Latest Submissions Open for Peer Review

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Using the Medical Research Council framework for development and evaluation of complex interventions in a low resource setting to develop a theory-based treatment support intervention delivered via SMS text message to improve blood pressure control.

    Date Submitted: Feb 9, 2017
    Open Peer Review Period: Feb 21, 2017 - Apr 18, 2017

    Background: Several frameworks now exist to guide intervention development but there remains only limited evidence of their application to health interventions based around use of mobile phones or devices, particularly in a low-resource setting. Objective: We describe our experience of using the Medical Research Council (MRC) Framework on complex interventions to develop and evaluate an adherence support intervention for high blood pressure delivered by SMS text message. We describe the developed intervention in line with reporting guidelines for a structured and systematic description. Methods: We used a non-sequential and flexible approach guided by the 2008 MRC Framework for the development and evaluation of complex interventions. Results: We reviewed published literature and established a multi-disciplinary expert group to guide the development process. We selected health psychology theory and behaviour change techniques that have been shown to be important in adherence and persistence with chronic medications. Semi-structured interviews and focus groups with various stakeholders identified ways in which treatment adherence could be supported and also identified key features of well-regarded messages: polite tone, credible information, contextualised, and endorsed by identifiable member of primary care facility staff. Direct and indirect user testing enabled us to refine the intervention including refining use of language and testing of interactive components. Conclusions: Our experience shows that using a formal intervention development process is feasible in a low-resource multi-lingual setting. The process enabled us to pre-test assumptions about the intervention and the evaluation process, allowing the improvement of both. Describing how a multi-component intervention was developed including standardised descriptions of content aimed to support behaviour change will enable comparison with other similar interventions and support development of new interventions. Even in low-resource settings, funders and policy-makers should provide researchers with time and resources for intervention development work and encourage evaluation of the entire design and testing process. Clinical Trial: The trial of the intervention is registered with South African National Clinical Trials Register number (SANCTR DOH-27-1212-386); Pan Africa Trial Register (PACTR201411000724141); (NCT02019823).

  • Private mentions of mammography and breast cancer terms on Facebook

    Date Submitted: Feb 14, 2017
    Open Peer Review Period: Feb 21, 2017 - Apr 18, 2017

    Background: Facebook is the most popular social networking site in the US, an online forum where circles of friends privately create, share and interact with each other’s content. Objective: We sought to understand what information was being shared regarding breast cancer and screening on Facebook. Methods: We used a novel proprietary tool from Facebook to analyze all the more than 1,700,000 unique interactions (comments on stories, reshares, and emoji reactions) and stories associated with breast cancer screening keywords which were generated by more than 1,100,000 unique Facebook users over the one month between November 15th through December 15th, 2016. We report frequency distributions of most popular shared web content by age group and keywords. Results: On average, each of 59,000 unique stories during the month was reshared one and a half times, commented on nearly 8x, and was reacted to more than 20x by other users. Posted stories were most often authored by women aged 45-54. Users shared, reshared, commented on and reacted to website links predominantly to e-commerce sites (36% of all the most popular links), celebrity news (26%) and major advocacy organizations (15%, almost all American Cancer Society breast cancer site) Conclusions: On Facebook, women shared and reacted to links to commercial and informative websites regarding breast cancer and screening. This information could inform patient outreach regarding breast cancer screening, indirectly through better understanding of key issues, and directly through understanding avenues for paid messaging to women authoring and reacting to content in this space. Clinical Trial: N/A

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

    Date Submitted: Feb 19, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

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

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

    Date Submitted: Feb 16, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

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

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

    Date Submitted: Feb 19, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

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

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

    Date Submitted: Feb 7, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

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

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

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

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

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

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

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

  • Meeting Patients Where They Are: Development of a Novel Patient Engagement Platform Using Accessible Text Messages and Calls

    Date Submitted: Feb 8, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Patient noncompliance with therapy, treatments, and appointments represents a significant barrier to improving health care delivery and reducing the cost of care. Objective: We created a novel, digital health intervention, “Epharmix”, to engage all patients where they are, enabling health care to reach them regardless of their socioeconomic position. Epharmix utilizes existing SMS and phone infrastructure to help patients reach their clinical goals. Methods: The platform utilizes a series of condition-specific, automated text message or phone calls that are optimized for both clinical utility and patient engagement. The intervention algorithms generate provider alerts and triaged patient rosters so patients receive clinical assistance earlier in their disease process. Results: In total, 28,386 text messages and 24,017 calls were sent to 929 patients over nine months. Patients responded to 80-90% of messages allowing the system to detect 1,164 clinically significant events. Patients reported increased satisfaction and communication with their provider. Epharmix increased the number of patient-provider interactions from less than one to over 10 in any given month. Conclusions: Engaging high risk patients remains a difficult process that may be improved through novel, digital health interventions. The Epharmix platform enables increased patient engagement, with very low risk, to improve clinical outcomes. We demonstrated that engagement and adherence among high risk populations is possible when health care comes conveniently to where they are.


    Date Submitted: Feb 14, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Despite the potential benefits described by international organizations, 68–80% of survivors do not meet the described guidelines in terms of diet and physical activity. This concern could be approached with a user-friendly mobile health (mHealth) application for assessing and monitoring healthy lifestyles in breast cancer survivors (BCS). Objective: The main aim is to investigate the test-retest reliability and concurrent validity against accelerometry and dietary records of a novel mHealth system called BENECA (ENErgy Balance on CAncer). Methods: We conducted a descriptive reliability study (N=20 BCS) who were recruited from the Virgen de las Nieves Hospital of the Andalusian Health Service in Granada (Spain) between December 2015 and April 2016. Test-retest reliability analysis used an overlap of approximately 2 hours between times. During an 8-day period tri-axial accelerometers (ActiGraphGT3X+, Pensacola, Fl., US) were worn by patients for concurrent validity analysis. Alike, at baseline 24-hour dietary recalls (also after 8-day period), sociodemographic questionnaire and daily dietary record questionnaires were recorded. For the inter-rater reliability trials, two-way random effect intra-class correlation coefficients (Rho) and their confidence intervals were calculated. Moreover, the agreement in diet between gold-standard and BENECA m-Health System was evaluated using a method described previously by Hillier. Finally, the accuracy of BENECA m-Health System was assessed using a linear regression analysis to determine the correlation coefficient and a Passing-Bablok regression to evaluate bias. Results: The compliance rates for all assessment methods were very high. All outcome measures showed reliability estimates (α)≥0.90; the lowest reliability was obtained for portions of the FV (α=0.94). The inter-rater reliability (gold standard method versus BENECA mHealth system) was very good (Rho≥0.90). The mean match rate between food items reported using BENECA and those registered by gold-standards was 93.51%, with a phantom rate of 3.35%. There were no substantial differences between the BENECA m-Health system and the gold standard assessment methods. There was no fised bias and mean differences between methods were -0.15 for FAT, -0.01 for fruits and vegetables and -8.89 for minutes of moderate-to-vigorous physical activity. There were not any adverse events. One breast cancer survivor could not use the BENECA m-Health System because she was using a previous version of the Android System with which BENECA was incompatible. Conclusions: The BENECA mHealth system is a simple, quick, reliable and low burden method to assess diet and physical activity in BCS. This novel option has potential implications in the cancer units to examine energy balance-related behaviours. Further research is now required to study the usage of both BENECA mHealth system and objective measurement of physical activity because it could suppose a major advance for a growing cancer population whose energy imbalance increases risk of some of the most prevalent cancer processes.

