinical nurses who worked on a medical-surgical unit in an academic center. Results: Major findings were categorized into 7 main themes with 53 subthemes. Nurses reported personal-level and organizational-level factors that facilitated HIT adaptation. We also generated network graphs to illustrate the occurrence of themes. Thematic interconnectivity differed due to nurses’ concerns and satisfaction at different time points. Equipment and workflow were the most frequent themes across all three rounds. Nurses were the most dissatisfied about 9 months after HIT implementation. Eighteen months after HIT implementation, nurses’ perceptions appeared more balanced. Conclusions: It is recommended that organizations invest in equipment to improve HIT functionality, refine policies to reflect nursing practice, and improve systems to focus on patient safety. Future research is necessary to confirm patterns of nurses’ adaptation to HIT in other samples.

  • The impact of digital health interventions on health-related outcomes in the workplace: a systematic review

    Date Submitted: Aug 12, 2017
    Open Peer Review Period: Aug 12, 2017 - Oct 7, 2017

    Background: Background: The impact of employee health on productivity in the workplace is generally evidenced through absenteeism and presenteeism. Multicomponent health promotion programs delivered in the workplace have been shown to effectively modify health risks, in turn impacting medical costs and supporting employees being more effective in their roles. Scalable, cost effective online programs have gained in popularity over the last two decades, due at least in part to their almost limitless scalability and lower cost of implementation. However, little is known about the impact of digital only interventions on health related outcomes in employee groups. Objective: Objective: To assess the impact of purely digital health interventions in the workplace on health-related outcomes. Methods: Methods: Using Scopus (i.e. search engine including databases such as MEDLINE, EMBASE, PubMed, PsycINFO, and CINAHL), literature was reviewed using PRISMA guidelines. Results: Results: Of the initial 1,345 records screened, the final number of eligible studies was 25. Most of these studies were RCTs (n=20) that included control or comparison groups and ran for an average of three months. The interventions within these studies targeted a broad range of health-related outcomes such as sleep, stress, mental health, sedentary behaviors, and physical activity levels, but did not always use standardized measures to quantify impact. All but one study found a significant improvement in at least one health-related outcome. Attrition rates ranged extensively, from 0 to 80%, suggesting program engagement was an issue. In addition, risk of bias assessment was generally unclear for the majority of the studies reviewed. Conclusions: Conclusions: Overall, the review found modest evidence that digital only interventions have a positive impact on health-related outcomes in the workplace. Due to a lack of robustly designed studies within the literature future research should include the evaluation of digital interventions with more RCTs and a focus on issues of engagement and the increased use of standardized measures.

  • A systematic review and proposed framework for providing just-in-time feedback in energy balance-related behavior change interventions

    Date Submitted: Aug 10, 2017
    Open Peer Review Period: Aug 11, 2017 - Oct 6, 2017

    Background: The integration of body-worn sensors with mobile devices presents a tremendous opportunity to enhance the timely, bi-directional communication between study participants and researchers or patients and health care providers to more effectively influence health behavior changes. Objective: The goal of this systematic review was to synthesize data on the content characteristics of performance feedback used in energy balance-related behavior change interventions and to update a theory-based framework to guide the design of just-in-time performance feedback interventions. Methods: Intervention studies published through 2016 that included just-in-time performance feedback on physical activity, sedentary behavior, and/or dietary intake were eligible for inclusion. Feedback content and efficacy data were synthesized descriptively. Results: Thirty-one intervention studies targeting physical activity (48%), diet and physical activity (42%), or diet only (10%) were included in the review. Feedback in 100% of the studies were timely (by design), 97% were personalized, and 78% were goal-oriented, but only 16% were actionable. The efficacy of providing feedback was tested in 9 studies; 4 studies reported significant effects and 5 studies reported no significant effects for intervention efficacy. Feedback was continuously-available, goal-oriented, and/or actionable in 3 of the 4 studies with significant intervention effects compared to 1, 3, and 2 of 5 studies with non-significant intervention effects, respectively. Conclusions: Performance feedback that is continuously-available, personalized, and actionable relative to a known behavioral objective or goal is prominent in intervention studies with significant behavior change outcomes. Future research using experimental designs such as the multiphase optimization strategy (MOST) and micro-randomization will be useful to optimize just-in-time feedback content and timing and frequency. Clinical Trial: Not applicable

  • Leveraging diverse clinical elements to predict unplanned ICU transfers at three large children’s hospitals

    Date Submitted: Aug 11, 2017
    Open Peer Review Period: Aug 11, 2017 - Oct 6, 2017

    Background: Increased mortality and morbidity is associated with deterioration in patients who require an unplanned transfer from the nursing floor to the ICU (Intensive Care Unit). The mortality rate associated with unrecognized deterioration that results in a delay of ICU transfer and the need for resuscitation can be as high as 67%.Missing precursors to deterioration reduces the window of opportunity and margin of error for effective intervention and increases the intensity and complexity of the required care. Objective: Machine learning methods that make use of large numbers of predictor variables are now commonplace. This work examines how different types of predictor variables derived from the electronic health record affect the performance of predicting unplanned transfers to the ICU at three large children’s hospitals. Methods: We trained separate models with data from three different institutions from 2011 through 2013 and evaluated models with 2014 data. Cases consisted of patients who transferred from the floor to the intensive care unit (ICU) and met one or more of 5 different a priori defined criteria for suspected unplanned transfers. Controls were patients who never transferred to the ICU. Predictor variables for the models were derived from vitals, labs, acuity scores and nursing assessments. Classification models consisted of L1 and L2 regularized logistic regression and neural network models. We evaluated model performance over prediction horizons ranging from 1-16 hours. Results: Across the three institutions, the c-statistic values for our best models were (0.892 [CI: .875-.904]), (0.902 [CI: .880-.923]) and (0.899 [CI: .879-.919]) for the task of identifying unplanned ICU transfer 6 hours prior to its occurrence and achieved (0.871 [CI: .855 -.888]), (0.872 [CI: .850-.895]) and (0.850 [CI: .825-.875]) for a prediction horizon of 16 hours. For our first model at 80% sensitivity, this resulted in a specificity of 80.5% [CI: 77.4-83.7%] and a positive predictive value of 5.2% [CI: 4.5-6.2%]. Conclusions: Feature-rich models with many predictor variables provide allow for patient deterioration to be predicted accurately, even up to 16 hours in advance.

