Open Peer-Review: Randomized controlled trial of web-based mindfulness training for mental health promotion: Enhancements with the Health Action Process Approach, and other submissions


 

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review


Randomized controlled trial of web-based mindfulness training for mental health promotion: Enhancements with the Health Action Process Approach

Background: With increasing evidence demonstrating the effectiveness of web-based interventions and mindfulness-based training in improving health, delivering mindfulness training online is an attractive proposition. Objective: This study evaluated the efficacy of two internet-based interventions (basic mindfulness and Health Action Process Approach (HAPA)-enhanced mindfulness) with waitlist control. HAPA principles were used to enhance participants’ efficacy and planning. Methods: Participants were recruited online and offline among local universities. Three hundred and twenty-one university students and staff were randomly assigned to three conditions. The basic and HAPA-enhanced groups completed the 8-week fully automated mindfulness training online. All participants (including control) were asked to complete an online questionnaire pre-program, post-program, and at 3-month follow-up. Results: Significant group by time interaction effect was found. The HAPA-enhanced group showed significantly higher levels of mindfulness from pre- to post-, and such improvement was sustained at follow-up. Both the basic and HAPA-enhanced mindfulness groups showed better mental well-being from pre- to post-, and improvement was sustained at 3-month follow-up. Conclusions: Online mindfulness training can improve mental health. Online platform is a viable medium to implement and disseminate evidence-based interventions and is a highly scalable approach to reach the general public. Clinical Trial: Chinese Clinical Trial Registry (ChiCTR) ChiCTR-TRC-12002954
 
Date Submitted: Aug 1, 2014
Open Peer Review Period: Aug 1, 2014 - Sep 26, 2014
 
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Preferences for a mobile HIV prevention application for men who have sex with men

Background: The CDC recommends that sexually active men who have sex with men (MSM) in the United States test for HIV at least three times per year, but actual testing frequency is much less. Though mHealth is a popular vehicle for delivering HIV interventions, there are currently no smartphone apps that target MSM with the specific aim to build an HIV testing plan, and none that focuses on developing a comprehensive prevention plan and link MSM to additional HIV prevention and treatment resources. Previous research has suggested a need for more iterative feedback from the target population to ensure utilization of these interventions. Objective: The purpose of this study is to understand MSM’s preferences for functionality, format, and design of a smartphone-based HIV prevention app and to examine MSM’s willingness to use an app for HIV prevention. Methods: We conducted focus group discussions (FGDs) with 38 gay and bisexual men, with two in-person groups in Atlanta, two in Seattle, and one online FGD with gay men in rural U.S. regions. FGDs addressed MSM’s general preferences for apps, HIV testing barriers and facilitators for MSM, and ways in which an HIV prevention app could address these barriers and facilitators to increase the frequency of HIV testing and prevention among MSM. During FGDs, participants were shown screenshots and provided feedback on potential app functions. Results: Participants provided preferences on functionality of the app, including: the type and delivery of educational content, the value of interactive engagement, and the importance of social networking as an app component. Participants also discussed preferences in how the language should be framed for the delivery of information, identifying that an app needs to be simultaneously fun and professional. Privacy and altruistic motivation were considered to be important factors in men’s willingness to use a mobile HIV prevention app. Finally, men described the potential impact that a mobile HIV prevention app could have, identifying individual, interpersonal, and community-based benefits. Conclusions: In summary, participants described a comprehensive app that should incorporate innovative ideas to educate and engage men so that they would be motivated to use the app. In order for an app to be useful, it needs to feel safe and trustworthy, which is essential when considering the app’s language and privacy. Participants provided a range of preferences for using an HIV prevention app, including what they felt MSM need with regards to HIV prevention and what they felt want in order to engage with an app. Making an HIV prevention app enjoyable and useable for MSM is a difficult challenge; however, the usability of the app is vital because no matter how great the intervention, if MSM do not utilize the app, then it would not be useful.
 
Date Submitted: Jul 31, 2014
Open Peer Review Period: Aug 1, 2014 - Sep 26, 2014
 
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Top-down or bottom-up? Building information systems for healthcare

In this study we compare a large scale top-down project with a small scale bottom-up project within Norwegian healthcare. Both projects aimed to establish inter-organizational services with integration to the installed bases in the involved organizations. The aim of the paper is to explore how inter-organizational information system projects can be organized and run. In particular the paper discusses bottom-up and top-down approaches to project organization and development models including conditions for user participation. The paper concludes by outlining a possible middle position on organization and development: an approach resembling networked governance.
 
Date Submitted: Aug 1, 2014
Open Peer Review Period: Aug 1, 2014 - Sep 26, 2014
 
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Quality of Websites of Obstetrics and Gynecology Departments: Cross-sectional Study

Background: The internet has become an easily accessible and widely used source of healthcare information. There are, however, no standardized or commonly accepted criteria for the quality of Obstetrics and Gynecology websites. Objective: To evaluate the quality of websites of Obstetrics and Gynecology departments and to compare websites nationally and internationally. Methods: We scored 672 websites from Germany (n=566), Austria (n=57), and Switzerland (n=49) using the objective criteria: Google presentation (2 items), technical aspects (11 items), navigation (8 items), and content (6 items) for a 26 point score. Scores were compared nationally and internationally. A multivariable regression model assessed good quality score (≥50% of maximum) as the dependent variable and country, Google presentation, technical aspect, navigation and content scores as independent variables. Results: The mean score of websites was 13.8±3.3. 4.2% were rated as excellent (≥75% of maximum), 61.8% as fair (≥50% of maximum). German (14.0±3.2) and Swiss (13.8±4.0) websites scored significantly higher compared to Austrian websites (11.6±2.5) (P<.001 and P=.005, respectively). Academic had higher scores than non-academic departments (14.9±3.2 vs. 13.7±3.1, P<.001). Single institutions had higher scores compared to healthcare consortium institutions (14.1±3.2 vs. 13.2±2.6, P=.003). Departments in Northern and Southern states had higher scores compared to Eastern states (14.4±3.2 and 14.2±3.2 vs. 13.0±3.0, P<.001). In a multivariable logistic regression model, Google presentation, technical aspects, navigation, and content (all: P<.001) independently predicted a website’s reaching a good quality score. Conclusions: The quality of websites of Obstetrics and Gynecology departments varies widely. We found marked differences depending on country, affiliation, and region.
 
Date Submitted: Aug 1, 2014
Open Peer Review Period: Aug 1, 2014 - Sep 26, 2014
 
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Determinants of the attitude to the introduction of ehealth services among patients suffering from chronic conditions

Background: Provision of care to patients with chronic diseases remains a great challenge for modern health care systems. Ehealth is indicated as one of the strategies which could improve care delivery to this group of patients. National policies targeting the development of information systems in health care in Poland assume the involvement of patients and citizens. Objective: The main objective of this study was to assess determinants of the acceptance of the use of ehealth solutions remaining in scope of current nationwide initiatives in Poland. Methods: The survey was carried out among patients with diagnosed chronic conditions who were hospitalized or attended ambulatory visits at three health care facilities in Krakow, Poland. Survey data was used to develop univariate and multivariate logistic regression models for six outcome variables originating from the items assessing the acceptance of types of ehealth applications. The variables used as predictors were related to the sociodemographic characteristics of respondents, burden related to chronic disease, and the use of the Internet and its perceived usefulness in making personal health-related decisions. Results: Among 395 respondents, there were 60.3% of Internet users. The respondents revealed the highest acceptance of the use of the Internet for making appointments to see physicians (77.4%) and accessing education resources for patients (66.9%). The lowest acceptance was seen in the use of ehealth applications for consulting physicians (51.6%). Univariate logistic regression models developed for six types of ehealth solutions demonstrated their higher acceptance among younger respondents living in urban areas who have attained a higher level of education, used the Internet on their own, and were more confident about its usefulness in making health-related decisions. Furthermore, the duration of chronic disease and hospitalization due to chronic disease predicted the acceptance of some of ehealth applications. However, when combined in multivariate models, only the belief in the usefulness of the Internet (five of six models), level of education (four of six models), and previous hospitalization due to chronic disease (three of six models) maintained the effect on the independent variables. The duration of chronic disease was a predictor for two independent variables and the use of the Internet for just one. Conclusions: The perception of the usefulness of the Internet in making health-related decision is a key determinant of the acceptance of ehealth applications among patients with chronic diseases. Among sociodemographic factors, only the level of education demonstrates a consistent impact on the level of acceptance. Interestingly, a greater burden of chronic disease related to previous hospitalizations leads to lower acceptance of ehealth solutions. The results of the survey tend to indicate that patients with a greater burden related to long-term medical conditions show lower trust in electronic delivery of services. The use of the Internet is not sufficient in itself to predict the acceptance of ehealth and the attitude toward its usefulness in health contexts exerts a prevailing effect.
 