  • An eAlert System Between Family Caregivers and Clinicians Reduces Symptom Distress in Patients With Advanced Cancer: A Pooled Analysis of Two Randomized Clinical Trials

    Date Submitted: Feb 8, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Symptom distress toward the end of life can change rapidly. Family caregivers have the potential to help manage those symptoms, as well as their own stress, if they are equipped with the proper resources. eHealth systems may be able to provide those resources. Very sick patients may not be able to use such systems themselves to report on their symptoms, but family caregivers could. Objective: Assess the effects of an eHealth system that alerts clinicians to significant changes in a cancer patient’s symptom distress, as reported by a family caregiver. Methods: A pooled analysis from two randomized clinical trials (NCT00214162 and NCT00365963) compared outcomes at 12 months for two unblinded groups: a control group (CHESS-Only) that gave caregivers access to an online support system, the Comprehensive Health Enhancement Support System (CHESS), and an experimental group (CHESS+CR [Clinician Report]), which also had CHESS, but with a Clinician Report that automatically alerted clinicians if symptoms exceeded a predetermined threshold. Participants were dyads (n = 235) of patients with advanced lung, breast, or prostate cancer and their family caregivers from five oncology clinics in the United States. The proportion of improved patient threshold symptoms was compared between groups using area-under-the-curve analysis and binomial proportion tests. The proportion of threshold symptoms out of all reported symptoms was also examined. Results: When caregivers in CHESS+CR reported an over-threshold symptom, they were more likely to subsequently report threshold symptom improvement, P < .001, than in the group that did not include CR. Moreover, fewer caregivers in the CHESS+CR group completed symptom reports than in the CHESS-Only group (P < .001). Knowing their reports might be sent to a doctor, they might have been reluctant to “bother” the clinician. Conclusions: This study suggests that a caregiver-focused eHealth system that alerts clinicians to worrisome changes in patient health status may lead to a reduction in patient distress. Clinical Trial: NCT00214162; (Archived by WebCite at NCT00365963; (Archived by WebCite at )

  • Content Analysis of Smartphone Apps for Smoking Cessation in China

    Date Submitted: Feb 16, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone applications (apps) for smoking cessation are increasingly used in China to help smokers quit. Objective: This study analyzed and evaluated the contents of all smoking cessation apps (iOS & Android) available in China, applying the China Clinical Smoking Cessation Guideline (CCSSG; identical to the U.S. Clinical Practice Guideline for Treating Tobacco Use and Dependence) as a framework for analysis. Methods: We conducted a content analysis of Chinese Android and iOS smoking cessation apps (N=64) designed to assist users in quitting smoking. Each app was independently coded by two raters for its approach to smoking cessation and adherence to the CCSSG. We also recorded the features of smoking cessation apps (e.g., release date, size, frequency of downloads, user ratings, type, quality scores by raters, and designers). Linear regression was used to test predictors of popularity and user-rated quality. Results: Chinese smoking cessation apps have low levels of adherence, with an average score of 11.1 for Android and 14.6 for iOS apps, on a scale of 0 to 46. There was no significant association between popularity, user rating, and the characteristics of apps. However, there was a positive relationship between popularity, user rating, and adherence score. Conclusions: Chinese apps for smoking cessation have low levels of adherence to standard clinical practice guidelines. New apps need be developed and existing apps be revised following evidence-based principles in China.

  • Barriers and facilitators to use eHealth in daily practice, perspectives of patients and professionals in dermatology

    Date Submitted: Feb 15, 2017
    Open Peer Review Period: Feb 18, 2017 - Apr 15, 2017

    Background: The number of eHealth interventions in the management of chronic diseases, such as atopic dermatitis (AD) is growing. Despite promising results, the implementation and use of these interventions is limited. Objective: This study aimed to assess opinions of most important stakeholders influencing the implementation and use of eHealth services in daily dermatology practice. Methods: A cross sectional survey based on the eHealth implementation toolkit (eHit) was conducted to explore factors influencing the adoption of eHealth interventions offering the possibility of e-consultations, online monitoring and online self-management training among dermatologists and dermatology nurses. Perspectives of patients with atopic dermatitis (AD) regarding the use of eHealth services were discussed in an online focus group. Results: Healthcare professionals (n=99) and patients (n=9) acknowledged the value of eHealth services and were willing to use these digital tools in daily dermatology practice. Key identified barriers in the implementation and adoption of eHealth interventions included concerns about the availability and allocation of resources; financial aspects; reliability, security and confidentially of the intervention itself and the lack of education and training. Conclusions: Healthcare professionals and patients acknowledge the benefits arising from the implementation and use of eHealth services in daily dermatology practice. However, we identified some important barriers that might be useful in addressing the implementation strategy in order to enhance the implementation success of eHealth interventions in dermatology.

  • ICT for health in the EU: the effect of multimorbidity

    Date Submitted: Feb 10, 2017
    Open Peer Review Period: Feb 18, 2017 - Apr 15, 2017

    Background: Multimorbidity is becoming increasingly common and is a key challenge that societies with ageing populations are now facing. The presence of multimorbidity entails the implication of patients to coordinate, understand and use the information obtained from different health care professionals, in addition to striving to distinguish the symptoms of different diseases and self manage their sometimes conflicting health problems. Information and communications technology (ICT) tools are an opportunity for health information and education for both patients and health professionals, and hold promise for more efficient and cost-effective care processes. Objective: This study aims to analyze the use of ICT tools, particularly the Internet, for health purposes, taking into account the citizens’ socio-demographic and clinical characteristics, and above all, the presence of multimorbidity. Methods: Cross-sectional and exploratory research using online survey data from July-August 2011 was conducted, including a total of 14,000 citizens from 14 European countries between 16 and 74 years of age, and who had used the Internet in the previous three months. The variables of study were the questionnaire items related to how often the Internet was used for health purposes, the degree of morbidity and the ICT for health gradient. Chi-square tests were conducted to classify participants and examine the relationship between the sociodemographic and clinical variables of participants and the ICT user group. A one-way analysis of variance (Anova) made it possible to compare the ICT for health gradient average between different groups of individuals according to their morbidity level. A two-way between-groups Anova was performed to explore the effects of multimorbidity and age group on the ICT for health gradient. Results: According to the ICT for health gradient, most participants (68.1%; 9,541) were labelled as Rare Users, being the majority of them (55.1%) 25-54 years old, with upper secondary education (50.3%), employed (49.3%) and living in medium-sized cities (40.7%). Results of the one-way Anova showed that the number of health problems significantly affected the use of ICT for health purposes [F (2, 13996) = 11.584; p = .001]. A two-way ANOVA showed there was a statistically significant interaction between the effects of age and number of health problems on the ICT for health gradient, F (4, 11991) = 7.936, p = .001. Conclusions: Although multimorbidity patients can benefit from Internet use for health-related activities, there is a need to consider different strategies to make ICT for health tools more sensitive to the particularities of older people and to reduce digital disadvantages.