  • A Scoping Study on mHealth Initiatives in Vietnam

    Date Submitted: Aug 6, 2017
    Open Peer Review Period: Aug 7, 2017 - Oct 2, 2017

    Background: MHealth offers a promising solution to the multitude of challenges the Vietnamese health system faces, but there is a scarcity in published information on mHealth in Vietnam. Objective: The objectives of this scoping study are 1) to summarize the extent, range, and nature of mHealth initiatives in Vietnam and 2) to examine the strengths, weaknesses, opportunities and threats of mHealth utilization in the Vietnamese context. Methods: This scoping study systematically identified and extracted relevant information from 19 past and current mHealth initiatives in Vietnam. The study includes multimodal information sources including published literature, gray literature (i.e., government reports and unpublished literature), conference presentations, online documents, and key informant interviews. Results: Our findings suggest the largest advantage of mHealth in Vietnam is its ability to reach hard-to-reach populations and vulnerable groups. On the other hand, mHealth implementation in Vietnam has been challenged by factors including features unique to the Vietnamese language, sociocultural factors, and technological infrastructure. Conclusions: The largest threats to mHealth moving forward are the absence of government policy, lack of government interest, and heavy dependence on foreign funding. Lastly, while current mHealth initiatives have already demonstrated promising opportunities for alternative models of funding, such as social entrepreneurship or private business models, there have yet to be sustainable mHealth initiatives outside of those funded by external donors.

  • Few Tweets After Flu Peak: Twitter-based Influenza Detection by Referring Indirect Information

    Date Submitted: Aug 2, 2017
    Open Peer Review Period: Aug 4, 2017 - Sep 29, 2017

    The recent rise in popularity and scale of social networking services (SNSs) has resulted in an increasing need for SNS-based information extraction systems. A popular application of SNS data is health surveillance for predicting the outbreak of epidemics by detecting diseases from text messages posted on SNS platforms. Such applications share the same logic: they incorporate SNS users as social sensors. These social sensor approaches also share a common problem: SNS-based surveillance can be reliable if sufficient numbers of users are active, but small inactive populations produce inconsistent results. This paper proposes a novel approach that overcomes this problem using indirect information covering both urban areas and rural areas within the posts. Experiments were conducted using a collection of tweets spanning three years (seven million influenza-related tweets in Japanese). Both direct information and indirect information that mentions other places were used. As indirect information is less reliable (too noisy or too old) than direct information, the indirect information data were not utilized directly but were considered as inhibiting direct information. For example, when indirect information appeared often, it was considered as signifying that everyone already had a known disease, leading to a small amount of direct information. The proposed approach improved the detection performance not only in rural cities, but also in urban cities, thereby demonstrating that it is feasible.

  • Application of Machine Learning Algorithms to Depression Screening and Attempt at Pattern Extraction of Patient-Reported Outcomes that Negatively Affect Classification Accuracy

    Date Submitted: Aug 1, 2017
    Open Peer Review Period: Aug 3, 2017 - Sep 28, 2017

    Background: Smartphone applications have recently been used as a breakthrough technology for monitoring mental health conditions in cancer outpatient settings. However, the use of electronic patient-reported outcomes (ePROs) on mental conditions through smartphone applications raises new concerns, which includes the question of the accuracy of depression screening. Thus, research is essential for improving the depression-screening performance. Objective: This study aims to (1) test whether deep-learning-based algorithms can overcome the limitations of traditional statistical methods in terms of depression screening accuracy. In addition, the study aims to (2) explore ePRO patterns that adversely affect depression screening accuracy. Methods: As a deep learning-based algorithm, a feedforward neural network algorithm was used. As a traditional statistical method, a random intercept logistic regression was employed. To explore the ePRO patterns that negatively impact model accuracy, mental fluctuations, missing data, and compounding effects between mental fluctuations and missing data were tested. The performances of the algorithms and the effects of the ePRO patterns were measured through the receiver operating characteristic comparison test. Results: The results of the study show that the performance of the deep-learning-based models was superior to that of the traditional statistical approach. The study found that mental fluctuations statistically reduced the accuracy of depression-screening models. A weak association between ePRO omissions and screening accuracy was found. Moreover, the compounding effects that had a negative effect on the depression screening accuracy were statistically significant. Conclusions: Although well-trained deep-learning-based models exhibit excellent performance, they still have some limitations. Thus, it is very important to focus on data quality to predict health outcomes when using data that is difficult to quantify, such as mental conditions.

  • Applicability of a web-based, individualized exercise intervention in patients with liver disease, cystic fibrosis, esophageal cancer, and psychiatric disorders

    Date Submitted: Aug 2, 2017
    Open Peer Review Period: Aug 3, 2017 - Sep 28, 2017

    Background: Regular physical activity is recommended in different diseases to improve disease related symptoms, to delay the progression of the disease, to enhance postoperative outcomes, and to increase the physical activity level. In the preoperative context, there has been a paradigm shift in favor of using preconditioning concepts prior to surgery. Web-based interventions seem an innovative and effective tool for delivering general information, tailored exercise recommendations, and peer support. Objective: Our first objective was to assess feasibility of our web-based interventional concept and to analyze similarities and differences in a sustained exercise implementation in different diseases. The second goal was to investigate the overall participants’ satisfaction with our web-based concept. Methods: Study participants were recruited by physicians in the cooperating centers. Four clinical trials are still being carried out, including patients with esophageal carcinoma scheduled for oncologic esophagectomy (iPEP study; internet-based perioperative exercise program), nonalcoholic fatty liver disease (HELP study; hepatic inflammation and physical performance in patients with NASH), depression (EXDEP study; exercise in depression) or cystic fibrosis (COMMED study; cystic fibrosis online mentoring for microbiome, exercise & diet). During the intervention period, the study population had access to the website with disease-specific contents and a disease-specific discussion forum. All participants received weekly individual tailored exercise recommendations from the sports therapist. Results: A total of 20 participants (5 of each trial) were analyzed. During the intervention period, a regular contact and a consequent implementation of exercise prescription were easily achieved in all substudies. Across the four studies, there was a significant decrease in login rates (P <.001) and login durations (P<.001) with time. A detailed view into the different studies shows a significant decrease in login rates and login durations in the HELP study (p=.004; p=.002) and iPEP study (P=.021; P=.001), whereas the EXDEP study (P=.583; P=.378) and COMMED study (P=.867; P=.558) showed no significant over the eight weeks intervention period. There was no significant change in physical activity within all studies (P=.311). Only in the HELP study, the physical activity level increased steadily over the period analyzed (P= .045). Overall, 85% (n=17) felt secure and were not scared of injury, with no major differences in the subtrials. Conclusions: The theoretical framework of the web-based intervention appears to be applicable across the heterogonous collectives of our study patients with regard to age and disease. Although the development of physical activity shows only moderate improvements, flexible communication and tailored support could be easily integrated into patients’ daily routine. Clinical Trial: iPEP study: NCT02478996; (Archived by WebCite at HELP study NCT02526732; (Archived by WebCite at EXDEP study: NCT02874833; (Archived by WebCite at