Date Submitted: Aug 1, 2014
Open Peer Review Period: Aug 1, 2014 - Aug 9, 2014
 
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Need of Information via Online Consultations According to Characteristics of Visitors Facing Breast Cancer: A Qualitative Study

Background: Online health consultations serve as an alternative source of information for breast cancer patients and a valuable tool in assisting breast cancer patients with managing their physical and psychosocial needs and communicating those needs to physicians. Objective: Our goal was to investigate the information needs of the visitors to a website by analyzing the questions they asked the breast cancer specialists in the website interactive section “Ask the Physician” and defined the characteristics of the information sought by visitors according to cancer treatment phase and degree of identification. l needs and communicating those needs to physicians. Methods: Via an online health consultation question-and-answer board, breast cancer patients posted 1117 requests between 2009 and 2014. The transcribed data were coded and linked into ICF categories and information categories using the NVivo 9 data management software. Treatments were categorized into three phases: initial diagnosis, treatment, and post-treatment. The degree of identification provided by visitors was categorized into anonymous or nick name, real name, and real name with hospital ID. Descriptive statistics were used to characterize the sample and data. Results: Our results showed that of the users, 36.5% used a nick name or were anonymous, 43.1% used their real names, 12.1% were caregivers and 8.3% used real names and hospital IDs. All requests were translated into 81 meaningful categories, which were linked to 64 ICF categories and 17 additional categories that were related to information regarding diagnosis, treatment, and hospital processes. Most questions concerned specific information on breast cancer and breast cancer disease course posed by users with nick names. The most common categories were breast cancer and breast cancer disease course asked by users with nick names (21%), second opinions about cancer treatment by caregiver (16%), symptoms or dysfunction after treatment by users with real names and IDs (27%) who received recommendations to specific departments or were connected to the reservation process at the hospital. The most common categories were for information of diagnosis (14.4%), emotional function (16.5%), and pain and physical function (15.4%) at the initial diagnosis, during treatment, and after treatment, respectively. Conclusions: Breast cancer patients and their caregivers asked variable questions, from exact information about disease course, treatment, and prognosis, to special care with their symptoms after treatment, depending on user status, such as whether they used their real name and treatment history or sought offline contact with the physicians. Further implementation of an online and offline dialogue with physicians may more adequately match their information needs.
 
Date Submitted: Aug 1, 2014
Open Peer Review Period: Aug 1, 2014 - Aug 9, 2014
 
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Integrating mHealth in oncology: experience in the province of Trento

Background: Over the last 15 years, we have developed various integrated eHealth solutions aimed at healthcare professionals, citizens and patients. Objective: We have developed two mobile health applications: for the home monitoring of cancer patients receiving oral chemotherapy or targeted therapies, such as capecitabine or sunitinib, and for the safe delivery of infusion chemotherapy. Methods: Using mobile communication technology, information from patient-held diaries may be conveyed to a specific database and made available to health professionals in real time. Moreover, a specific rule-based alarm system may alert doctors and nurses of critical events so that they can promptly contact the patient to give him proper indications. Safe Therapy Mobile system The system is based on a Radio-Frequency Identification (RFID)/barcode reader which checks the patient, the nurse and the infusion bag before each drug administration and communicates via Bluetooth with a tablet. This in turn communicates via Wi-Fi with the server of the Oncologic Patient Record (OPR), in order to import the detailed prescription of chemotherapy and ancillary therapy. All drug administrations are tracked and recorded in the patient’s digital OPR. Results: Home monitoring of cancer patients In the diary application, deployed on the patient tablet, the prescribed therapy is converted in the number and type of pills that the patient has to take day by day. In the case of toxicity, the patient is helped by a scale of predefined drug-specific symptoms in which each grade is defined in simple language and, for skin toxicities, illustrated by pictures. All data appear in the patient diary and in the doctor/nurse dashboard. This allows professionals to check the condition of the patient at a glance. A rule-based alarm system, alerts doctors or nurses in the case of potentially “critical” situations. The preliminary results of the more advanced pilot studies on chronic patients, have confirmed that this approach appears useful and reliable to clinicians and patients. Safe Therapy Mobile system At the patient’s bedside, the system identifies and matches the patient, the drug infusion bag and the nurse, to verify the right drug administration, and tracks the entire infusion process. In a proper testing, the system never failed to match the patient-drug-nurse association correctly and didn’t impact on the duration of chemotherapy. It was well accepted by nurses and patients and is presently adopted for routine activity. Conclusions: Although the mobile health applications that we have developed have yet to prove their role in the validation trials, we are confident that they may result beneficial to our patients, because they have been tightly integrated with our complex and composite information system, which guarantees privacy, security, architecture, interoperability and particularly a true and real time patient-health professional communication.
 
Date Submitted: Jul 31, 2014
Open Peer Review Period: Jul 31, 2014 - Sep 25, 2014
 
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Analysis of PubMed User Sessions Using a Full-Day PubMed Query Log: A Comparison of Experienced and Non-Experienced PubMed Users

Background: PubMed is the largest biomedical bibliographic information source in the Internet. PubMed has been considered as one of the most important and reliable source of up-to-date healthcare evidence. Previous studies targeted to learn about the effects of domain expertise/knowledge on the search performance using PubMed. However, very little is known about PubMed users’ knowledge of information retrieval (IR) functions and their usage in query formulation. Objective: The purpose of the study was to shed light on how experienced/non-experienced PubMed users perform their search queries by analyzing a full-day query log. Our hypothesis is that (1) experienced PubMed users who use system functions quickly retrieve relevant documents and (2) non-experienced PubMed users who do not use them take longer search sessions than experienced users. Methods: To test the hypothesis we analyzed PubMed query log data containing nearly 3 million queries. User sessions are categorized into two categories: experienced and non-experienced user sessions. We compared the experienced and non-experienced users per number of sessions, and the experienced and non-experienced user sessions per session length with the focus on how fast they complete their sessions. Results: To test the hypothesis, we measured how much the information retrieval session is successful (retrieving relevant documents), that is represented as the decrease rates of the experienced and non-experienced users from the session length of 1 to 2, 3, 4, and 5. The decrease rate (from the session length of 1 to 2) of the experienced users is significantly larger than those of the non-experienced groups. Conclusions: The experienced PubMed users quickly retrieve relevant documents than the non-experienced PubMed users.
 