  • Internet-based assessment of oncology healthcare professional learning style and optimization of materials for web-based learning: Controlled trial with concealed allocation

    Date Submitted: Feb 14, 2017
    Open Peer Review Period: Feb 15, 2017 - Apr 12, 2017

    Background: Precision medicine has resulted in increasing complexity in the treatment of cancer. Web-based educational materials can help address the needs of oncology healthcare professionals seeking to understand up-to-date treatment strategies. Objective: This study aimed to assess learning styles of oncology healthcare professionals and to determine whether learning style–tailored educational materials leads to enhanced learning. Methods: 21,465 oncology healthcare professionals were invited by email to participate in the fully automated, parallel group study. Enrollment and follow-up occurred between July 13 and September 7, 2015. Self-enrolled participants took a learning style survey and were assigned to the intervention or control arm using concealed alternating allocation. Participants in the intervention group viewed educational materials consistent with their preferences for learning (reading, listening and/or watching); participants in the control group viewed educational materials typical of the My Cancer Genome website. Educational materials covered the topic of treatment of metastatic ER+ breast cancer using CDK4/6 inhibitors. Participant knowledge was assessed immediately before (pre-test), immediately after (post-test), and two weeks after (follow-up test) review of the educational materials. Study statisticians were blinded to group assignment. Results: 751 participants enrolled in the study. Of these, 367 were allocated to the intervention arm, and 384 were allocated to the control arm. Of those allocated to the intervention arm, 256 completed all assessments. Of those allocated to the control arm, 296 completed all assessments. An additional 12 participants were deemed ineligible, and one withdrew. Four hundred thirty-eight of 552 participants (79.3%) self-identified as multi-modal learners. The intervention arm showed greater improvement in post-test score compared to the control group (0.4 points, or 4.0%, more improvement on average; P = 0.004) and a higher follow-up test score than the control group (0.3 points, or 3.3%, more improvement on average; P = 0.016). There were no important harms. Conclusions: While the study demonstrated more learning with learning style–tailored educational materials, the magnitude of increased learning and the largely multimodal learning styles preferred by the study participants led us to conclude that future content-creation efforts should focus on multimodal educational materials rather than learning style–tailored content.

  • A Mobile Application to Streamline the Development of Wearable Sensor Based Exercise Biofeedback Systems: System Development and Evaluation

    Date Submitted: Feb 7, 2017
    Open Peer Review Period: Feb 13, 2017 - Apr 10, 2017

    Background: Biofeedback systems which utilise inertial measurement units (IMUs) have been shown recently to have the ability to objectively assess exercise technique. However, there are a number of challenges in developing such systems; vast amounts of IMU exercise datasets must be collected and manually labelled for each exercise variation and naturally-occurring technique deviations may not be well detected. One method of combatting these issues is through the development of personalised exercise technique classifiers. Objective: We aimed to create a tablet application for physiotherapists and personal trainers which would automate the development of personalised multiple and single IMU based exercise biofeedback systems for their clients. We also sought to complete a preliminary investigation of the accuracy of such individualised systems in a ‘real world’ evaluation. Methods: A tablet application was developed which automates the key steps in exercise technique classifier creation through synchronising video and IMU data collection, automatic signal processing, data segmentation, data labelling of segmented videos by an exercise professional, automatic feature computation and classifier creation. Fifteen volunteers (12 males, 3 females, age: 23.6 +/- 2 years, height: 1.79 +/- 0.07 m, body mass: 77.4 +/- 9.9 kg) then completed 4 lower-limb late stage rehabilitation exercises using a personalised single IMU based classification system. The real world accuracy of the systems was evaluated. Results: The tablet application successfully automated the process of creating individualised exercise biofeedback systems. The personalised systems achieved an average of 90% accuracy, with 90% sensitivity and 89% specificity for assessing aberrant and acceptable technique with a single IMU positioned on the left thigh. Conclusions: A tablet application was developed that automates the process required to create a personalised exercise technique classification system. This tool can be applied to any cyclical, repetitive exercise. The personalised classification model displayed excellent system accuracy even when assessing acute deviations in compound exercises with a single IMU. Clinical Trial: N/A.

  • Scaling up the adoption and use of health technologies: Insights from practice theory

    Date Submitted: Feb 10, 2017
    Open Peer Review Period: Feb 11, 2017 - Apr 8, 2017

    Background: The challenge of promoting the spread and scale of new health technologies (including mobile health, telemedicine, and telehealth technologies) is now widely recognized around the world. Despite the growing attention to methods to achieve successful spread and scale, many scale-up initiatives continue to yield disappointing results. One central reason for the continued failure of these scale-up initiatives is a lack of understanding of how context influences the diffusion of technologies. Objective: In this paper we describe the contributions of “practice theory” to informing efforts to scale-up health technologies across entire systems of health and social care. Methods: Drawing on an individual case study from the Studies in co-Creating Assisted Living Solutions (SCALS) research program in the United Kingdom, and a review of practice theory, we identify key considerations in the effort to scale and spread health technologies. After describing the key tenets of practice theory, we present data from a case study of the implementation of a Global Positioning System (GPS) “geo-fence” for a person living with dementia. We conclude by summarizing the key insights that practice theory brings to efforts to scale up this technology and others, and offer questions to guide further work in this important field. Results: Illustrated through the case of the GPS “geo-fence”, practice theory suggests that efforts to scale-up technologies must attend to three key insights. First, scaling up technologies is in part unpredictable as a result of the experience and judgment integrated into clinical decision-making. Second, the successful scale-up of technologies depends on existing social networks, and considering those social networks will enable stronger plans for the scale and spread of health technologies. Finally, scaling up new technologies means changing routines of a wide range of people, raising the importance of understanding which routines are most likely to change. Conclusions: If health care leaders, policymakers, and other figures driving the scaling up of health technologies continue to neglect the real-world contexts of individual experiences, social networks, and habitual routine practices, the scaling up process will continue to be thwarted by the more important stuff that dominates peoples’ everyday lives. Future work in this domain should include a focus on strategies by which new technologies can be tailored to individual needs, and system-level strategies to provide enabling contexts for the integrated of technologies into routine care delivery.

  • Online Physician Ratings for California Physicians on Probation

    Date Submitted: Feb 10, 2017
    Open Peer Review Period: Feb 10, 2017 - Apr 7, 2017

    Background: Online physician ratings systems are a popular tool to help patients evaluate physicians. Websites help patients find information regarding physician licensure, office hours and disciplinary records along with ratings and reviews. Whether higher patient ratings are associated with higher quality of care is unclear. Objective: We sought to characterize the impact of physician probation on consumer ratings by comparing website ratings between doctors on probation against matched controls. Methods: A retrospective review of data from the Medical Board of California for physicians placed on probation from 12/1989 to 9/2015 was performed. Violations were categorized into nine types. Non-probation controls were matched by zip code and specialty with probation cases in a 2:1 ratio using the California Department of Consumer Affairs website. Online reviews were recorded from,, and (ratings range from 1-5). Results: 410 physicians were placed on probation for 866 violations. The mean ( standard deviation) number of ratings per doctor was 5.2 7.8 for cases and 4 6.3 for controls (P=0.003). The mean rating for physicians on probation was 3.7 1.6 compared to 4.0 1.0 for controls when all 3 rating websites were pooled (P<0.001). Violations for medical documentation, incompetence, prescription negligence and fraud were found to have statistically significant lower rating scores. Conversely, scores for professionalism, drugs/alcohol, crime, sexual misconduct and personal illness were similar between cases and controls. In a univariate analysis, probation was found to be associated with lower rating, odds ratio = 1.5 (95% confidence interval 1.0 – 2.2). This association was not significant in a multivariate model when we included age and gender. Conclusions: Online physician ratings were lower for doctors on probation indicating that patients may perceive a difference. Despite these statistical findings, the absolute difference was quite small. Physician rating websites have utility but are imperfect proxies for competence. Further research on physician online ratings is warranted to understand what they measure and how they are associated with quality.