  • Primary care providers’ response to an online lifestyle modification intervention

    Date Submitted: Aug 1, 2017
    Open Peer Review Period: Aug 1, 2017 - Sep 26, 2017

    Background: Online tools are a convenient and effective method of delivering lifestyle interventions to obese adult primary care patients. A referral model allows physicians to efficiently direct their patients to the intervention during a primary care visit. However, little is known of physicians’ perspectives and utilization of the referral model for an online lifestyle modification intervention. Objective: To evaluate primary care providers’ (PCP) response to a referral model for implementing a year-long online intervention for weight loss to obese adult patients. Methods: PCPs at six primary care clinics were asked to refer adult obese patients to a year-long online lifestyle intervention providing self-management support for weight loss. Following the one year intervention, all providers at the participating practices were surveyed regarding their views of the program. Respondents completed survey items assessing their attitudes regarding the one-year intensive weight loss intervention and identifying resources they would find helpful for assisting patients with weight loss. Referring physicians were asked about their level of satisfaction with implementing the counseling services using standard electronic health record (EHR) referral processes. Attitudes towards obesity counseling among referring and non-referring providers were compared. Impressions of how smoothly the referral model of obesity treatment integrated with the clinical workflow were also quantified. Results: Non-referring providers were more likely to prefer counseling themselves (P=.04) and to report having sufficient time to do so (P=.03). Non-referring providers were more likely to report that their patients lacked computer skills (77% versus 35%) or had less access to the internet (64% versus 33%). Conclusions: Understanding providers’ views and barriers regarding the integration of online tools will facilitate widespread implementation of an online lifestyle modification intervention.

  • Development and Pilot Testing of a mHealth Pain Coping Skills Training Intervention Designed for Patients Following Hematopoietic Stem Cell Transplantation

    Date Submitted: Jul 27, 2017
    Open Peer Review Period: Jul 29, 2017 - Sep 23, 2017

    Background: Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT). Objective: This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients. Methods: Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development qualitative data was collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT; n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Meaures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report, two-minute walk test) were collected. Results: Participants in the focus groups and user testing provided qualitative data that was used to iteratively refine the mPCST protocol. Focus group qualitative data included participants’ experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of video-conferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in person session) and home settings (5 video-conferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (i.e., electronic handouts, short videos, audio files). Intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful activities and leisure activities. In the RCT phase of this research, HCT patients (N=36) were randomized to receive the mPCST intervention or to treatment as usual. Results revealed that the mPCST participants completed an average of 5/6 sessions. The participants reported that the intervention was highly acceptable (M=3/4), and they found the sessions to be helpful (M=8/10) and easy to understand (M=7/7). mPCST participants demonstrated significant improvements pre- to post-treatment in pain self-efficacy (P=.03, d=0.61) and on the two-minute walk test (P=0.03, d=0.66) while those in the treatment as usual group did not. Significant changes in pain disability and fatigue were found for both groups (ps<0.02); the magnitudes of the effect sizes were larger for the mPCST group than the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs. 0.81). There were no significant changes in pain severity in either group. Conclusions: Using focus groups and user testing, we developed a mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain. Clinical Trial: NCT01984671

  • Evaluation of a website supporting sensitive religious and cultural advance care planning: ACPTalk

    Date Submitted: Jul 27, 2017
    Open Peer Review Period: Jul 29, 2017 - Sep 23, 2017

    Background: Advance care planning (ACP), encourages consideration of future health care decision making and fosters collaborative, informed end-of life-care. To meet the needs of multicultural and multi-faith populations in Australia, an ACP website, ACPTalk, was funded to support health professionals in conducting conversations within diverse religious and cultural populations. ACPTalk aimed to provide religion-specific ACP content and complement existing resources. Objective: The purpose of this paper was to utilise the Context Input Process Product (CIPP) framework to conduct a formative and summative evaluation of an ACP website, ACPTalk. Methods: Context: health professionals’ solutions for the website were determined through thematic analysis of exploratory key stakeholder interviews. Included religions were determined through an environmental scan, Australian population statistics, and documentary analysis of project steering committee meeting minutes. Input: project implementation and challenges were examined through documentary analysis of project protocols and meeting minutes. Process: to ensure religion-specific content was accurate and appropriate, a website prototype was built with content review and functionality testing by representatives from religious and cultural organizations and other interested health care organizations who completed a web-based survey. Product: Website analytics were used to report utilisation and stakeholder perceptions were captured through interviews and a website survey. Results: Context: Sixteen health professionals (n=7 general practitioners, n=7 primary health nurses, n=2 palliative care nurses) participated in key stakeholder interviews. Website solutions included: religious and cultural information, communication ideas, education and role plays, legal information, downloadable content and web-based accessibility. Both Christian and non-Christian faiths were deemed important to be included in religion-specific content. Input: There were no project delays. Difficulties gaining consensus on religion-specific content were overcome by further state and national religious organizations providing feedback. Process: Thirty-seven content reviewers included representatives of religious and cultural organizations (n=29), health care (n=5) and community organizations (n=3). The majority strongly agree/agree that the content used appropriate language and tone (92%), would support health professionals (89%) and was accurate (83%). Product: Resource usage within the first nine months was 12,957 page views in 4,260 sessions: majority (89%) from Australia. A total of 107 Australian-based users completed the website survey; most felt information was accurate (78%), easy to understand (82%), useful (86%) and appropriate (86%). Twenty nurses (general practice n=10, palliative care n=10, both disciplines n=2) participated in stakeholder interviews. Qualitative findings indicated overall positivity in relation to accessibility, functionality, usefulness, design and increased knowledge of ACP. Recommended improvements included shortened content, a comparable website for patients and families, and multilingual translations. Conclusions: The CIPP framework was effectively applied to evaluate the development and end product of an ACP website. While overall findings were positive, further ACP website development should consider the recommendations derived from this study.