Date Submitted: Jul 30, 2014
Open Peer Review Period: Jul 31, 2014 - Sep 25, 2014
 
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VALIDITY OF ELECTRONIC DIET RECORDING NUTRIENT ESTIMATES COMPARED TO DIETITIAN ANALYSIS OF DIET RECORDS: A RANDOMIZED CONTROLLED TRIAL

Background: Dietary intake assessment with diet records (DR) is a standard research and practice tool in nutrition. Manual entry and analysis of DR is time-consuming and expensive. New electronic tools for diet entry by clients and research participants may reduce the cost and effort of nutrient intake estimation. Objective: To determine the validity of electronic diet recording, we compared responses to 3-day DR kept by Tap & Track™ software for the Apple iPod touch™ and records kept on the Nutrihand® website to DR coded and analyzed by a research dietitian into a customized USDA nutrient analysis program. Methods: Adult participants (n=19) enrolled in a cross-over designed clinical trial [1]. During each of two wash-out periods participants kept written 3-day DR. In addition they were randomly assigned to enter their DR in an online dietary analysis program (Nutrihand®) or a hand-held electronic device (Tap & Track™). They completed an additional 3-day DR and the alternate electronic diet recording methods during the second wash-out. Entries resulted in 228 daily diet records; or 12 for each of 19 participants. Means and standard deviations of nutrient intake were calculated for each method. Concordance of the intake estimates were determined by Bland-Altman plots. Coefficients of determination (R2) were calculated for each comparison to assess the strength of the linear relationship between methods. Results: No significant differences were observed between the mean nutrient values for energy, carbohydrate, protein, fat, saturated fatty acids, total fiber or sodium between the recorded DR analyzed in GRAND and either Nutrihand® or Tap & Track™, or for total sugars comparing GRAND and Tap & Track™. Reported values for total sugars were significantly reduced (p<.05) comparing Nutrihand® to GRAND. Coefficients of determination (R2) for Nutrihand® and Tap & Track™ compared to DR entries into GRAND, respectively, were energy 0.56, 0.01; carbohydrate 0.58, 0.08; total fiber 0.65, 0.37; sugar 0.78, 0.41; protein 0.44, 0.03; fat 0.36, 0.03; saturated fatty acids 0.23, 0.03; sodium 0.20, 0.00; and for Nutrihand® only for cholesterol 0.88; vitamin A 0.02; vitamin C 0.37; calcium 0.05; and iron 0.77. Bland-Altman analysis demonstrates high variability in individual responses for both electronic capture programs with higher 95% limits of agreement for dietary intake recorded on Tan & Track™. Conclusions: In comparison to dietitian entered 3-day DR, electronic methods resulted in no significant difference in mean nutrient estimates but exhibited larger variability, particularly the Tap & Track™ program. However, electronic DR provided mean estimates of energy, macronutrients, and some micronutrients which approximated those of the dietitian analyzed DR and may be appropriate for dietary monitoring of groups. Electronic diet assessment methods have the potential to reduce the cost and burden of DR analysis for nutrition research and clinical practice. Clinical Trial: This study was registered at clinicaltrials.gov (NCT01183520).
 
Date Submitted: Jul 30, 2014
Open Peer Review Period: Jul 31, 2014 - Sep 25, 2014
 
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Familial, Associational & Incidental Relationship initiative [FAIR]

Background: The widespread development of medical data warehouses has occurred over the last several years. Current data warehouses focus on individual cases, but lack the ability to identify family members that could be used for dyadic or familial research. Currently, the patient’s family history in the medical record is the only documentation we have to understand the health status and social habits of family members of the patient. Identifying familial linkages in a phenotypic data warehouse can be valuable in cohort identification, and beginning to understand interactions of diseases among families. Objective: The goal of the Familial, Associational, & Incidental Relationships (FAIR) system is to identify an index set of patients’ relationships through elements in a data warehouse. Methods: Using a test set of 500 children, we measured the sensitivity and specificity of available linkage algorithm (e.g: insurance id and phone numbers) and validated this tool/algorithm through a manual chart audit. Results: The average age of children in the sample was 8 years of age (SD=5). The cohort was 52% male. Fifty-two percent of these children were identified as white in Race. The identifiers used for FAIR were available on the majority of patients insurance number 97%, phone number 100%, and address 99%. When utilizing the FAIR tool, sensitivity varied from 16% to 87%, and specificity from 70% to 100% using various combinations of identifiers. Using the “i2b2” warehouse infrastructure, we have now developed a web app that facilitates FAIR for any index population. Conclusions: FAIR is a valuable research and clinical resource that extends the capabilities of existing data warehouses and lays the groundwork for family-based research. FAIR will expedite studies that would otherwise require registry or manual chart abstraction data sources.
 
Date Submitted: Jul 29, 2014
Open Peer Review Period: Jul 30, 2014 - Sep 24, 2014
 
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Occupational therapists’ perceptions of using a virtual reality interior design application within the pre-discharge home visit process: A qualitative feasibility study

Background: A key role of Occupational Therapists (OTs) is to carry out pre-discharge home visits (PHV) and propose appropriate adaptations to the home environment, to enable patients to function independently after hospital-home discharge. However, research shows that more than 50% of specialist equipment installed as part of home adaptations is not used by patients. A key reason for this is that decisions about home adaptations are often made without adequate collaboration and consultation with the patient. Consequently, there is an urgent need to seek out new and innovative uses of technology to facilitate patient/practitioner collaboration, engagement and shared decision making in the PHV process. Virtual reality interior design applications (VRIDAs) primarily allow users to simulate the home environment and visualise changes prior to implementing them. Customised VRIDAs, which also model specialist occupational therapy equipment, could become a valuable tool to facilitate improved patient/practitioner collaboration if developed effectively and integrated into the PHV process. Objective: To explore the perceptions of occupational therapists with regards to the feasibility of using VRIDAs as an assistive tool within the PHV process. Methods: Task-oriented interactive usability sessions, utilising the think-aloud protocol and subsequent semi-structured interviews were carried out with seven Occupational Therapists who possessed significant experience across a range of clinical settings. Template analysis was carried out on the think-aloud and interview data. Analysis was both inductive and driven by theory, centring around the parameters that impact upon the acceptance, adoption and use of this technology in practice as indicated by the Technology Acceptance Model (TAM). Results: OTs’ perceptions were identified relating to three core themes: (1) perceived usefulness (PU), (2) perceived ease of use (PEoU), and (3) actual use (AU). Regarding PU, OTs believed VRIDAs had promising potential to increase understanding, enrich communications and patient involvement, and improved patient/practitioner shared understanding. However, it was unlikely that VRIDAs would be suitable for use with cognitively impaired patients. For PEoU, all OTs were able to use the software and complete the tasks successfully, however, participants noted numerous specialist equipment items that could be added to the furniture library. AU perceptions were positive regarding use of the application across a range of clinical settings including children/young adults, long-term conditions, neurology, older adults, and social services. However, some “fine tuning” may be necessary if the application is to be optimally used in practice. Conclusions: Participants perceived the use of VRIDAs in practice would enhance levels of patient/practitioner collaboration and provide a much needed mechanism via which patients are empowered to become more equal partners in decisions made about their care. Further research is needed to explore patient perceptions of VRIDAs, to make necessary customisations accordingly, and to explore deployment of the application in a collaborative patient/practitioner-based context.
 
Date Submitted: Jul 25, 2014
Open Peer Review Period: Jul 28, 2014 - Sep 22, 2014
 
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Veteran, Primary Care Provider, and Specialist Satisfaction with Electronic Consultation

Background: Access to specialty care is challenging for Veterans in rural locations. To address this challenge, in December 2009, the VA implemented an electronic consultation (e-consult) program to provide primary care providers (PCPs) and patients enhanced specialty care access. Objective: This quality improvement (QI) project evaluation was designed to: (1) assess satisfaction with the e-consult process and (2) identify perceived facilitators and barriers to using the e-consult program. Methods: We conducted semi-structured telephone interviews with Veteran patients (N=15), Community Based Outpatient Clinic (CBOC) PCPs (N=15), and VA Pittsburgh specialty physicians (N=4) who used the e-consult program December 2009-August 2010. Participants answered questions regarding satisfaction in 8 domains and identified factors contributing to their responses. Results: Most participants were white (patients=87%; PCPs=80%; specialists=75%) and male (patients=93%; PCPs=67%; specialists=75%). On average, patients had one e-consult (SD=0), PCPs initiated 6 e-consults (SD=6), and VAPHS specialists performed 17 e-consults (SD=11). Patients, PCPs, and specialty physicians were satisfied with e-consults (mean+SD of 4.6+0.5 on 1-5 Likert-scale, 4.1+0.8, and 3.8+1.0 respectively). The most common reason why patients and specialists reported increased overall satisfaction with e-consults was improved communication, whereas improved timeliness of care was the most common reason for PCPs. Interestingly, communication was the most reported perceived barrier and facilitator to e-consult use. Conclusions: Veterans and VA healthcare providers were satisfied with the e-consult process. Our findings suggest that while reasons for satisfaction with e-consult differ somewhat for patients and physicians, e-consult may be a useful tool to improve VA Healthcare System access for rural patients.
 