  • Cognitive impairment evaluation in adult subjects by telemedicine: a review

    Date Submitted: Feb 9, 2017
    Open Peer Review Period: Feb 10, 2017 - Apr 7, 2017

    Background: Telemedicine covers different aspects of cognitive neurosciences and neuropsychology is one of them. It allows to achieve a cognitive evaluation of adult subjects, to screen cognitive impairments, and can contributes significantly to Alzheimer’s disease diagnosis. Objective: In this work we have investigated, through a systematic analysis of the literature, which neuropsychological tests among those used for diagnosing adult-onset cognitive dysfunctions can be reliably administered applied by telemedicine approaches. Methods: A PubMed search for the 10-years period 2006–2016 was performed. Results: Mini-Mental State Examination (MMSE), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Montreal Cognitive Assessment (MoCA) 5-minute protocol, Token Test, Aural Comprehension of Words and Phrases (ACWP) and Controlled Oral Word Association Test and other tests are reliable when administered by telemedicine. No significant score differences were found compared to the face-to-face modality. However, videoconference-based assessment may require modifications in test instructions and procedures. Conclusions: Telemedicine may be properly applied to neuropsychology and several tests commonly used for dementia disorders can be easily administered at a distance with minor adaptations in their instructions and procedures.

  • Public Perceptions Regarding Use of Virtual Reality in Healthcare: A Social Media Ethnographic Analysis Using Facebook

    Date Submitted: Feb 7, 2017
    Open Peer Review Period: Feb 8, 2017 - Apr 5, 2017

    Background: Virtual reality (VR) technology provides an immersive, multisensory, and three-dimensional environment that enables users to have modified experiences of reality. VR is increasingly used to manage patients with pain, disability, obesity, neurologic dysfunction, anxiety, or depression. However, public opinion regarding use of VR in healthcare has not been explored. Understanding public attitudes, concerns, beliefs, and recommended use cases for VR is critical to ensure effective implementation and appropriate dissemination of this emerging technology. Objective: We sought to examine public opinion about healthcare VR using digital ethnography, a qualitative analysis method that allows for exploration of unfiltered views of topics discussed online. Methods: In March 2016, NBC News produced a video depicting use of VR for patient care. The video was repackaged by NowThis, a social media news website, and distributed on Facebook by Upworthy, a news aggregator, yielding 4.3 million views and 2,401 comments. We used Microsoft Power Query and ATLAS.ti software to analyze the comments using thematic analysis and categorized the comments around first-, second-, and third-order concepts. We determined self-identified gender from the user’s Facebook page and performed sentiment analysis of language to analyze whether perception of VR differed by gender using Pearson’s chi-square tests. Results: Of the 1,614 analyzable comments, 1,021 (63.26%) were attributed to female Facebook users, 572 (35.44%) to male users, and 21 (1.30%) to users of unknown gender. There were 1,197 comments coded as expressing a positive perception about VR (74.16%), 251 as a negative perception and/or concern (15.55%), and 560 as neutral (34.70%). Respondents identified 20 use cases for VR in healthcare, including for pain and stress reduction, bed-bound individuals, women during labor, and patients undergoing chemotherapy, dialysis, radiation, or imaging procedures, among others. Negative comments expressed concerns about patient safety and overdependence on technology. Respondents also expressed concerns about radiation, infection risk, motion sickness, and the ubiquity of and overall dependence on technology. There was a statistically significant association between language valence and gender of the Facebook user; men were more likely to post negative perceptions about VR use for healthcare, while women were more likely to post positive perceptions (P < 0.001). Conclusions: This study provides a blueprint for healthcare organizations and the VR community regarding where to prioritize research and implementation of VR for patient care. Most respondents to this natural experiment expressed positive perceptions about the use of VR in a wide range of healthcare settings. However, many expressed concerns that should be acknowledged and addressed as healthcare VR continues to evolve. Our results provide guidance in determining whether, when, and where to implement VR in patient care, and offer a formal opportunity for public opinion to shape the VR research agenda.

  • Effectiveness of a Web-based tailored intervention with virtual assistants promoting the acceptability of HPV-vaccination among mothers of invited girls: Randomized Controlled Trial

    Date Submitted: Feb 6, 2017
    Open Peer Review Period: Feb 6, 2017 - Apr 3, 2017

    Background: In the Netherlands, in 2010, the HPV-vaccination was introduced in the National Immunization Program (NIP) for 12-year-old girls aiming to reduce the number of cervical cancer cases. HPV-vaccination uptake remains to be lower than expected (61% compared to 70%). Mothers were shown to play the most important role in the immunization decision of these girls. They expressed a need for interactive, personal information about the HPV-vaccination over and above the existing general information. To improve the existing communication about the HPV-vaccination and increase HPV-vaccination uptake, we systematically developed a Web-based tailored intervention with virtual assistants providing mothers of girls-to-be-invited with tailored feedback on the HPV-vaccination of their daughter. Objective: The aim of the study was to evaluate in a randomized controlled trial the effectiveness of the Web-based tailored intervention with virtual assistants to promote HPV vaccination acceptance. Methods: Mothers were recruited through the Dutch individual-based vaccination register (Praeventis) (n = 36,000) and through three online panels (n = 2,483). Those who gave informed consent (n = 8,062) were randomly assigned to: (1) a control (n = 4,067) or (2) the intervention condition (n = 3,995). HPV-vaccination uptake, as registered by Praeventis once the data on the HPV-vaccination round was complete, was used as the primary outcome measure. Secondary measures were differential scores across conditions between baseline (prior to the first vaccination) and follow-up (just before or during the first vaccination) regarding the mothers’ degree of informed decision-making, decisional conflict, and critical determinants of HPV-vaccination uptake among which intention, attitude, risk perception, and outcome beliefs. Results: Intention-to-treat analysis (N = 8,062) showed a significant positive effect of the intervention on informed decision-making, decisional conflict, and on nearly all determinants of HPV-vaccination uptake (P <.001). No effect was found on HPV-vaccination uptake (P = .60). This may be attributed to the overall high uptake rates in both conditions. Mothers evaluated the intervention as positive, specified by the high subjective evaluation of both the website and the virtual assistants that were used to deliver the tailored feedback. Conclusions: This computer-tailored intervention has the potential to improve HPV-vaccination acceptability and informed decision-making and decrease decisional conflict among mothers of invited girls. Implications for future research to better understand effects on vaccination uptake are discussed. Clinical Trial: Dutch Trial Register NTR4935;

  • Computerised adaptive testing improves the reliability and efficiency of depression assessment using the CES-D scale

    Date Submitted: Feb 6, 2017
    Open Peer Review Period: Feb 6, 2017 - Apr 3, 2017

    Background: The CES-D is a commonly-used measure of depression. We assess its performance as an item bank for measuring depression using a computer adaptive testing (CAT) administration protocol. Objective: To provide evidence on the efficiency and accuracy of the CES-D when administer using CAT. Methods: We applied a battery of psychometric assessments to the legacy CES-D questionnaire. Dimensionality as assessed using confirmatory factor and Mokken analysis. Advanced psychometric properties were assessed using item response theory (IRT) including assessments of item and scale fit to the graded response model, local dependency and differential item functioning. Results: Confirmatory Factor analysis (CFA) was employed to investigate the unidimensionality of the CES-D scale. Initial CFA results indicate a poor fit to the model. Thus, Mokken analysis was employed to explore the dimensional structure of the CESD-D. Three items were eliminated to conform to a single dimension. The remaining 17 items to Samejima’s graded response model. Examination of the factor loadings revealed that all items loaded significantly on the single factor. Evaluation of local dependency resulted in no correlated residuals greater than 0.2. Significant differential item functioning was not found between age and gender groups. Estimates of the level of CES-D trait score provided by the simulated CAT algorithm and the original CES-D trait score derived from original scale were correlated highly. The CAT simulation conducted using real data found a downward trend in the length of items given to individuals, indicating higher precision at the extreme (higher) levels of the depression spectrum. Conclusions: In summary, the CES-D CAT is a precise and efficient measurement of a highly relevant psychological construct. Even in its current form, the CES-D CAT shows the immediate advantages which can be employed to measure depression that is more accurate, interpretable, and efficient than using a paper-based test.