  • Assessing the Efficacy of mHealth Applications Using the Basic Principles of CBT: A Systematic Review

    Date Submitted: Jul 28, 2017
    Open Peer Review Period: Jul 28, 2017 - Sep 22, 2017

    Background: CBT in its basic principle has developed itself as a stand-alone, substantial method of therapy. With effective application in therapy for a range of mental health issues the spread of CBT therapy methods to online therapy sources is evident. The development of mobile smartphone applications using CBT principles is increasing within the research area. Despite the move to online methods of therapy it is argued that these methods lack the same efficacy of face to face CBT therapy sessions. Objective: This review was conducted in order to assess extent research findings with regards to the effectiveness of CBT related mHealth applications. By assessing only studies employing an RCT design the review aimed to determine app efficacy within the highly regarded method of investigation. Methods: A comprehensive literature search was conducted across several databases. Search results were filter and results were subject to strict inclusion and exclusion criteria due to the nature of the review. Where possible analysis of effect size was calculated and results reported. Results: A total of 8 studies investigating the effectiveness of mHealth CBT related apps across a range of mental health issues were reviewed. 3 studies used the app against a control group and 5 studies used the app intervention against another form of treatment or intervention. A range of effect sizes were seen across all included studies (d=-0.13 – 1.83; 0.03 – 1.44) with the largest effects often being seen when comparing the data from pre- to post-test for the app engaged group. Conclusions: The studies reviewed support the use of mHealth apps containing CBT principles for a range of mental health issues. However the effectiveness over longer time periods should be assessed. Researchers and CBT professionals should seek to collaborate effectively when creating new apps to enhance their effectiveness as a treatment for the general public.

  • Relationship Using multiple linear regression analysis and Bayesian network model analysis of factors affecting bone mineral density of residents in snowy region of Japan

    Date Submitted: Jul 28, 2017
    Open Peer Review Period: Jul 28, 2017 - Sep 22, 2017

    Background: Since the onset of osteoporosis leads to a decrease in daily living behavior and may lead to bedridden state, efforts to suppress decrease in bone density are necessary. Various studies have been conducted on the relationship between sex, age, nutrients, exercise habits, etc. and bone mineral density to date. However, for the residents of snowy region, the magnitude of the influence of various factors on bone mineral density and the degree of causal relationship have not been clarified. Objective: In this research, we aimed to clarify the influence degree and the causal relation of factors influencing bone mineral density, based on survey results on health conditions, lifestyle habits etc. for heavy snow areas. Methods: Questionnaires on lifestyle and exercise habits, BDHQ (Brief-type self-administered Diet History Questionnaire), 354 citizens who visited the drug store in the target area, height meter, weight, body composition, bone densitometer and the like were analyzed by multiple regression analysis to calculate the degree of influence on bone density. In addition, a Bayesian network model was constructed, and the causal relation between each factor was calculated as conditional probability. Results: As a result of the Bayesian network analysis, factors influencing bone mineral density were only age and sex, and influence of other nutrients and exercise was not clarified.However, calcium intake and T Score proved to be a factor in the presence or absence of fracture experiences.It was suggested that ingesting calcium is the most important as an approach that can be done to prevent fractures. Conclusions: From the results of the multiple regression analysis, age, sex, history of bone fracture, and calcium intake were selected as models, but the effects of other nutrients and exercise were not assessed. In the results of the Bayesian analysis, the only factors that affected bone density were age and sex; these results also did not show the effects of other nutrients or exercise. However, the fact that calcium intake and T score were shown to affect bone fracture history suggests that calcium intake is an important measure that can be implemented to prevent bone fractures. Overall, these results suggest that measures such as ensuring an environment where bone fractures do not occur and providing nutritional advice for calcium intake are effective for inhibiting bone loss.

  • Enhancing Outcomes of Non-Communicable Diseases Care in Rural Settings and Refugee Camps: Could Low-cost mHealth Interventions Make a Difference?

    Date Submitted: Jul 24, 2017
    Open Peer Review Period: Jul 24, 2017 - Sep 18, 2017

    Background: Rural areas and refugee camps are characterized by poor access of patients to needed NCD-related health services, including diabetes and hypertension. Employing low-cost innovative eHealth interventions such as mobile health (mHealth) may help improve NCDs prevention and control among disadvantaged populations through delivering NCD-targeted care. Objective: Assess the effect of employing low-cost mHealth tools on the accessibility to health services and health outcomes of individuals with NCDs residing in rural areas and refugee camps in Lebanon. Methods: This is a randomized control trial study in which centers were allocated randomly into control and intervention sites. The effect of an employed mHealth intervention is assessed through selected quality indicators (QIs) examined in both control and intervention groups. Sixteen primary healthcare centers (8 controls, 8 interventions) located in rural areas and Palestinian refugee camps across Lebanon were included in this study. Data on diabetic and hypertensive patients- 1433 in the intervention groups and 926 in the control groups was extracted from patient files in the pre and post intervention periods. The intervention entailed weekly SMS messages including medical information, importance of compliance and reminders of appointments/ regular physician follow-up. QIs included results of Blood Pressure (BP), Glycosylated hemoglobin (HbA1c), smoking status, and dates of last visit for HbA1c testing, eye check-up, and foot exam. Descriptive analysis of baseline characteristics of participants, bivariate analysis, logistic regression, and linear regression were conducted using SPSS. Statistical significance was set at p-value of 0.05. Results: Bivariate analysis of QIs indicated that the intervention group had a significant increase in BP control (p= 0.03), as well as a significant decrease in the mean Systolic Blood Pressure (SBP) (p=0.02), mean HbA1c (p<0.01) and in the proportion of HbA1c poor control (p=0.02). Separate regression models controlling for age, gender, and setting, showed a 28% increase in the odds of BP control (p=0.05) and a 38% decrease in the odds of HbA1c poor control (p=0.04) among the intervention group in the post-test period. Females were at a lower odds of HbA1c poor control (p=0.01) and age was statistically associated with annual HbA1c testing (p<0.01). Regression models for mean SBP, mean Diastolic Blood Pressure, and mean HbA1c showed that a mean decrease in HbA1c of 0.87% (p<0.01) pre-test to post-test period was observed among the intervention group. Patients in rural areas belonging to the intervention group had a lower HbA1c score as compared to those in refugee camps (p<0.01). Conclusions: This study underlines the importance of employing integrative approaches of diseases prevention and control in which existing NCD programs in underserved communities (i.e. rural and refugee camps settings) can be coupled with innovative, low-cost approaches such as mHealth to provide an effective and amplified effect of traditional NCD-targeted care, that can be reflected by improved clinical outcomes among the population.