Date Submitted: Jul 23, 2014
Open Peer Review Period: Jul 25, 2014 - Sep 19, 2014
 
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A Review and Content Analysis of Depression Apps Available to Health Consumers

Background: Depression is highly prevalent and causes considerable suffering and disease burden; yet many people remain untreated, although effective treatments exist. Smartphone applications (apps) offer the potential to help close this treatment gap by addressing some of the barriers to accessing depression treatment. Objective: To identify and characterize the different types of smartphone depression apps available in the marketplace. Methods: A systematic review of depression apps was conducted on the application stores of the five major smartphone platforms: Android, iPhone, Blackberry, Nokia and Windows. Apps were included if they focused on depression and were available to people who self-identify as having depression. Datum were extracted from the app descriptions found in the app stores. Results: This study identified 243 unique depression applications that met the inclusion criteria. Over one-quarter (27.7%, 210/758) of the excluded apps failed to mention depression in the title or description. Two-thirds of the apps had as their main purpose providing therapeutic treatment (n=82; 33.7%) or psychoeducation (n=78; 32.1%). The other main purpose categories were medical assessment (n=41; 16.9%), symptom management (n=20; 8.2%) and supportive resources (n=4; 1.6%). A majority of the apps failed to sufficiently describe their organizational affiliation (n=158; 65.0%) and content source (n=150; 61.7%). There was a significant relationship (χ2=50.5, df=5, P<.001) between the main purpose of the app and the reporting of content source, with medical assessment apps having the greatest proportion of reporting (80.5%; 33/41). Over half of the apps featured an eBook (n=50; 20.6%), audio therapy (n=41; 16.9%) or screening (n=41; 16.9%) function. Most apps had a dynamic user interface (n=176; 72.4%) and used text as the main type of media (n=126; 51.9%). Thirty-five (14.4%) apps incorporated more than one form of media. Conclusions: Without guidance, finding an appropriate depression app may be challenging, as the search results yielded non-depression–specific apps to depression apps at a 3:1 ratio. Inadequate reporting of organization affiliation and content source increases the difficulty of assessing the credibility and reliability of the app. Furthermore, there is a lack of evidence on the effectiveness of using apps to support people with depression. While certification and vetting initiatives are underway, this study demonstrates the need for standardized reporting in app stores to help consumers select appropriate tools, particularly among those classified as medical devices.
 
Date Submitted: Jul 24, 2014
Open Peer Review Period: Jul 25, 2014 - Sep 19, 2014
 
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A web based cross-platform application for teleconsultation in radiology

Background: The growing complexity of radiologic examinations and interventional procedures requires frequent exchange of knowledge. Consequently there is the great need for a simple way to quickly share and discuss patient images between radiology experts and with colleagues from other medical disciplines. Objective: Aims of this work were the design, development and initial performance evaluation of a fast and user friendly, platform independent teleconsultation system for medical imaging. Methods: A local backend system receiving DICOM images via push commands or a predefined import-folder on the local network was created. The application automatically generates anonymized JPEG files and uploads them to an internet accessible webserver. The user frontend running on that webserver comprises an image viewer application with a specially developed collaborative feature. A pointer element was realized that can be freely positioned to indicate findings to the collaborative partners. The application was built using standard web technologies (HTML 5, CSS and JavaScript). The operational reliability of the user frontend was tested on various operating systems and devices. Moreover upload and download times of different imaging studies were evaluated. Results: The frontend with all of its features could be successfully used with a variety of different platforms, mobile devices and desktop computers. An imaging study can be accessed by simply calling up a special internet address (URL) in a standard web browser that may be exchanged between users (e.g. via email) like any other link to an interesting webpage. The evaluation of the system concerning its speed showed good results: For example the preparation and upload of a standard head CT series to the webserver took less than 21 seconds. On the other hand the data volume of the same series and the viewer application, which is lower than 2mb in total, could be transferred to a mobile phone in less than 42 seconds via a UMTS network or in less than 3 seconds via a HSPA network. Conclusions: The presented system with its minimal hard- and software requirements, its simplicity and platform independence might be a promising tool in the increasingly important area of teleconsultation.
 
Date Submitted: Jul 21, 2014
Open Peer Review Period: Jul 22, 2014 - Sep 16, 2014
 
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Development of patient-centered mhealth living donor education programs for African Americans

Background: There is a critical need to expand the pool of available kidneys for African Americans who are on the transplant waitlist due to the disproportionally lower availability of deceased donor kidneys compared to other races/ethnic groups. Encouraging living donation is one method to fill this need. Incorporating mobile health (mHealth) strategies may be a way to deliver educational and supportive services to African American transplant eligible patients and improve reach to those living in remote areas or unable to attend traditional group session based programs . Prior to program development, it is essential to perform formative research with target populations to determine acceptability and cultivate a patient-centered and culturally relevant approach to be used for program development. Objective: The objectives of this study was to investigate African American transplant eligible patients’ attitudes and perceptions toward mobile technology and its viability in a mHealth program aimed at educating patients about the process of living kidney donation. Methods: Using frameworks from the Technology Acceptance Model and Self-Determination Theory, 9 focus groups (n=57) were administered to African Americans at a southeastern medical center which included deceased/living donor kidney recipients and living donors/caregivers. After a demo of a tablet-based video education session and explanation of a group-based videoconferencing session, focus groups examined members’ perceptions about how education messages should be presented on topics pertaining to the process of living kidney donation and the transplantation. Questionnaires were administered on technology use and perceptions of the potential program communication platform. Transcripts were coded and themes were examined using NVivo 10 software. Results: Qualitative findings found five major themes that were common among all participants. These included: (1) strong support for use of mobile technology, (2) different media formats would be nice to have, (3) willingness to engage in video chats, but face-to-face interaction sometimes preferred, (4) media needs to work quickly and be easy to use, (5) high prevalence of access to technology help within their immediate circles. Differences showed that recipients were willing to spend more time on education topics than the living donors/caregivers, that they wanted to build skills on how to have conversations with others, and preferred getting information from many sources where the living donors/caregivers predominantly wanted to hear from other living donors and wanted the facts to make their decisions. The questionnaires showed a high amount of acceptability and interest to use the proposed program with 80% of responses scored 4 or 5 out of a 5-point Likert scale. Also, high utilization of mobile technology with 71.9% of the participants having a smartphone and 43.9% already had a tablet computer in their household. Conclusions: Our study supports the use a mHealth education platform for African Americans to learn about living donation. However, potential recipients and potential donors have differing needs and programs should be tailored to each target audience.
 
Date Submitted: Jul 21, 2014
Open Peer Review Period: Jul 21, 2014 - Sep 15, 2014
 
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A Health Checkup and Tele-Medical Intervention Program for Preventive Medicine in Developing Countries: A Verification Study

Background: The prevalence of non-communicable diseases is increasing throughout the world, including developing countries. Objective: To conduct a study of a preventive medical service in a developing country, combining e-health checkups and tele-consultation as well as assess stratification rules and the short-term effects of intervention. Methods: We provided e-health checkups for the populations of 5 villages and the employees of 5 companies in Bangladesh. Individual health condition was automatically categorized into 4 grades, green (healthy), yellow (caution), orange (affected), and red (emergent), based on international diagnostic standards. We provided tele-consultation for orange- and red-grade subjects, and we provided tele-prescription for these subjects as required. Results: The first checkup was provided to 16,741 subjects. After 1 year, 2361 subjects participated in the second checkup, and the blood pressure of these subjects was significantly decreased (P < .001). Based on these results we proposed a cost-effective method using a predictor, to ensure sustainability of the program in developing countries. Conclusions: The results of this study demonstrate the benefits of an e-health checkup and tele-consultation program as an effective healthcare system in developing countries.
 