  • Ontology-based analysis of social media data related to adolescent depression

    Date Submitted: Feb 6, 2017
    Open Peer Review Period: Feb 6, 2017 - Apr 3, 2017

    Background: Social network services (SNSs) contain abundant information about the feelings, thoughts, interests, and patterns of behavior of adolescents that can be obtained by analyzing SNS postings. An ontology that expresses the shared concepts and their relationships in a specific field could be used as a semantic framework for social media data analytics. Objective: The aims of this study were to develop an ontology and terminology as a framework for analyzing social media data on adolescent depression and to evaluate a formal description of classes and relationships in the ontology and its applicability. Methods: The domain and scope of the ontology were defined using competency questions. Concepts constituting the ontology and terminology were collected from clinical practice guidelines, the literature, and social-media postings on adolescent depression. Class concepts, their hierarchy, and relationships among class concepts were defined. An internal structure of the ontology was designed using the entity-attribute-value (EAV) triplet data model, and superclasses of the ontology were aligned with the upper ontology. Description logics of the ontology were evaluated by competency questions using description logic queries. Applicability of the ontology was validated by examining the representability of 10 sentiment phrases using the ontology data model and conducting sentiment analyses of social media data using logistic regression, decision tree, and association rules. Results: The ontology consisted of five top-level classes with 438 subordinate classes arranged into three or four levels of hierarchy. In total, 443 classes with 1,682 synonyms had 19 different types of property relationships. All of the answers that were inferred from the ontology according to the queries were found to be correct. Regarding applicability, it was possible to represent the 10 sentiment phrases using the EAV triplet of the ontology class concepts. It was also found that ‘academic stresses’ and ‘suicide’ contributed negatively to the sentiment of adolescent depression. Conclusions: The ontology and terminology developed in this study provide a semantic foundation for analyzing social media data on adolescent depression. To be useful in social media data analysis, the ontology, especially the terminology, needs to be updated constantly to reflect rapidly changing terms used by adolescents in social media postings.

  • The use of Facebook in recruiting participants for research purposes – a systematic review

    Date Submitted: Feb 4, 2017
    Open Peer Review Period: Feb 4, 2017 - Apr 1, 2017

    Background: Social media is a popular online tool that allows users to communicate and exchange information. It allows digital content such as pictures, videos and websites to be shared, discussed, republished and endorsed by its users, their friends and businesses. Recruiting for research purposes is complex with strict requirement criteria imposed on the participants. Traditional research recruitment relies on flyers, newspaper adverts, radio and television broadcasts, letters, emails, website listings, and word of mouth. These methods are potentially poor at recruiting hard to reach demographics, can be slow and expensive. Recruitment via social media, in particular Facebook, may be faster and cheaper. Objective: Objective: To systematically review the literature regarding the current use and success of Facebook to recruit participants for research purposes. Methods: Method: A literature review was completed in November 2015 in the English language using Medline, Embase, Web of Science, PubMed, PsycInfo, Google Scholar and a hand search of article references. Papers from the past 10 years were included and number of participants, recruitment period, number of impressions, cost per click/participant and conversion rate extracted. Results: Results: Twenty-four studies were identified and appraised using the CASP checklist from the USA (n=15), Australia (n=6) Canada (n=1), Japan (n=1) and Germany (n=1). All focused on the feasibility of recruitment via Facebook with some also testing interventions such as smoking cessation and depression reduction. Most recruited young age groups (16-24 years) with the remaining targeting specific demographics, for example military veterans. All available information from the 24 studies was analyses with median data showing 254 recruited participants, a 3-month recruitment period, 4.8 million impressions, cost per click of $0.48, conversion rate of 4.4%, eligibility of 69.5% and cost per participant of $9.82. The studies showed success in penetrating hard to reach populations and found the results representative of their control or comparison demographic except for an over representation of young white women. Conclusions: Conclusion: There is growing evidence to suggest that Facebook is a useful recruitment tool and its use, therefore, should be considered when implementing future research. Benefits include; reduced costs, shorter recruitment periods, better representation and improved participant selection in young and hard to reach demographics. It remains limited by internet access and the over representation of young white women. Future studies should recruit across all ages and explore recruitment via other forms of social media.

  • Access to electronic personal health records: The case of patients with multiple chronic conditions

    Date Submitted: Feb 1, 2017
    Open Peer Review Period: Feb 2, 2017 - Mar 30, 2017

    Background: National incentives for offering access to electronic personal health records (ePHRs) through electronic means are geared toward creating a culture of patient engagement. One group of patients who stand to benefit from online access to ePHRs is the growing population with multiple chronic conditions (MCC). Little is known, however, about the current availability and use of ePHRs and patient portals among those managing MCC. Objective: To determine the associations between number of chronic conditions and sociodemographic characteristics, and usage of ePHRs; and to assess how the public’s use of ePHRs varies across subpopulations, including those with MCC. Methods: Using data collected in 2014 from the Health Information National Trends Survey (HINTS), we assessed differences in use of ePHRs between those with and without MCC (total n = 3497) using multiple logistic regression techniques. We included variables associated with healthcare systems (insurance status, having a regular provider) and patient-reported self-efficacy in our models. Results: While those with MCC had significantly higher odds of accessing their records three or more times in the past year compared to those reporting no chronic conditions (OR = 2.46, 95% CI = 1.37 to 4.45); the overall percentage of those with MCC using ePHRs remained low (25.6%). Conclusions: We conclude that ePHRs provide a unique opportunity to enhance MCC patient self-management, but additional effort is needed to ensure that these patients are able to access their ePHRs. An increase in availability of patient access to their ePHRs may provide an opportunity to increase patient engagement and support self-management for all patients but especially those with MCC. Clinical Trial: Not applicable.

  • Is there Evidence of Cost and Benefits on Electronic Medical Records, Standards and Interoperability in Hospital Information Systems? An Overview of Systematic Reviews

    Date Submitted: Jan 24, 2017
    Open Peer Review Period: Jan 25, 2017 - Mar 22, 2017

    Background: eHealth interventions may improve the quality of care by providing timely, accessible information about one patient or an entire population. Electronic patient care information forms the nucleus of computerized health information systems. However, data exchange among systems depends on the adoption of information standards. Additionally, investing in technology systems requires cost-effectiveness studies to ensure the sustainability of processes for stakeholders. Objective: To assess cost effectiveness in the use of electronically available inpatient data systems, information exchange, and standards to support interoperability among systems. Methods: An overview of systematic reviews was conducted, assessing the Medline, Cochrane Library, Lilacs and IEEE Library databases to identify relevant studies published through February 22nd 2016. The search was supplemented by citations from the selected articles. The direct outcome sought was cost effectiveness, and the indirect outcome was the impact on quality of care. Independent reviewers selected studies, and disagreement was resolved by consensus. The quality of the included studies was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR). Results: The primary search identified 286 papers, and two were manually included. Two hundred eleven were systematic reviews. From the 20 studies that were selected after screening the title and abstract, 14 were deemed ineligible, and six accepted to the reviewing process. The interventions did not show a direct, measurable effect on cost effectiveness. Despite the limited number of studies, the heterogeneity of electronic systems reported, and types of intervention on hospital routines, it was possible to identify some preliminary, indirect benefits on quality of care. Hospital information systems, along with information sharing, had the potential to improve clinical practice by reducing staff errors or incidents, improving automated harm detection, monitoring infection more effectively, and enhancing the continuity of care during physician handoffs. Conclusions: This review identified some indirect benefits on the quality of care but did not provide evidence that the implementation of eHealth interventions had a measurable impact on cost effectiveness or patient outcomes in hospital settings. However, further evidence is needed to infer the impact of interoperability on costs or benefits of health care; that requires further research.