  • An Efficient Automated Classification Approach for Free-text Medical Narratives using Word Embedding and Convolutional Neural Networks

    Date Submitted: Jul 20, 2017
    Open Peer Review Period: Jul 21, 2017 - Sep 15, 2017

    Background: Automated disease code classification using free-text medical information is important for public health surveillance. However, traditional natural language processing (NLP) pipelines are limited, so a method combining word embedding with a convolutional neural network (CNN) is proposed. Objective: We conducted a classification task identifying chapter-level ICD-10-CM diagnosis codes in discharge notes and compared the performance of traditional pipelines (NLP + supervised machine learning models) with that of word embedding combined with a CNN. Methods: Two classification methods are presented: (1) some features (terms, n-gram phrases, and SNOMED CT categories) are extracted from discharge notes and used to train a set of supervised machine learning models (support vector machine, random forests, and gradient boosting machine); (2) a feature matrix is built by a pre-trained word embedding model and used to train a CNN. These methods were used to identify the chapter-level ICD-10-CM diagnosis codes in a set of discharge notes. An evaluation was conducted using 103,390 discharge notes covering patients hospitalized from June 1, 2015 to January 31, 2017 in the Tri-Service General Hospital. The receiver operating characteristic curve was used as an evaluation measure, and the area under the curve (AUC) was taken as a global measure of effectiveness. Results: In five-fold cross-validation tests, our method had a higher testing accuracy (a mean AUC of 0.9696) than traditional NLP-based approaches (a mean AUC of 0.8183–0.9571). A real-world simulation that split the training sample and testing sample by date verified this result (a mean AUC of 0.9645 using the proposed method). Further analysis showed that the convolutional layers of the CNN effectively identified a large number of keywords and automatically extracted enough concepts to predict the diagnosis codes. Conclusions: Word embedding combined with a CNN shows outstanding performance compared with traditional methods, and it needs hardly any data pre-processing. This shows that future studies will not be limited by incomplete dictionaries. A large amount of unstructured information from free-text medical writing will be extracted by automated approaches in the future, and we believe that the healthcare field is about to enter the age of big data.

  • Use of social network services for communication among health professionals: a systematic review

    Date Submitted: Jul 20, 2017
    Open Peer Review Period: Jul 20, 2017 - Sep 14, 2017

    Background: Social network services (SNSs) are subject to tremendous exploitation in health communication. Although much research has been done investigating the roles of SNSs in linking patients and health professionals, there is a lack of evidence on their uses, benefits and limitations in connecting health professionals. Objective: This review aimed to examine the utilization of SNSs for communication among health professionals in (1) frontline clinical practice, (2) professional networks and (3) education and training, so as to identify areas for future health communication research. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the literature published in the last ten years (1 January 2007–1 March 2017) was performed in March 2017, using the following electronic databases: Medline via OvidSP, Embase, CINAHL Complete and InfoSci Journals. The searches were performed using the following defined search terms: ‘social media’ OR ‘social network’ OR ‘social network site’ OR ‘Facebook’ OR ‘Twitter’ OR ‘Linkedin’ OR ‘Instagram’ OR ‘Weibo’ OR ‘Whatsapp’ OR ‘Telegram’ OR ‘WeChat’ AND ‘health’ OR ‘health profession’. Results: A total of 32 studies were included in this review. They were exploratory in nature, and the majority utilized surveys, interviews and content analysis. The most reported SNSs were Twitter, Facebook, WhatsApp Messenger and LinkedIn. All retrieved studies stated that SNSs enhanced effective communication and information sharing. In clinical practice, SNSs were used for supporting operations, making referrals, and disseminating guidelines. They were beneficial in network building and professional collaboration. SNSs were novel tools to enhance educational interactions among peers, students, instructors and preceptors. Yet, the application of SNSs for professional communication came with restraints in technical knowledge and techniques. Concerns regarding data protection, privacy and liability should be addressed by proper institutional policy and training. Conclusions: SNSs create a new dimension in communication among health professionals. Expanding professional networks, disseminating multimedia information and producing positive learning experiences are the benefits observed. The evolving use of SNSs necessitates that health professionals match the pace of development. Further robust research such as randomized controlled trials is required to explore the full potential and relative effectiveness of SNSs in professional communication.

  • Security and Privacy Concerns Regarding Genetic Data in Mobile Health Record Systems: An Empirical Study from Turkey

    Date Submitted: Jul 19, 2017
    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: In today’s health services, it has become a necessity to keep patients’ health data in electronic format. There are many theories and considerable research on the design of electronic health record applications. As the use of genetic testing, and applications of bioinformatics is increasing in healthcare, genetic and genomic information needs to be included within these systems. Objective: In this study, we carried out a descriptive survey with 174 participants to acquire their views on the privacy and the security of mobile health record systems and inclusion of their genetic data in these systems. Methods: An online survey and an on-site survey in the two genetic diagnostic centers were conducted to reach patients or relatives of patients that had undergone genetic testing. Descriptive statistics is used to summarize the data. Results: Nearly half of the participants or their relatives (48.9%) had undergone genetic testing. Doctors are the only profession group that people trust for the privacy of their health and genetic information (61.2%); however, people chose to limit even their doctor’s access to their genetic/medical records (52.5%). Majority of the respondents (94%) prefer to keep full access right option only for themselves. The regulations and security measurements are suggested in the questionnaire are found to be acceptable by the majority of the respondents. A significant amount of participants had bad experiences and prejudices about electronic health records: 9.7 % of respondents’ medical records were used or released without their consents, 15.1 % stated that they had avoided being tested because of violation risks, and 3.5 % asked their doctors to enter a less embarrassing health status into their records. Also our analysis showed that participants attribute special importance to their genetic records, as significantly more participants stated that storing genetic records in a mobile system is more risky compared to other health records (P=.00). Conclusions: People have various negative experiences and there are plenty of information disclosure events in the media; hence people have concerns about the privacy and security of their health and genetic data. The results of our survey showed that people would like to see security measurements and regulations to protect their privacy, before they start to use any application to keep track of their health/genetic data. They also would like to have sole control on these applications. Personal Health Record (PHR) applications offers solutions to the data management problem as an electronic system, since they enable the users to have full control over their records.

  • Clinical Videoconferencing: A Systematic Review and Analysis of eHealth Enacted in User Patterns

    Date Submitted: Jul 19, 2017
    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: Earlier work has described videoconferencing technologies, peripheral equipment, organizational models, human relations, purposes, goals and roles as versatile, multifaceted and used differently in different clinical practices. Knowledge about benefits and challenges connected to specific characteristics of services are lacking. A 2005 systematic review of published definitions of “eHealth” identified 51 unique definitions and concluded that it had become an accepted neologism despite the lack of clear, precise, agreed-upon definitions. In 2015, the question “What Is eHealth: Time for an Update?” was posed. Objective: Considering videoconferencing as eHealth, the objective of the paper is twofold: to demonstrate and cluster (different) clinical videoconferencing practices and their situated implications and to explore and analyze whether—and how—common features and implications across clusters can contribute to an update of the eHealth concept. Methods: We performed a literature search via the National Center for Biotechnology Information (NCBI), encompassing PubMed and PubMedCentral, for quality reviews and primary studies. This paper reports results for primary studies. We used the terms “videoconferencing” and “clinical practices.” The selection process was based upon clearly defined criteria. We used an electronic proforma to extract data. The analysis was inspired by realist review and “the ten e’s of eHealth”. Results: The search returned 154 reviews and primary studies. This paper considers the primary studies, and eleven were included. We identified three broad clusters; 1) Videoconferencing as singular intstrument within existing organisational frameworks for expert advice, and effectiveness and quality improvement goals; 2) Videoconferencing as multifaceted with novel organisational arrangements, reaching out to homes and family caregivers with the purpose of co-creating improvement; 3) Videoconferencing as an operational instrument for improving administration of triage. The analysis of common features of videoconfeerencing across the clusters that might add to the understanding of eHealth resulted in a proposal to add four d’s to the existing ten e’s. The four d’s are: dynamic, differentiated along services and temporal lines, demanding of fresh resources and (inter) dependent of human and socio economic components. Conclusions: Videoconferencing for clinical work appear as a dynamic of differentiation and adaptation along service and temporal lines, made to work from an ongoing demand for fresh resources. Additionally, videoconferencing is an (inter)dependent assemblage of human, socio economic and technological constituent parts. The four d’s—dynamic, differentiated, demanding and (inter)dependent—can be added as an update of “the ten e’s of eHealth”.