Date Submitted: Jul 15, 2014
Open Peer Review Period: Jul 16, 2014 - Sep 10, 2014
 
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“Friending” teens: A systematic review of social media in adolescent and young adult healthcare

Background: Recently, social media have emerged as a potentially powerful medium for communication with adolescents and young adults (AYAs) in their health choices. Objective: The goal of this systematic review is to identify studies using social media to interact with adolescents and young adults (AYAs), in order to guide the use of social media in clinical research as well as healthcare delivery within this population. Methods: A PubMed Central electronic database search was performed between 1/1/2002 and 10/1/2013, using terms to identify papers in which interactive web-based platforms, “social media”, were an important feature. PRISMA guidelines for a systematic review were used. Results: We identified 285 studies involving social media, of which 84 met criteria for inclusion. Seventy-three studies were purely observational and eleven were interventional. The ways in which social media were leveraged by these studies included: 1) study of AYA behavior (n=75), 2) provide health information (n=12), 3) engage the AYA community (n=16) and 4) recruit research participants (n=22). Common healthcare topics addressed using SNS included high-risk sexual behaviors (n=22), alcohol, tobacco and other drug use (n=19), Internet safety (n=8), mental health issues (n=18), or specific medical conditions and behaviors (n=20). Several studies used more than one method of social networking sites and addressed more than one healthcare topic. Conclusions: Social media offer an exciting new means for engaging and communicating with AYAs. Further exploration and development of these strategies involving social media are necessary.
 
Date Submitted: Jul 8, 2014
Open Peer Review Period: Jul 9, 2014 - Sep 3, 2014
 
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Public perception of telemedicine and mobile health in China

Background: In recent years, telemedicine and mobile health (“mhealth”) technology have emerged as a viable solution to reduce unmet demands of health care services in the People’s Republic of China (“China” hereafter). Yet, the adoption of telemedicine and mhealth depends heavily on whether Chinese stakeholders believe that the new technology can actually work. It is therefore important to examine the public perception of this new technology in China. Objective: This paper seeks to reveal the perception towards telemedicine and mhealth among stakeholders in the Chinese health sector. We are interested in identifying the issues that have attracted attention from these stakeholders, particularly how they perceive and articulate the opportunities and barriers of this technology. Methods: In this paper, we collect data from a social media platform by adopting techniques from informatics. We focus attention on a social media site called Hc3i.cn, particularly its “telemedicine/mhealth” forum that began operation in November, 2009. We examine all the conversation threads (“threads”) in this forum, extracting both quantitative and qualitative information from these threads. We identify a number of keywords that have been used frequently as the first post to initiate a new thread, and analyze a selected list of these threads in depth. Results: The forum has produced 571 threads as of the research cut-off date in May, 2014. These threads consist of 2811 posts, so each thread has 2811/571 = 4.92 participation posts on average. Among other things, a relatively large number of forum participants initiated a new thread (32.57% of all first posts) to discuss the connections between telemedicine, mhealth and existing health information technology (HIT). Forum participants have put a great emphasis on the local relevance of telemedicine and mhealth to China but they also expressed interest in learning how other countries had utilized telemedicine and mhealth. Qualitative analysis shows that Chinese stakeholders see large organizational entities such as hospitals and multinational companies to be catalysts for telemedicine and mhealth development. Conclusions: This research has several significant observations: As mentioned, Chinese stakeholders have seen hospitals and multinational companies as significant entities in fostering telemedicine and mhealth in that country. Hospitals are seen to possess the capacity to absorb the costs of learning and facilitating large-scale change; whereas multinational companies are able to bring in enormous economic opportunities in association with telemedicine and mhealth technology. In addition, the participation of multinational companies is believed to increase acceptance among health stakeholders towards telemedicine and mhealth, as well as contribute useful capitals and knowledge to the new technology’s further development. Clinical Trial: N/A
 
Date Submitted: Jul 8, 2014
Open Peer Review Period: Jul 9, 2014 - Sep 3, 2014
 
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Scoping Review of Information and Communication Technology-Interventions to Support Patients and Health Care Providers in Person-centered care Management of Chronic Diseases

Background: Person centered Information and Communication-Technology (ICT) could involve patients to take an active part in their health care and decision-making process, “empower” them and make it possible for patients to interact directly with healthcare providers and services about personal health concerns. Yet, little is known about which ICT-interventions dedicated to Person-centered care (PCC) and connected care interactions have been studied, in particular with respect to “shared care management” of chronic diseases. The aim of this research is to investigate the extent, range and nature of these research-activities and identify research gaps in the existing evidence base of health studies regarding the “big five” of chronic disease namely diabetes mellitus, cardiovascular and chronic respiratory diseases, cancer and stroke. Objective: The objective of this article is to review the literature and to scope the field with respect to: Which ICT-interventions have been used to support patients and healthcare professionals in PCC-management of the 'big five' of chronic diseases? and: What is the impact of these interventions, such as on Health Related Quality of Life and costs efficiency? Methods: This research adopts a scoping review-method. Three electronic medical databases were accessed: PubMed, EMBASE and Cochrane Library with the timeframe of studies published between January 1989 and December 2013. In five phases of rigorous and systematically scanning and reviewing, relevant studies were identified, selected and charted, and finally we collated, summarized and reported the results. Results: From the initial 9,380 search results, we identified 350 studies that qualified for inclusion, diabetes mellitus (n=103), cardiovascular (n=89) and chronic respiratory diseases (n=73), cancer (n=67) and stroke (n=18). Persons with one of these chronic condition use ICT mainly for activities of self-measurement of the body when interacting with healthcare providers, with the highest ranking in chronic respiratory (63%) and cardiovascular diseases (53%). we found 60 relevant studies (17%) on shared decision-making ICT, mainly using telemedicine systems as personalized ICT-interventions. The highest impact measured, relates to the increase of empowerment (15%). Health Related Quality of Life accounts for 8%. The highest impact connected to health professionals is an increase in clinical outcome (12%). The impacts on organization outcomes are: decrease of hospitalization (12%) and cost efficiency (11%). Conclusions: This scoping review has outlined ICT-enabled Person-centered care to support patients and health care providers in chronic disease management. With the note that hardly any of these interventions could be regarded as “fully” addressing Person-centered care, this review will especially be helpful to those deciding on areas where further development into research or implementation of ICT-enabled PCC may be warranted.
 
Date Submitted: Jul 8, 2014
Open Peer Review Period: Jul 9, 2014 - Sep 3, 2014
 
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Exploring the Far Side of Mobile Health – Information Security and Privacy of Mobile Health Applications on iOS and Android

Background: Mobile health (mHealth) applications (apps) aim at providing seamless access to tailored health information technology (IT) and have the potential to alleviate global health burdens. Yet, they bear risks to information security and privacy because users need to reveal private, sensitive medical information to redeem certain benefits. Due to the plethora and diversity of available mHealth apps, implications for information security and privacy are unclear and complex. Objective: The objective of this research is to establish an overview of mHealth apps offered on iOS and Android with a special focus on potential damage to users through information security and privacy infringements. Methods: We assessed apps available in English and offered in the categories Medical and Health & Fitness in the iOS and Android app stores. Based on the information retrievable from the app stores, we developed a market overview, tagged apps to make offered information machine-readable, and clustered discovered apps to identify and group similar apps. Subsequently, information security and privacy implications were assessed based on health specificity of information available to apps, potential damage through information leaks, potential damage through information manipulation, potential damage through information loss, and potential value of information to third parties. Results: We discovered 24,405 health-related apps (iOS: 21,953; Android: 2,452). Absence or scarceness of ratings for 81.36% of iOS and 76.14% of Android apps indicates that less than a quarter of mHealth apps are in more or less widespread use. Clustering resulted in 245 distinct clusters, which were consolidated into 12 app archetypes grouping clusters with similar assessments of potential damage through information security and privacy infringements. The majority of apps (95.63% of apps) pose at least some potential damage through information security and privacy infringements. 11.67% of apps scored the highest assessments of potential damages. Conclusions: Various kinds of mHealth apps collect and offer critical, sensitive, private medical information calling for a special focus on information security and privacy of mHealth apps. In order to foster user acceptance and trust, appropriate security measures and processes need to be devised and employed so that users can benefit from seamlessly accessible, tailored mHealth apps without exposing themselves to the serious repercussions of information security and privacy infringements.
 