  • Mental health mobile apps for children and young people: A systematic review and synthesis

    Date Submitted: Jan 23, 2017
    Open Peer Review Period: Jan 23, 2017 - Mar 20, 2017

    Background: There are an increasing number of mobile applications (apps) available for children and young people (CYP) with mental health problems and an increasing interest in assimilating mHealth into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear. Objective: This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in CYP under the age of 18. Methods: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform – Children, Embase, Google Scholar, Pubmed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking and OpenGrey were systematically searched for relevant publications between January 2008 and July 2016. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self – harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis and insomnia) for mobile devices and for use by children and young people under the age of 18 years. Results: Thirty-two publications met the inclusion criteria. These described 19 apps, 3 of which were available to download. Two small randomised controlled trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Reviews which analysed the content of seven apps for CYP that are available to download established that none have undergone any research evaluation. Feasibility outcomes suggest acceptability of apps is good and app usage is moderate. Conclusions: Overall there is currently insufficient research evidence to support the effectiveness of apps for children and young people with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy and effectiveness is promptly needed.

  • Development and Testing of an Intelligent Pain Management System (IPMS) on smart phone by a Randomized Trial among Chinese Cancer Patients: a New Approach in Cancer Pain Management

    Date Submitted: Jan 18, 2017
    Open Peer Review Period: Jan 19, 2017 - Mar 16, 2017

    Background: Cancer has become increasingly prevalent in China over the past few decades. Among symptoms related to the quality of life of cancer patients, pain has commonly been recognized as a most critical one that may also result in ineffective treatment of cancer. More than one-third of cancer patients in China have experienced cancer pain. Driven by the need for better pain management for cancer patients, our research team developed a mobile-based Intelligent Pain Management System (IPMS) in the hope of providing a low-cost approach to prompt pain response and effective care for cancer patients. Objective: Our objective was to design, develop, and test the IPMS to facilitate real-time pain recording and timely intervention among cancer patients with pain. The system’s usability, feasibility, compliance, and satisfaction were also assessed. Methods: A sample of 46 patients with cancer pain symptoms were recruited at the Oncology Center of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Chongming Branch (hereinafter referred to as “the Oncology Center”). In a pre-test, participants completed a pain management knowledge questionnaire and were evaluated with the baseline cancer pain assessment and Karnofsky Performance Status (KPS) evaluation. The participants were then randomly assigned into two groups (the trial group and the control group). After a 14 days’ trial period, another round of cancer pain assessment was conducted. In the trial group, the data was fully automated collected by the IPMS. In the control group, the data was collected using conventional methods, such as phone interviews or door-to-door visits by physician. The pain management knowledge questionnaire and KPS evaluation were repeated in both groups at the end of the trial. The participants were also asked to complete a satisfaction questionnaire on the use of the IPMS. Results: All participants completed the trial successfully. The primary end point was to assess the feasibility of IPMS by observing the number of daily pain assessments recorded among patients. The usage of IPMS was very favorable with a mean of 2.37±0.53 pain assessment times per day. The secondary end point was to evaluate the users’ satisfaction, effectiveness of pain management and changes in the quality of their lives. All the participants gave high satisfaction score after they used IMPS. Both groups (IMPS=25 vs control=21) reported similar pain scores (3.28±0.68 of the trial group vs. 2.90±0.62 of the control group, P = 0.06) as well as the KPS scores (50.80±7.02 of the trial group vs. 50.95±7.40 of the control group, P = 0.94) at the baseline. During the trial period, the mean pain score of the trial group was 2.53±0.42, compared to a significantly higher score 2.81±0.47 of the control group (P < 0.001). At the end of the trial, the mean pain score of the trial group was 2.20±0.50, compared to a significantly higher score 2.95±0.59 of control group (P < 0.001). The ending KPS score was significantly higher of the trial group than of the control group (68.80±7.23 vs. 56.2±7.40, P < 0.001). As to the pain management knowledge score, there was a 2.96±0.61 increase in the trial group, compared to a 0.81±0.67 increase (P < 0.001) in the control group after using the IPMS for 14 days. At the same time, all the participants gave high satisfaction score after they used IMPS. Conclusions: The result demonstrated that IPMS was a feasible, effective, and low cost pain management tool for cancer patients. This study provided preliminary data to support the potentials of using IPMS in cancer pain communication between patients and doctors, and to provide real-time supportive intervention at a convenient basis in a low cost. Overall, the IPMS can serve as a reliable and effective approach to the control of cancer pain and improved quality of life for patients with cancer pain. Clinical Trial: Name: Intelligent Pain Management System for Assessing Pain in Cancer Patients Registration number: NCT02765269 URL:

  • A Web-Based Tailored Intervention to Support Illness Management in Patients Hospitalized for an Acute Coronary Syndrome: A Pilot Study

    Date Submitted: Jan 17, 2017
    Open Peer Review Period: Jan 18, 2017 - Mar 15, 2017

    Background: Illness management after an acute coronary syndrome (ACS) is crucial to prevent cardiac complications, foster participation in a cardiac rehabilitation program and optimize recovery. Web-based tailored interventions have the potential to provide individualized information and counselling to optimize patient’s illness management after hospital discharge. Objective: The primary objective of this pilot study was to develop and assess the feasibility, acceptability and preliminary effect of a Web-based tailored intervention (TAVIE@COEUR) designed to improve illness management related to self-care, medication adherence, anxiety management and cardiac risk factors reduction in patients hospitalized for an ACS. Methods: This pre-post pilot study was conducted with one group (N=30) of patients hospitalized for an ACS on the coronary care unit of a tertiary cardiology center. TAVIE@COEUR consists of three Web-based sessions with a duration ranging from 10 to 45 minutes and is structured around an algorithm to allow the tailoring of the intervention to different pathways according to patients’ responses to questions. TAVIE@COEUR includes 90 pages, 85 videos and 47 PDF documents divided across session 1 (S1), session 2 (S2) and session 3 (S3). These sessions concern self-care and self-observation skills related to medication-taking (S1), emotional control and problem-solving skills (S2) and social skills and interacting with health professionals (S3). Patients completed S1 before hospital discharge, and were asked to complete S2 and S3 within two weeks after discharge. Feasibility indicators were extracted from the TAVIE@COEUR Web-based platform. Data regarding acceptability and preliminary effect were assessed through telephone questionnaires at baseline and one month following discharge. Results: Twenty out of 30 participants (67%) completed S1, 10 (33%) completed S2 and 5 (17%) completed S3. High acceptability scores were observed for ease of navigation (mean 3.58, Standard Deviation [SD] 0.70; scale 0–4), ease of understanding (mean 3.46, SD 0.63; scale 0–4) and applicability (mean 3.55, SD 0.74; scale 0–4). The lowest acceptability scores were observed for information tailoring (mean 2.93, SD 0.68; scale 0–4) and individual relevance (mean 2.56, SD 0.96; scale 0–4). With regard to preliminary effect, we observed an overall self-care at 1 month following discharge score higher than at baseline (mean at one month: 54.07, SD 3.99 vs mean at baseline: 49.09, SD 6.92; scale 0–60). Conclusions: Although participants reported general satisfaction and appreciation of TAVIE@COEUR, feasibility results show the need for further development of the Web-based intervention to enhance its’ tailoring before undertaking a full-fledged randomized controlled trial. This may be accomplished by optimizing the adaptability of TAVIE@COEUR to patients’ knowledge, needs, interests, individual capabilities and emotional and cognitive responses during session completion.