  • Automatic Health Assessment of Smart Home Residents via Unsupervised Learning from Ambient Sensor Data: An Observational Study

    Date Submitted: Jul 18, 2017
    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: Existing approaches to health assessment for smart home residents mostly rely on the activities recognized by supervised learning methods, which require well-annotated sensor data. Obtaining such labeled data is not a feasible task, especially for senior adults. Objective: Developing an unsupervised learning method to health assessment for smart home residents without the need of labeled data. Methods: Ambient sensors are deployed in participants’ home to collect activity data. Home resident’s health is assessed via a two-step approach. In the first step, the clusters of sensor data are discovered using K-means or Gaussian Mixture Models (GMM). In the second step, the time spent on each data cluster is used to compute a health score that represents the physical health of the resident. As we could not obtain ground-truth labels, we conduct this project as an observational study. Results: We test the first step of our approach (sensor data clustering) on the Aruba dataset, which was acquired from a testbed occupied by a senior resident for more than a year. In this step, GMM achieves its best performance of 0.75 (𝐹1_score) and 0.79 (Rand_index) and outperforms K-means. Qualitative results obtained on our smart home dataset also demonstrate the correlation between the discovered sensor data clusters with resident’s daily routine. The health score derived in the second step of our approach is highly associated with the health events happened to one of our participants. Conclusions: The experimental results demonstrate that the sensor data clusters discovered by standard clustering methods are highly correlated with the ground-truth activities or daily routine. Between the two tested methods, GMM outperforms K-means in all metrics. The health score derived by our two-step unsupervised approach is highly related to the health events happened to the resident. Clinical Trial: The CSIRO Health and Medical Research Human Research Ethics Committee (#12/17).

  • Reproducibility and Validation of the Qardioarm Application in the Assessment of Blood Pressure and Heart Rate: Reliability and ValidityStudy

    Date Submitted: Jul 13, 2017
    Open Peer Review Period: Jul 17, 2017 - Sep 11, 2017

    Background: Self-measurement of blood pressure is a priority strategy for managing blood pressure. Objective: Following the European Society of Hypertension’s international validation protocol, we evaluated the reliability and validity of blood pressure and heart rate as measured with the Qardioarm, a fully automatic, non-invasive wireless blood pressure monitor and mobile application. Methods: Test-retest validation study, with two measurement sessions separated by 2-5 days. A single study site with an evaluation room that was maintained at an appropriate temperature and kept free from noises and distractions. 100 healthy volunteers over age 25 from the general population of Ciudad Real, Spain. In each measurement session, 7 systolic blood pressure, diastolic blood pressure, and heart rate assessments were taken, alternating between two devices. The test device was the Qardioarm and the previously validated criterion device was the Omron M3. Results: The Qardioarm displayed very consistent readings both within and across sessions (intraclass correlation coefficients = .80-.95, standard errors of measurement = 2.5-5.4). The Qardioarm measurements corresponded closely to those from the criterion device (Pearson correlations > .96) and mean values for the two devices were nearly identical. The Qardioarm easily passed all validation standards set by the European Society of Hypertension international protocol. Conclusions: The Qardioarm can be recommended for clinical use in individuals with similar characteristics as those who participated in this study. Clinical Trial: IT IS NOT A CLINICAL TRIAL

  • Exploring the role of in-person components for online health behaviour change interventions: Can a digital person-to-person component suffice?

    Date Submitted: Jul 14, 2017
    Open Peer Review Period: Jul 14, 2017 - Sep 8, 2017

    The growth of the digital environment provides tremendous opportunities to revolutionize health behaviour change efforts. This article explores the use of Web-based, mobile, and social media health behaviour change interventions and determine if there is a need for a face-to-face or an in-person component. It is further argued that that although in-person components can be beneficial for online interventions, a digital person-to-person component can foster similar results while dealing with challenges faced by traditional intervention approaches. Using a digital person-to-person component is rooted in social and behavioural theories such as the Theory of Reasoned Action, and the Social Cognitive Theory, and further justified by the human support constructs of the Model of Supportive Accountability. Overall, face-to-face and online behaviour change interventions have their respective advantages and disadvantages and functions yet both serve important roles. It appears that it is in fact human support that is the most important component in the effectiveness and adherence of both face-to-face and online behaviour change interventions and thoughtfully introducing a digital person-to-person component, to replace face-to-face interactions, can provide the needed human support while diminishing the barriers of in-person meetings. The digital person-to-person component must create accountability, generate opportunities for tailored feedback, and create social support to successfully create health behaviour change. As the popularity of the online world grows, and the interest in using the digital environment for health behaviour change interventions continues to be embraced, further research into not only the use of online interventions, but the use of a digital person-to-person component, must be explored.