Date Submitted: Jul 6, 2014
Open Peer Review Period: Jul 7, 2014 - Sep 1, 2014
 
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Analyzing the Mobile “Digital Divide”: Changing Determinants of Household Phone Ownership over Time in Rural Bangladesh

Background: We had a unique opportunity to examine demographic determinants of household mobile phone ownership in rural Bangladesh using socioeconomic data collected as part of a multi-year longitudinal cohort study of married women of reproductive age. Objective: This paper explores how the demographics of household mobile phone owners have changed over time in a representative population of rural Bangladesh. Methods: We present data collected between 2008 and 2011 on household mobile phone ownership and related characteristics including age, literacy, education, employment, electricity access and household wealth among 35,306 individuals. Women were enrolled when found to be newly pregnant and contributed socio-economic information once over the course of the time period serving as a “sample” of families within the population at that time. Univariate and multiple logistic regressions analyses were performed to identify the socio-economic determinants of household phone ownership. Results: Across three fiscal years, we found that reported household ownership of at least one working mobile phone grew from 29.85% in the first fiscal year to 56.07% in the third fiscal year. Illiteracy, unavailability of electricity, and low quartiles of wealth were identified as overall demographic constraints to mobile phone ownership. However, over time these barriers became less evident and equity gaps among demographic status began to dissipate as access to mobile technology became more democratized. We saw a high growth rate in ownership among households in lower economic standing (illiterate, without electricity, low and lowest wealth index), likely a result of competitive pricing and innovative service packages that improve access to mobile phones as the mobile phone market matures. In contrast, as market saturation is rapidly attained in the most privileged demographics (literate, secondary schooling, electricity, high wealth index), members of the lower wealth quartiles seem to be following suit, with more of an exponential growth. Conclusions: Upwards trends in household mobile phone ownership in vulnerable populations over time underline the potential to leverage this increasingly ubiquitous infrastructure to extend health and finance services across economic strata.
 
Date Submitted: Jul 1, 2014
Open Peer Review Period: Jul 2, 2014 - Aug 27, 2014
 
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The Cancer Experience Map: An Approach to Including the Patient Voice in Supportive Care Solutions

The patient voice is an essential element in materials created for cancer supportive care. Researchers and developers have often relied on the use of a persona during the design of supportive care materials. But creating a persona to adequately represent a cancer patient turned out to be a daunting task for our team at a health information company. Instead, we produced a persona adaptation in the form of a cancer experience map, a model that not only represents the complexity of the cancer experience but also summarizes some common transitions throughout and beyond the treatment experience. In this article we report on our process for creating the cancer experience map as well as the map's first use as a resource in building cancer supportive care videos. We also address the broader policy implications of including the patient voice in supportive cancer content, particularly with regard to mHealth apps.
 
Date Submitted: Jun 28, 2014
Open Peer Review Period: Jun 30, 2014 - Aug 25, 2014
 
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An Evaluation of Utilization in a Web-Based versus Integrated Phone/Web Cessation Program among 140,000 Tobacco Users across 10 Free State Quitlines

Background: Phone-based cessation program effectiveness has been established, and randomized controlled trials have provided some support for web-based services. Relatively little is known about who selects different treatment modalities and how they engage with treatments in a real-world setting. Objective: This paper describes the characteristics, web utilization patterns, and return rates of tobacco users who self-selected into a web-based versus integrated phone/web cessation program. Methods: We examined the demographics, baseline tobacco use, web utilization patterns, and return rates of 141,429 adult tobacco users who self-selected into a Web Only or integrated Phone/Web cessation program through one of 10 state quitlines from August 2012 through July 2013. For each state, registrants were only included from the timeframe in which both programs were offered to all enrollees. Utilization data were limited to site interactions occurring in the 6 months after registration. Results: The majority of participants selected the Phone/Web program (79.9%). After enrollment in Web Coach, Web Only were more likely to log in compared to Phone/Web (76.9% vs. 42.0%; P < .001), but less likely to return after their initial login (40.2% vs. 58.4%; P < .001). Those who chose Web Only were younger, healthier, more highly educated with higher household incomes, more likely to be uninsured or commercially insured, more likely to be white non-Hispanic and less likely to be Black non-Hispanic, more likely to be married or in a domestic partnership, more likely to live and/or work with other tobacco users, and less likely to be highly nicotine-addicted or long-term tobacco users (Ps < .001). Among both program populations, participants were more likely to return to Web Coach if they were women, older, more highly educated, long-term tobacco users, were sent NRT through their quitline, or were Medicare-insured (Ps < .001). Phone/Web were also more likely to return if they had higher incomes or identified as white non-Hispanic or “other” race (Ps < .001). The interactive Tobacco Tracker, Cost Savings Calculator, and Quitting Plan were the most widely used features overall. Web Only were more likely than Phone/Web to use most key features (Ps < .001), most notably the 5 Quitting Plan behaviors. Among quitlines that offered NRT to both Phone/Web and Web Only, Web Only were less likely to have received NRT from their quitline. Conclusions: This paper adds to our understanding of who selects different cessation treatment modalities and how they engage with the program in a real-world setting. Web Only were younger, healthier smokers of higher socio-economic status who interacted more intensely with services in a single session, but were less likely to reengage or access NRT benefits. Further research should examine the efficacy of different engagement techniques and services with different subpopulations of tobacco users.
 
Date Submitted: Jun 27, 2014
Open Peer Review Period: Jun 30, 2014 - Aug 25, 2014
 
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Identifying Key Hospital Service Quality Factors in Online Health Communities

Background: The volume of health-related user-created content (UCC), especially hospital related questions and answers (Q/As) in online health communities, has rapidly increased. Patients and caregivers participate in online community activities to share their experiences, exchange information, and ask about recommended or discredited hospitals. Objective: In-depth analysis of these hospitals has used random sampling surveys. However, such surveys are becoming impractical owing to the rapidly increasing volume of online data and the diverse analysis requirements of related stakeholders. As a solution to this challenge, we propose a novel approach to identify social media-based key quality factors for hospitals (SM-KQFH) automatically from online health communities, especially hospital related Q/As. Methods: In addition to the identification of SM-KQFH that represents qualitative aspects of hospitals, we integrate sentiment analysis to discover the types of recommendations in messages posted within online health communities. Korea’s two biggest online portals are used to test the effectiveness of SM-KQFH detection. Results: Further analysis reveals that there exist differences in the details of SM-KQFH according to the regions in Korea and the patterns of change seem to accurately reflect social events (e.g., influenza epidemics). Conclusions: These findings could be used to provide timely information to caregivers, hospital officials, and medical officials for healthcare policies.
 