  • Online smoking cessation interventions in the Netherlands: effects, cost-effectiveness, and theoretical underpinnings

    Date Submitted: Jan 13, 2017
    Open Peer Review Period: Jan 17, 2017 - Mar 14, 2017

    Background: Tobacco smoking is a worldwide public health problem. In 2015, 26.3% of the Dutch population of 18 years and older smoked, which of 74.4% were daily smoker. More and more people have access to the internet worldwide, with about 94% of the Dutch population having online access. Internet-based smoking cessation interventions (online cessation interventions) have opportunities to tackle the scourge of tobacco. Objective: The goal of this paper was to provide an overview of online cessation interventions in the Netherlands, while exploring its effectivity, cost-effectiveness, and theoretical underpinnings. Methods: A mixed-method approach was used to identify Dutch online cessation interventions, using: (1) scientific literature search; (2) grey literature search; (3) and Expert input. In search for Dutch interventions, two independent researchers screened titles, abstracts, and then full-text in scientific literature, and titles and first page of the grey literature. Including expert input, this resulted in six interventions identified in the scientific literature and 39 interventions via the grey literature. Extracted data included: effectiveness, cost-effectiveness, theoretical factors and behavior change techniques used. Results: Overall, many interventions were offered without providing data on the effectiveness, except six interventions that were included in trials. Four of them were shown to be effective and cost-effective. The most important theoretical techniques used were: changing attitudes, providing social support, increasing self-efficacy, motivating smokers to make concrete action plans to prepare quit attempts and to cope with challenges, supporting identity change, rewarding abstinence, advising on changing routines, advising on coping, and advising on medication use. Conclusions: While the internet may provide the opportunity to offer various smoking cessation programs, the user is left in bewilderment concerning its efficacy, as most of these data are not available nor offered to the smokers. If the internet wants to live up its promising perspective, clear regulations need to be made concerning the effectiveness of these interventions, in order to avoid disappointment and useless quit attempts. Policy regulations are thus clearly needed in order to regulate the outburst of these interventions and to foster quality.

  • Social media use and access to digital technology in U.S. young adults, 2016

    Date Submitted: Jan 11, 2017
    Open Peer Review Period: Jan 17, 2017 - Mar 14, 2017

    Background: In 2015, 90% of U.S. young adults with internet access used social media. Digital and social media are highly prevalent modalities through which young adults explore identity formation, and by extension, learn and transmit norms about health and risk behaviors during this developmental life stage. Objective: The purpose of this study was to provide updated estimates of social media use from 2014 to 2016 and correlates of social media use and access to digital technology in data collected from a national sample of U.S. young adults in 2016. Methods: Young adult participants aged 18-24 years in Wave 7 (October 2014; N = 1,259) and Wave 9 (February 2016; N = 989) of the Truth Initiative Young Adult Cohort Study were asked about use frequency for eleven social media sites and access to digital devices, in addition to sociodemographic characteristics. Regular use was defined as using a given social media site at least weekly. Weighted analyses estimated the prevalence of use of each social media site, overlap between regular use of specific sites and correlates of using a greater number of social media sites regularly. Bivariate analyses identified sociodemographic correlates of access to specific digital devices. Results: In 2014, 89.42% (weighted n, 1126/1298) reported regular use of at least one social media site. This increased to 97.5% (weighted n, 965/989) of young adults in 2016. Among regular users of social media sites in 2016, the top five sites were Tumblr (85.5%), Vine (84.7%), Snapchat (81.7%), Instagram (80.7%), and LinkedIn (78.9%). Respondents reported regularly using an average of 7.6 social media sites, with 85% using 6 or more sites regularly. Overall, 87% of young adults reported access or use of a smartphone with internet access, 74% a desktop or laptop computer with internet access, 41% a tablet with internet access, 29% a smart TV or video game console with internet access, 11% a cell phone without internet access, and 3% none of these. Access to all digital devices with internet was lower in those reporting a lower subjective financial situation; there were also significant differences in access to specific digital devices with internet by race/ethnicity and education. Conclusions: The high mean number of social media sites used regularly and the substantial overlap in use of multiple social media sites reflect the rapidly changing social media environment. Mobile devices are a primary channel for social media and our study highlights disparities in access to digital technologies with internet access among U.S. young adults by race/ethnicity, education, and subjective financial status. Findings from the current study may guide the development and implementation of future health interventions for young adults delivered via the internet or social media sites.

  • Assess suicide risk and emotional distress in Chinese social media by natural language use

    Date Submitted: Jan 9, 2017
    Open Peer Review Period: Jan 13, 2017 - Mar 10, 2017

    Background: The mainstream assessment of individuals’ suicide risk or emotional distress relies on self-report scales or clinical assessments. Such assessment relies on individuals’ willingness and ability to seek help/treatment, which is often challenging for distressed or suicidal people. Objective: The present study explores how natural language can be utilized to proactively assess one’s suicide risk and emotional distress in Chinese social media. Methods: An online survey was conducted on Sina Weibo to assess the respondents’ suicide risk and emotional distress. With the respondents’ consent, we also downloaded all of their Weibo posts which were posted in the public domain during the 12 months prior to the survey by calling the Weibo API. Weibo posts were tokenized and language features were extracted by applying Simplified Chinese Linguistic Inquiry and Word Count (SC-LIWC). Logistic regression analysis were operated to examine the relationship between use of SC-LIWC categories and the respondents’ suicide risk with emotional distress. Support Vector Machines were trained to automatically classify whether a respondent was showing suicide risk or emotional distress. ROC curve analysis was operated for examining the diagnostic accuracy of the machine classifiers. Results: Weibo users with high suicide risk were marked by a higher usage of pronoun, prepend words, and multifunction words, a lower usage of verb, and a greater total word count. Severe depression was marked by more use of second-person plural and achievement-related words, but less use of work-related words. Anxiety was also marked by less use of work-related words. Stress was marked by more use of third-person and second-person plural, health-related words, and death-related word. and stress were marked by more use of second-person plural, and less use of work-related words. The machine classification on suicide risk and depression achieved satisfying results after adding a filter of Weibo suicide communication. However, the classification results for severe depression and stress were still not significant. Conclusions: The study demonstrates the utility of natural language as alternative assessment tool of suicide risk and emotional distress in Chinese social media. The current development can improve assessment coverage and efficiency but still requires experts’ inputs to increase accuracy. Clinical Trial: N/A

  • Critical Appraisal of E-Health Intervention for Anxiety Management in Youths

    Date Submitted: Jan 3, 2017
    Open Peer Review Period: Jan 11, 2017 - Mar 8, 2017