  • Using a Web-based Transitions Intervention to Help Informal Caregivers of Older Adults with Dementia and Multiple Chronic Conditions: A Qualitative Study

    Date Submitted: Jul 14, 2017
    Open Peer Review Period: Jul 14, 2017 - Sep 8, 2017

    Background: Informal caregivers (ie, family members and friends) play a vital role in the ongoing care and well-being of older persons with Alzheimer disease and related dementia (ADRD) in combination with multiple chronic conditions (MCC) who are living at home. However, they often do so to the detriment of their own physical, mental and emotional health. Caregivers often experience multiple, concurrent transitions (eg, changes to their roles and responsibilities). Recent evidence suggests that Web-based interventions have the potential to support informal caregivers by decreasing caregiver stress and burden. However, we know little about how Web-based supports help caregivers deal with the complex transitions they experience. Objective: The objectives of this paper were to describe: (a) how the use of a self-administered, psychosocial, supportive, Web-based Transition Toolkit, My Tools 4 Care (MT4C), helped informal caregivers of older adults with ADRD and MCC deal with the transitions they experienced as caregivers; (b) which features of MT4C caregivers found most and least beneficial; and (c) what changes would they would recommend making to MT4C. Methods: This study was part of a larger multi-site mixed methods pragmatic randomized controlled trial (RCT). The qualitative portion of the study and the focus of this article used a qualitative descriptive design. Data collectors conducted semi-structured, open-ended, telephone interviews with study participants who were randomly allocated to use MT4C for 3 months. All interviews were audio-taped and ranged from 20-40 minutes. Interviews were conducted at 1 and 3 months following a baseline interview. Qualitative content analysis was used to analyze collected data. Results: Fifty-six informal caregivers from Alberta and Ontario, Canada, participated in either 1 or both of the follow-up interviews (89 interviews in total). Five main themes, describing how MT4C helped caregivers deal with transitions in the context of caring for an older adult with ADRD and MCC, were identified: (1) using MT4C encouraged reflection; (2) using MT4C encouraged sharing of caregiving experiences; (3) using MT4C provided a source of information and education; (4) using MT4C provided affirmation; and (5) for some participants, using MT4C did not help with significant changes. Conclusions: Study results indicate that a self-administered psychosocial supportive Web-based resource helps caregivers of community-dwelling older adults with ADRD and MCC deal with the complex transitions they experience in their roles and responsibilities, identifying supports for caring, caring for self, and planning for future caregiving roles and responsibilities. Caregivers shared important recommendations for future development of Web-based supports.

  • Digital health interventions in type 2 diabetes: a qualitative study of patient perspectives on digital diabetes self-management education and support

    Date Submitted: Jul 13, 2017
    Open Peer Review Period: Jul 14, 2017 - Sep 8, 2017

    Background: The prevalence of type 2 diabetes is increasing globally and health services in many countries are struggling with the morbidity, mortality and costs associated with the complications of this long-term condition. Diabetes self-management education and behavioural support can reduce the risks of developing diabetes-related complications and improve glycaemic control. However, their uptake is low. Digital health interventions can provide sustained support and may overcome challenges with attendance at diabetes self-management sessions. They have the potential for delivery at multiple locations at convenient times, anonymity, and presentation of content in attractive and tailored formats. This study investigates the needs and wants of patients with type 2 diabetes to inform the development of digital self-management education and support. Objective: To explore patient perspectives on unmet needs for self-management and support and the role of digital health interventions in adults living with type 2 diabetes. Methods: Qualitative study based on data generated from four focus groups with 20 patients. Results: The data generated by the focus groups illustrated the significant burden that the diagnosis of diabetes places on many patients and the negative impacts on their emotional wellbeing, work, social life and physical health. Although patients’ experiences of the health care services varied, there was agreement that even the best services were unable to meet all users’ needs to support the emotional regulation and psychological adjustment needed for successful self-management. Conclusions: By focusing on medical management and information provision, existing healthcare services and education programmes may not be adequately meeting all the needs of patients with type 2 diabetes. Digital health interventions have the potential to improve access to diabetes self-management education and behavioural support and extend the range of content offered by health services to fit with a wider range of patient needs. Features that could help digital health interventions meet some of the unmet needs described by participants in this study included placing an emphasis on emotional and role management, being available at all times, having up-to-date evidence based guidance for patients and providing access to peer-generated and professional advice.

  • Internet- and mobile-based general practice: Who are the suitable consultants?

    Date Submitted: Jul 7, 2017
    Open Peer Review Period: Jul 9, 2017 - Sep 3, 2017

    Background: As a promising technology for the promotion of quality healthcare, mHealth is increasing in the world. To make full use of the advantages, an increase of internet hospitals established in China. However, there is no study of the service scope and patient satisfaction of the internet hospital yet. Objective: The aim of the study was to explore the features of outpatients in general practice clinic of the internet hospital in order to provide the references for general practitioners (GPs) who will work for online clinic. Methods: Data were collected from the internet hospital of the first affiliated hospital, Zhejiang University between February 2016 and February 2017. Patients logon the internet hospital with the computer or mobile phone. The information included patients’ characteristics and the information of diseases. Results: There were totally 715 visits. According to the system classification, the former five ones were musculoskeletal system (12.73%), the digestive system (11.33%), the reproductive system (9.23%), urinary tract (7.69%) and the endocrine system (6.58%). According to the management, 451 patients (63.08%) should visit the offline clinic, 181 patients (25.31%) had received medication or test appointment, 9 people (1.26%) should use emergency department, and 74 people (10.35%) need supportive counseling. All patients received the corresponding health education. According to the diagnosis, 563 patients (78.74%) are diagnosed, while 152 individuals (21.26%) are medically unexplained physical symptoms (MUPS). Conclusions: Internet- and mobile-based online practice is feasible and convenient for patients with high satisfaction. Patients with chronic disease, health consultation and health education are suitable for internet hospital.

  • Development of e-Health Literacy Assessment (eHLA): a seven tool toolkit for assessesing the competencies needed to engage with digital health services

    Date Submitted: Jul 7, 2017
    Open Peer Review Period: Jul 7, 2017 - Sep 1, 2017

    Background: Digitalisation of health care systems has added a new dimension to health care services. To gain full potential of digitalization in healthcare, we need to better understand individuals’ e-health literacy. However, there is a lack of tools that provide a short and multi-facetted assessment of individuals engaging with digital health services. Objective: n response to this, the authors initiated the development and validation of the e-Health Literacy Assessment (eHLA) toolkit. eHLA consists of seven tools with four health-related (tool 1. “Functional Health Literacy”, tool 2. “Self-rated health literacy”, tool 3. “Familiarity with health and disease”, and tool 4. “Knowledge of health and disease”) and three digitally-related (tool 5. “Digital familiarity”, tool 6. “Digital confidence”, tool 7. “Digital motivation”) tools. The seven tools are a mix of existing, adapted, and original scales. Methods: eHLA was validated in a population sample of 475 respondents from the general community and an outpatient clinic north of Copenhagen, Denmark. Initial statistical analyses examined floor and ceiling effects, inter-item correlations, item-total correlations, calculation of Cronbach’s coefficient alpha (CCA), and further analyses examined fit of the data to the Rasch model (RM) and evaluated differential item functioning (DIF) with regards to age and sex. Each tool was reduced in items based on a combination of statistics results, face validity, and content validity. Results: Tool 1 was not reduced in items, and it consequently consists of 10 items. The overall fit to the RM was acceptable (Andersens CLR=10.8, df=9, p=0.2876), and CCA was 0.67. Tool 2 was reduced from 20 to nine items. The overall fit to a log linear RM was acceptable (Andersens CLR=78.4, df=45, p=0.0015) and CCA was 0.85. Tool 3 was reduced from 23 to five items. The final version of tool 3 consists of five items and showed excellent fit to a log linear RM (Andersens CLR=47.7, df=40, p = 0.1870). CCA was 0.90. Tool 4 was reduced from 12 to six items. The fit to a log linear RM was acceptable (Andersens CLR=42.1, df=18, p=0.0011) and CCA was 0.59. Tool 5 was reduced from 20 to six items. The fit to the RM was acceptable (Andersens CLR=30.3, df=17, p=0.0240) and CCA was 0.94. Tool 6 was reduced from five to four items. The fit to a log linear RM taking local dependency into account was acceptable (Andersens CLR=26.1, df=21, p=0.2031) and CCA was 0.91. Tool 7 was reduced from six to four items. The fit to a log linear RM taking LD and DIF into account was acceptable (Andersens CLR=23.0, df=29, p=0.7760) and CCA was 0.90. Conclusions: The eHealth Literacy Assessment toolkit is a validated set of tools to describe facets of individuals’ knowledge and skills in the engagement with digital health services.