Date Submitted: Jun 26, 2014
Open Peer Review Period: Jun 26, 2014 - Aug 21, 2014
 
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Garnering Traffic for Online Public Reports and Engaging Visitors

Background: In the context of the Affordable Care Act, there is extensive emphasis on making provider quality transparent and publicly available. Online public reports of quality exist, but little is known about how users find reports and what engages them. Objective: In order to address this gap, we gathered website analytics data from a national group of online public reports of hospital or physician quality and surveyed visitors to those websites. Methods: Websites were recruited from a national group of multistakeholder collaboratives with online public reports. Web analytics data was gathered: number of unique visitors; method of arrival for each unique visitor; search terms resulting in visits. A survey invitation was launched for, depending on website, unique visitors on landing pages, or on pages with quality information. Survey topics covered demographics, type of respondent (e.g., consumer, healthcare professional, etc.), quality measures of interest, and website experience. Results: There were 116,657 unique visitors to the 18 participating websites (1440 unique visitors/month per website), with most unique visitors arriving through search (63%). Websites with a higher percent of traffic from search engines garnered more unique visitors (R=0.76, P=.001). The most common search terms were for individual hospitals (23%) and website names (19%); medical condition terms were uncommon (1%). Survey view rate was 42.5% (n=49,560 invited) resulting in 1755 respondents (participation rate=3.6%). Consumers were frequently interested in using the information to choose providers or assess the quality of their provider (52.7%); the majority of those choosing a provider reported that they had used the information to do so (78.4%). Healthcare professional (26.6%) and consumer (20.8%) respondents wanted cost information and consumers wanted patient narrative comments (31.5%) on the public reports. Healthcare professional respondents (31.4%, n=551) rated the experience on the reports higher than consumers (7.2 vs. 6.2, scale 0-10, P<.001). Consumer respondents (48.4%, n=850) were most often 45-64 (57.6% of consumers), white (86.1%) and had private insurance (72.8%). Conclusions: Public reporting websites can help consumers and providers find and use quality information. Report sponsors interested in increasing the influence of their reports could consider: improving search engine ranking through optimizing hospital name searches; providing cost information and patient comments; and reaching out to populations currently not finding the reports.
 
Date Submitted: Jun 23, 2014
Open Peer Review Period: Jun 24, 2014 - Aug 19, 2014
 
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Measurement and data transmission validity of a multi-biosensor system for real-time remote exercise monitoring among cardiac patients

Background: Remote telemonitoring holds great potential to augment management of patients with coronary heart disease (CHD) and atrial fibrillation (AF) by enabling regular physiological monitoring during physical activity. Remote physiological monitoring may improve home and community exercise-based cardiac rehabilitation programmes, and could improve assessment of the impact of pharmacological interventions on heart rate control management in individuals with AF. Objective: To evaluate the measurement validity and data transmission reliability of a remote telemonitoring system comprising a wireless multi-parameter physiological sensor, custom smartphone application (app) and middleware platform, among individuals in sinus rhythm and atrial fibrillation. Methods: Participants in sinus rhythm and with atrial fibrillation undertook simulated daily activities, low, moderate and/or high intensity exercise. Remote monitoring system heart (HR) and respiratory rate (RR) were compared to reference measures (12-lead ECG and indirect calorimeter). Wireless data transmission loss was calculated between the sensor, smartphone app and remote internet server. Results: Median HR (-0.30 to 1.10 b∙min-1) and RR (-1.25 to 0.39 br∙min-1) measurement biases were small, yet statistically significant (all p ≤ 0.003) due to the large number of observations. Measurement reliability was generally excellent (ρ = 0.87 to 0.97, all p < 0.001; ICC = 0.94 to 0.98, all p < 0.001; CV = 2.24 to 7.94%), although respiratory rate measurement reliability was poor among atrial fibrillation participants (ρ = 0.43, p < 0.001; ICC = 0.55, p < 0.001; CV = 16.61%). Data loss was minimal (<5%) when all system components were active; however, instability of the network hosting the remote data capture server resulted in data loss at the remote internet server during some trials. Conclusions: System validity was sufficient for remote monitoring of heart and respiratory rates across a range of exercise intensities. Remote exercise monitoring has potential to augment current exercise-based cardiac rehabilitation and heart rate control management approaches by enabling the provision of individually tailored care to individuals outside of traditional clinical environments.
 
Date Submitted: Jun 23, 2014
Open Peer Review Period: Jun 24, 2014 - Aug 19, 2014
 
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Rapport between cancer patients and physicians is a critical issue for patients’ satisfaction with treatment decision

Background: Cancer patients’ satisfaction with their treatment decision has been proven to be associated with improved health outcome, but few studies have been conducted in Japan. Objective: We assess that cancer patients’ satisfaction with their treatment can enhance their psychological outcomes. In addition, we predict the association between their satisfaction and rapport with their doctors. Methods: We conducted cross-sectional questionnaire surveys among patients who had received cancer treatment. One source was inpatients and outpatients from a Cancer Center Hospital, and the other was through a website of Japan’s biggest newspaper. The questionnaire included demographics, and general self-rated life status such as peace of mind, quality of life, daily activities, family relationships, rapport with attending physician, assessment of physician’s explanations and feeling of happiness during the previous week. Results: Of 576 participants who responded, 383 subjects were satisfied and 193 dissatisfied. It was confirmed that the Internet based survey was comparable to the paper-based survey in examining patient satisfaction. The dissatisfied group included more females and fewer mandatory retired subjects than did the satisfied group. The patients in the more satisfied group had a more favorable subjective opinion on their recent life. The patients in the dissatisfied group received more chemotherapy and had more side effects than those in the satisfied group. Assessment of physician’s role showed significant differences between the two groups; the patients in the satisfied group felt more than those in the dissatisfied group that the doctors’ explanations of treatment were sufficient and were satisfied with the rapport with their doctors. Multiple logistic regression analysis revealed that rapport with their doctors showed a significant odds ratio (3.79, 95% CI, 2.25-6.39). Conclusions: Cancer patients’ well-being is associated with treatment satisfaction. Rapport between physicians and patients is the most important key factor for patients’ satisfaction with their treatment decision.
 
Date Submitted: Jun 22, 2014
Open Peer Review Period: Jun 24, 2014 - Aug 19, 2014
 
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Which frail older patients use online health communities and why? A mixed methods process evaluation of use of the Health and Welfare portal (ZWIP)

Background: Older people suffering from frailty often receive fragmented chronic care from multiple professionals. According to the literature there is an urgent need for coordination of care. Objective: To evaluate differences in use of a personal Online Health Community (OHC) for frail older people in relation to personal characteristics, and to explore barriers and facilitators for use as experienced by older persons themselves and their informal caregivers, using the case of the Health and Welfare Information Portal (ZWIP). Methods: Design: Mixed methods study. For the quantitative analysis, we used usage information (2 years follow-up) and baseline characteristics of frail older people. For the qualitative analysis we used semi structured interviews with older people and caregivers. Setting: 11 GPs group practices in the east of the Netherlands. Participants: Frail older people above 70 years. Intervention: ZWIP, an online health community for frail older people, their caregivers and professionals. Measurements: We collected data on OHC use for 2 years, and relevant patient characteristics. Interview topics were: description of use, reasons for (non) use, user profiles. Results: 290 of 622 frail patients in the intervention group were connected to ZWIP, of whom 79 used ZWIP regularly. Main predictors for use were having an informal caregiver, scoring low on ADL, and having a large number of professional caregivers. GP level predictors were being located in a village, if the GP had experience with e-health, and cared for a large percentage of frail older people. From 23 interviews, main reasons for use were the ZWIP’s good, quick and easy way for communication and the presence of active health problems. Important reasons for non-use were lack of computer skills and preference for the traditional ways of consultation. Conclusions: A small number of older people used the OHC intensively. For implementation of personal OHCs, older people with active health problems and a sizable number of healthcare professionals have to be selected, and the informal caregiver should be approached early in the implementation process. Clinical Trial: ISRCTN11165483 at controlled-tials.com
 
Date Submitted: Jun 17, 2014
Open Peer Review Period: Jun 18, 2014 - Aug 13, 2014
 
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An Update on Telemedicine and eHealth Publishing in Poland: Systematic Review of the Literature

To date, there has been no comprehensive analysis of Telemedicine and eHealth in Poland. To address this, scientific literature review was conducted. 101 articles were selected for full review out of 132 citations from Medline and 97 from Embase. Med-e-Tel conference proceedings were also reviewed. 56% of the papers were published in journals listed in the Journal Citation Report (Impact Factor ranging from 0.30 to 7.08). Original findings were reported in 54% of publications, including 11% randomized studies. Affiliation with the Polish Telemedicine Society was mentioned in only seven publications (6.9%). The papers focused primarily on cardiology (19%), pathology (14%), and diabetes (10%). Telemedicine and eHealth scientific activity in Poland as measured by the annual number of published articles and Med-e-Tel conference contributions has fluctuated but overall is increasing. Articles have been written mostly by researchers and practitioners not affiliated with Polish Society of Telemedicine. Over half of the articles reported original contribution and were published in well recognized journals. It is interesting to note that access to EU funds in 2004 did not result in an immediate increase in publications, although rates did increase in subsequent years suggesting increased funding may have resulted in more research being conducted and thus more publications being written once results were obtained.
 