    Background: Advances in technology are progressively more relevant to the clinical practice of psychology and mental health services generally. Studies indicate that technology facilitates the delivery of interventions, such as Cognitive Behavioral Therapy (CBT), in the treatment of a number of psychological disorders in adults, including depression, anxiety, obsessive–compulsive disorder, panic symptoms, and eating disorders. Fewer data exist for computer-based (stand-alone; self-help) and computer-assisted (in combination with face-to-face therapy; therapist guided) programs in youths. Objective: This article summarizes and critically reviews the literature evaluating the acceptability and efficacy of using technology with treatment and prevention programs for anxiety in young children and adolescents. The aim is to improve the understanding of what would be critical for future development of effective technology-based interventions. Methods: A systematic literature search was conducted in three scientific electronic databases (including PsycINFO, Science Direct and PubMed). Keywords with various combinations were used: child/children, adolescent, pre-school children, anxiety, intervention or treatment or program, smartphone applications or apps, online or web-based tool, computer-based tool, serious games, cognitive behavioral therapy (CBT), biofeedback. Results: Available studies demonstrate promising results in reducing anxiety, especially relative to the application of CBT with technology. For those programs demonstrating efficacy, no difference was noted when compared with traditional intervention. Other approaches have been applied to technology-based interventions with inconclusive results. The majority of existing programs are developed to be used concurrently with traditional treatments and lack long term evaluation. Very little has been done in terms of prevention interventions. Conclusions: Future development of e-Health programs for the management of anxiety in children will have to address several unmet needs and overcome key challenges: although developmental stages may limit the applicability to preschool children, prevention should start in early ages; self-help format and personalization are highly relevant for large-scale dissemination; automated data collection should be built in for program evaluation and effectiveness assessment; a strategy to stimulate motivation to play and maintain high adherence should be carefully considered.

  • Towards understanding pain-monitoring electronic technologies for adults: a Systematic Literature Review

    Date Submitted: Jan 6, 2017
    Open Peer Review Period: Jan 9, 2017 - Mar 6, 2017

    Background: Remote monitoring of patients may decrease treatment costs and improve quality of care. Pain is the most common health problem that people seek help for in hospitals. Therefore, remote monitoring of patients with pain may have significant impact in improving treatment. Several studies have studied factors affecting pain, however, no previous study has characterized a patient’s situation through all the relevant contextual information that a monitoring system may capture. Objective: The objective of this study was to conduct a systematic review to (1) determine what types of technologies have been used to monitor adult patients with pain, and (2) construct a model of the context information relevant to pain monitoring that may be used to implement applications and devices aimed at monitoring patients with pain. Methods: A literature search (2005-2015) was conducted in electronic databases pertaining to medical and computer science literature (PubMed, Science Direct, ACM Digital Library, and IEEE Xplore), using a defined search string. Article selection was done through a process of removing duplicates, analyzing title and abstract, and then reviewing the full text of the article. Results: 87 articles were included in the final analysis and 53 of them (61%) used technologies to collect contextual information. 49 types of context information were found and a five-dimension model of context information to monitor patients was proposed, expanding a previous model. Most technological interfaces for pain monitoring are wearable, possibly because they can be used in more realistic contexts. Few studies focus on older adults, creating a relevant avenue of research on how to create devices for users that may have impaired cognitive skills or low digital literacy. Conclusions: The design of remote monitoring devices and interfaces for patients with pain must deal with the challenge of selecting relevant contextual information to understand the user’s situation, and not overburdening or inconveniencing users with information requests. A complete model of contextual information that a device can capture may be used by designers to review possible contextual information and choose which is relevant for a particular device.

  • A health professional-led synchronous discussion in Facebook can provide personalized information and support but does not generate a peer-support network.

    Date Submitted: Jan 3, 2017
    Open Peer Review Period: Jan 6, 2017 - Mar 3, 2017

    Background: Arthritis is a major cause of pain and disability. Arthritis New Zealand is a non-government organization that provides advocacy, information, and advice and support services for people with arthritis in New Zealand. Since many people seek health information online Arthritis New Zealand has a webpage and a Facebook page. In addition to static content, Arthritis New Zealand provides synchronous discussions with an Arthritis Educator (AE) each week via Facebook. Objective: To determine how synchronous discussion with a health educator on a social media platform may provide information and support to people with arthritis and if such activity on social media can provide useful insights into consumers’ health care needs. Methods: Interpretive multi-methods were used. Facebook Analytics were used to describe the users of the Arthritis NZ Facebook page and provide descriptive summary statistics. Gephi and manual graphic analysis were used to summarise activity during a convenience sample of ten AE-led synchronous discussions. Principles of thematic analysis were employed to interpret transcripts of all comments from these ten weekly AE-led discussions. Results: Users of the Arthritis NZ Facebook page were predominately female (81%), aged 18-54 years. Three major activities occurred during AE-led synchronous discussions: (1) seeking or giving support; (2) information enquiry; and (3) information sharing across a broad range of topic areas, largely relating to symptoms and maintaining physical functioning. There was limited peer-to-peer interaction, with most threads consisting of two-comment exchanges between users and the AEs. Conclusions: The AE-led discussions provided a forum for informational and emotional support for users. The facilitated discussion forum for people with arthritis on Facebook could be enhanced by encouraging increased user participation and increasing peer-to-peer interactions, and further training of AEs in facilitation of online discussion. Future research should focus on addressing barriers to user participation and assessing the impact of AE facilitation training, with the latter leveraging the Action Research paradigm.

  • The Impact of Crowdfunding on Knowledge of Science and Rare Genet-ic Diseases Research

    Date Submitted: Dec 24, 2016
    Open Peer Review Period: Jan 2, 2017 - Feb 27, 2017

    Background: Although the cost to sequence a genome has been substantially reduced, it is still unaffordable for many patients because it is rarely covered by health insurance. Financial strain is all too familiar to many Americans today. Nearly half of respondents to a 2011 poll from the National Bureau of Economic Research stated that if they were given a 30-day timeframe, they would be unable to produce an extra $2,000. Beyond overtaxed household budgets, families dealing with undiagnosed or rare diseases incur countless unexpected healthcare costs that create tremendous financial burdens. These families shoulder these staggering health care expenses accumulated over years of seeking treatment. Crowdfunding may help support patients in need of DNA sequencing by providing access to a test that might uncover the cause of their disease and potentially lead to viable clinical treatment. Objective: The goal of Amplify Hope was to test the effectiveness of strategies for raising the necessary funding for trio exome sequencing through crowdfunding campaigns. More generally, we sought to understand the strategies that are the most successful for crowdfunding campaigns for medical expenses. Methods: Our research sought to 1) provide demographic information on the donor population; 2) identify common factors among successful medical crowdfunding campaigns; 3) identify factors that influenced people to donate, as reported by donors; and 4) describe the im-pact crowdfunding campaigns had on donors’ knowledge of genomics. We conducted the study in several phases, including a needs assessment, participant recruitment, a 30-day crowdfunding training period, a 30-day online crowdfunding period, and follow-up surveys given to participants and donors. Results: We found that social media played an important role in all campaigns. Specifically, a strong social media network, an active outreach process, and a high degree of comfort with networking all correlated with a higher success rate. Amplify Hope donors were more likely to support projects that were near their fundraising goals, and found video far more effective for learning about genomics than any other medium. Conclusions: The campaigns that achieved complete funding during the 30-day online crowdfunding campaign study period shared several characteristics. Individual campaign organizers who reached their campaign goals engaged more during the training program prior to the start of the crowdfunding campaign, as compared to those that did not achieve their campaign goals. These organizers read our shared Amplify Hope study materials, followed recommended guidelines, and perhaps most importantly initiated communication via phone calls and emails to their networks prior to the campaign launch. In other words, the successful campaigners frontloaded their campaigns. They also actively engaged their network and donors by providing updates throughout the campaigns rather than trailing off.