  • The Significance of “Witness Sensors”

    Date Submitted: Jul 4, 2017
    Open Peer Review Period: Jul 6, 2017 - Aug 31, 2017

    Due to the increasing number of natural and man-made disasters, mass casualty incident (MCI) events occur more often than ever before. As a result, the health providers need to adapt in order to cope with the overwhelming patient surge. On the quality and safety aspects of the health issues, the accurate information of pandemic disease control, death reduction, and health quality promotion should be further highlighted. Nevertheless, obtaining precise information in real-time is a hydra-headed challenge to all the researchers of the field. In this article, innovative strategies are presented, so to develop a sound information network by using the concept of “Witness Sensors” (WSs). In order to overcome the reliability and quality limitations of the information obtained by social media, researchers pay great attention to develop solutions that secure the authenticity of the messages, especially for matters related to health. In this research, we introduce a pioneering concept that is based on the two potential elements of “witness” and “sensor” to face the aforementioned matters. It is now more accepted than ever before, that the social media and any kind of information exchange through the internet is being transformed to a major communication tool for health providers and receivers. In this article, the WSs are designed to alleviate possible limitations and to distinguish fact from fiction in critical information matters. In order to enhance the health communication practices and deliver valid information to end users, the education and management of WSs should be further investigated, especially for the implementation of MCIs and epidemic outbreaks.

  • The Promise of Patient Portals for Adolescent Research

    Date Submitted: Jul 3, 2017
    Open Peer Review Period: Jul 4, 2017 - Aug 29, 2017

    Background: While adolescents can receive confidential health care without parental/guardian notification, they are rarely asked about their experiences and opinions regarding their care because participation in research often requires parental consent. Anonymous research with adolescents via confidential patient portals may ameliorate this research gap. Objective: Because use of a confidential online adolescent patient portal is high at one academic institution, we hypothesized that adolescents would also respond to this portal for survey-based research. We sought to anonymously ask adolescents without parental consent about their knowledge, opinions and perceptions regarding their health and health care, including information on a long-acting reversible contraceptive (LARC). A secondary aim was to examine if and how adolescents use their patient portal to consider research participation. Methods: Upon receiving IRB approval, we sent two portal-based surveys about confidential services to two groups of females, ages 14-25 years, who had attended an adolescent clinic in the past three years. This clinic mostly serves Medicaid recipients (80%) and is racially and ethnically diverse with patients evenly divided between African-American and Caucasian, with roughly 10% Hispanic. The control group was a random sample of female patients who never received a LARC (n=150) and the intervention group included all female adolescents who had received a LARC from the same clinic (n=107). This second sample was manually cross-checked to confirm they had an office visit for this insertion. Consenting for themselves, the control group received an email through the patient portal with a link and a request to perform an assessment. The survey for the control group included items assessing health literacy and health communication preferences. The survey for the intervention group included health literacy items as well as items to assess their opinions and perceptions regarding their LARC. We tracked click-through rates and opened messages; each participant received four reminders. Results: While only three participants fully completed either survey, email ‘read rates’ (32.6% of LARC recipients and 37.5% of controls) were encouraging. Additionally, of those who opened the messages, almost twice as many of the LARC recipients (45.4%) read the entire survey as compared to those who received the survey asking about health literacy and health care preferences (22.2%). Conclusions: This study did not yield sufficient participation to understand these adolescents’ preferences. However, the methodology of using adolescent portals for online surveys was promising. Future studies need to test if a different survey topic would engage adolescents or if other methods like text-based reminders would improve participation.

  • A systematic literature review of models used in clinical decision support systems supporting healthcare professionals treating diabetic foot ulcers

    Date Submitted: Jun 30, 2017
    Open Peer Review Period: Jun 30, 2017 - Aug 25, 2017

    Background: Diabetic foot ulcer is one of the most devastating late diabetic complications. Many randomised controlled trials on the different wound care elements have been conducted and published in the Cochrane Library, all of which have only a low evidential basis. Thus, healthcare professionals are forced to rely on their own experience when making decisions regarding the treatment of diabetic foot ulcers. To progress from experience-based practice to evidence-based wound care practice, clinical decision support systems that help healthcare providers with decision-making in a clinical workflow have been developed. These systems have proven useful in many areas within the healthcare sector, partly because they have increased the quality of care, and partly because they have generated a solid basis for evidence-based practice. However, no systematic reviews focus on clinical decision support systems within the field of diabetic foot ulcer care. Objective: The aims of this systematic literature review are to identify models used in clinical decision support systems that specifically support healthcare professionals treating diabetic foot ulcers, to classify each clinical decision support model according to selected variables and to create an overview. Methods: A systematic review was conducted using six databases. This systematic literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic reviews. The following aspects were extracted from each article: authors, year, country, sample size of data and variables describing the type of clinical decision support models. The decision support models were described and classified according to the variables. Results: The final number of studies included in the systematic literature review was 10: the ten clinical decision support models included four quantitative decision support models and six qualitative decision support models. The earliest eligible article was published in 2007, and the most recent article was from 2015. Conclusions: The clinical decision support models were targeted at a variety of different types of chronic wounds. The degree of accessibility of the inference engines varied. Quantitative models served as the engine and were invisible to the healthcare professionals, while qualitative models required interaction with the user. None of the decision support models focused specifically on supporting healthcare professionals treating diabetic foot ulcers. Clinical Trial: The protocol for this systematic literature review was registered on PROSPERO with the registration no.: CRD42017068495 and is available in full on (