Date Submitted: Jun 15, 2014
Open Peer Review Period: Jun 18, 2014 - Aug 13, 2014
 
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Blogging as a viable research methodology for young people with arthritis

Background: The development of services that are responsive to the needs of users is a health policy priority. Finding ways of engaging young people in research to gain insights into their particular experiences, perspectives and needs is vital but challenging. These data are vital to improve services in ways that meet the needs of young people. Objective: This article describes online blogging as a viable method for understanding the daily experiences and condition management strategies of young people with juvenile arthritis. Methods: To meet the objectives of the study, a qualitative approach was required to gather information on the experiences and perspectives of young people regarding the management of their condition and its daily impact. In collaboration with a group of young people with arthritis, a bespoke website was developed. This website provided the opportunity for young people (aged 11-19) with arthritis from a UK paediatric hospital to contribute ‘blogs’. It was designed so that young people were free to write about whatever was important to them; but the site also included some structure and prompts to facilitate the writing of blogs. Qualitative analytical procedures were employed, supported by NVivo software. Results: Engagement in the study by young people was variable in terms of their participation rates, frequency of website visits, and the length of their blogs. Young people used the site in different ways, some responding to the website categories and prompts that the team created, others using it as a diary to record their experiences and thoughts. In line with principles of qualitative enquiry, the data collection was ‘participant-led’. Young people were in control of what, how much and how often they wrote. However, some young people expressed difficulty regarding knowing what they should blog about. For a number of reasons, discussed here, the blogs may also not be fully reflective of experiences and perspectives of the participants. However, the data obtained provided insights into young people’s experiences of living with arthritis, and their use of medicines in the context of their daily lives. Conclusions: Online research with young people presents opportunities and challenges for researchers. Online blogging methodology has the potential to give young people and parents the space and empowerment to express their own ideas and concerns. However, this project suggests that it might not be the best way to engage a large, diverse group of young people, and might most effectively be combined with other approaches. Despite these limitations, the study provided valuable data about the experience and impact of living with a long-term condition from the perspectives of young people with arthritis. Clinical Trial: n/a
 
Date Submitted: Jun 16, 2014
Open Peer Review Period: Jun 16, 2014 - Aug 11, 2014
 
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WeScript: Collaborative and social note taking in medical lectures

Background: Longhand individual lecture notes are still one of the major sources of medical education today. Despite current trends of collaboration and social-media most students use not shareable or combinable individual paper-based lecture notes. Today most lectures provide no real-time feedback to the lecturer. Objective: In this work, a novel web-based software called WeScript for real-time collaborative taking of lecture notes with later creation of lecture manuscripts is established. Methods: Social-media techniques allow students to create lecture manuscripts based on shared contributions of their peers. For this an automatic text combination from multiple sources is used. The system follows a four phases approach from preparation to final manuscripts refinements. Results: As a result a prototype was produced and tested for proof-of-concept in lectures at curricular courses at RWTH Aachen University Medical School. Conclusions: A novel way of supporting collaborative note taking in medical lectures is established by WeScript. The system addresses issues with current state of the art approaches, like the coordination problem of multiple authors in one document. Additionally, self-directed learning is fostered by students’ individually generating manuscripts and the lecturer receiving instant feedback from students on several levels.
 
Date Submitted: Jun 12, 2014
Open Peer Review Period: Jun 12, 2014 - Aug 7, 2014
 
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Perspectives on Online Health Information Seeking and Communication Barriers from a Sample of Patients 50 years old and over

Background: As health care systems around the world shift toward models that emphasize self-care management, there is increasing pressure for patients to obtain health information online. It is critical that patients are both able to identify potential problems with online health information seeking and that they feel comfortable communicating with their doctor about the health information they acquire from the Internet. Objective: To examine patient identified 1) problems with using the Internet to diagnose and treat a health issue and 2) barriers to communication between patients and their doctors about health information obtained online. Methods: Semi-structured interviews were conducted with a sample of 56 adults age 50 years old and over who were in regular contact with a doctor and had experience using the Internet to identify and treat a health issue. A subset of 14 individuals who never discussed their online health searches with a doctor talked about barriers to communication. All respondents were also asked a set of close-ended demographic and Internet use questions. Results: Respondents were able to identify a range of concerns associated with using the Internet to diagnose and treat a health issue that were coded into seven distinct categories. On average, respondents who communicated with their doctor about their online health searches mentioned a greater number of potential problems with using the Internet to diagnose and treat a health issue and a greater proportion of these respondents mentioned problems that directly relate to health. Four themes regarding barriers to communication emerged: “Lack of thorough understanding of online information creates doubt and possible embarrassment”, “The doctor doesn’t want to hear about it”, “If it matters I just do it”, and “I forget to bring it up.” Conclusions: A high degree of awareness about potential problems with online health information seeking was evident among respondents. Findings provide support for theories of uncertainty management suggesting that avoidance behaviors and emotional responses can inhibit communication about health issues. Findings point to several reasons patients may avoid discussions about their online health searches, thus highlighting the need in some cases for doctors to initiate conversations about patient online health information seeking.
 
Date Submitted: Jun 9, 2014
Open Peer Review Period: Jun 9, 2014 - Aug 4, 2014
 
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Doctors’ attitudes towards and usage of online and social media: a national survey

Background: Doctors are uncertain of the ethical and legal obligations when communicating with patients online. Professional guidelines for patient-doctor interaction online have been written with limited quantitative data about doctors’ current usage and attitudes toward the medium. Further research into these trends will help to inform more focussed policy and guidelines for doctors communicating with patients online. Objective: To provide the first national profile of doctors’ use of, online social media and their attitudes to this. Methods: A quantitative, cross-sectional online survey of Australian doctors, using a random sample from a large representative database. Results: Of the 1500 doctors approached, 187 participated (12.5%). Most participants used social media privately, with only a quarter not using any social media websites at all (25.7%). One in five participants (19.4%) have received a ‘friend request’ from a patient. There is limited use of online communication in clinical practice; only 30.5% had communicated with a patient through email and fewer than half (48.1%) could offer their patients electronic forms of information if that were the patient’s preference. Three in five participants (60.8%) reported not being uncomfortable about interacting with patients who had accessed personal information about them online, prior to the consultation. Most of the participants (65.8%) were hesitant to immerse themselves more fully in social media and online communication due to concerns about public access and legal concerns. Conclusions: Doctors have limited confidence communicating appropriately with patients online, despite online and social media becoming an increasingly common feature of clinical practice. Additional training is required to assist doctors in protecting their personal information online, integrating online communication in patient care, and guidance on the best approach in ethically difficult online situations.
 
Date Submitted: Jun 8, 2014
Open Peer Review Period: Jun 9, 2014 - Aug 4, 2014
 
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