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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2017: 4.671, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (eg, in grant proposals), and for open peer-review purposes. We also invite patients to participate (eg, as peer-reviewers) and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

  • An all-in-one device for vital-sign monitoring. Source: Sebastian JH Bredie; Copyright: Sebastian JH Bredie; URL:; License: Creative Commons Attribution (CC-BY).

    Feasibility of a New Cuffless Device for Ambulatory Blood Pressure Measurement in Patients With Hypertension: Mixed Methods Study


    Background: Frequent home blood pressure (BP) measurements result in a better estimation of the true BP. However, traditional cuff-based BP measurements are troublesome for patients. Objective: This study aimed to evaluate the feasibility of a cuffless device for ambulatory systolic blood pressure (SBP) measurement. Methods: This was a mixed method feasibility study in patients with hypertension. Performance of ambulatory SBPs with the device was analyzed quantitatively by intrauser reproducibility and comparability to a classic home BP monitor. Correct use by the patients was checked with video, and user-friendliness was assessed using a validated questionnaire, the System Usability Scale (SUS). Patient experiences were assessed using qualitative interviews. Results: A total of 1020 SBP measurements were performed using the Checkme monitor in 11 patients with hypertension. Duplicate SBPs showed a high intrauser correlation (R=0.86, P<.001). SBPs measured by the Checkme monitor did not correlate well with those of the different home monitors (R=0.47, P=.007). However, the mean SBPs measured by the Checkme and home monitors over the 3-week follow-up were strongly correlated (R=0.75, P=.008). In addition, 36.4% (n=4) of the participants performed the Checkme measurements without any mistakes. The mean SUS score was 86.4 (SD 8.3). The most important facilitator was the ease of using the Checkme monitor. Most important barriers included the absence of diastolic BP and the incidental difficulties in obtaining an SBP result. Conclusions: Given the good intrauser reproducibility, user-friendliness, and patient experience, all of which facilitate patients to perform frequent measurements, cuffless BP monitoring may change the way patients measure their BP at home in the context of ambulant hypertension management.

  • Source: Unsplash; Copyright: Lesly Juarez; URL:; License: Licensed by the authors.

    Participant Engagement in and Perspectives on a Web-Based Mindfulness Intervention for 9-1-1 Telecommunicators: Multimethod Study


    Background: Demanding working conditions and secondary exposure to trauma may contribute to a high burden of stress among 9-1-1 telecommunicators, decreasing their ability to work effectively and efficiently. Web-based mindfulness-based interventions (MBIs) can be effective in reducing stress in similar populations. However, low engagement may limit the effectiveness of the intervention. Objective: The aim of this study was to assess participant engagement in a Web-based MBI designed for 9-1-1 telecommunicators. Specifically, we sought to describe the following: (1) participant characteristics associated with intervention engagement, (2) participant perspectives on engaging with the intervention, and (3) perceived challenges and facilitators to engaging. Methods: We used qualitative and quantitative data from participant surveys (n=149) that were collected to assess the efficacy of the intervention. We conducted descriptive and bivariate analyses to identify associations between demographic, psychosocial, and workplace characteristics and engagement. We conducted a thematic analysis of qualitative survey responses to describe participant experiences with the MBI. Results: We found that no individual participant characteristics were associated with the level of engagement (low vs high number of lessons completed). Participant engagement did vary by the call center (P<.001). We identified the following overarching qualitative themes: (1) the participants perceived benefits of mindfulness practice, (2) the participants perceived challenges to engage with mindfulness and the intervention, and (3) intervention components that facilitated engagement. The participants expressed positive beliefs in the perceived benefits of practicing mindfulness, including increased self-efficacy in coping with stressors and increased empathy with callers. The most commonly cited barriers were work-related, particularly not having time to participate in the intervention at work. Facilitators included shorter meditation practices and the availability of multiple formats and types of intervention content. Conclusions: The findings of this study suggest that efforts to improve intervention engagement should focus on organizational-level factors rather than individual participant characteristics. Future research should explore the effect of mindfulness practice on the efficiency and effectiveness of 9-1-1 telecommunicators at work. Trial Registration: NCT02961621;

  • Integrated Internet of Things button to gauge restroom cleanliness. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An Internet of Things Buttons to Measure and Respond to Restroom Cleanliness in a Hospital Setting: Descriptive Study


    Background: Restroom cleanliness is an important factor in hospital quality. Due to its dynamic process, it can be difficult to detect the presence of dirty restrooms that need to be cleaned. Using an Internet of Things (IoT) button can permit users to designate restrooms that need cleaning and in turn, allow prompt response from housekeeping to maintain real-time restroom cleanliness. Objective: This study aimed to describe the deployment of an IoT button–based notification system to measure hospital restroom cleanliness reporting system usage and qualitative feedback from housekeeping staff on IoT button use. Methods: We deployed IoT buttons in 16 hospital restrooms. Over an 8-month period, housekeeping staff received real-time notifications and responded to button presses for restroom cleaning. All button presses were recorded. We reported average button usage by hospital area, time of day, and day of week. We also conducted interviews with housekeeping supervisors and staff to understand their acceptance of and experience with the system. Results: Over 8 months, 1920 requests to clean restrooms in the main hospital lobby and satellite buildings were received. The hospital lobby IoT buttons received over half (N=1055, 55%) of requests for cleaning. Most requests occurred in afternoon hours from 3 PM to midnight. Requests for cleaning remained stable throughout the work week with fewer requests occurring over weekends. IoT button use was sustained throughout the study period. Interviews with housekeeping supervisors and staff demonstrated acceptance of the IoT buttons; actual use was centered around asynchronous communication between supervisors and staff in response to requests to clean restrooms. Conclusions: An IoT button system is a feasible method to generate on-demand request for restroom cleaning that is easy to deploy and that users will consistently engage with. Data from this system have the potential to enable responsive scheduling for restroom service and anticipate periods of high restroom utilization in a hospital.

  • Source: Pexels; Copyright: LinkedIn Sales Navigator; URL:; License: Licensed by the authors.

    Comparing Treatment Acceptability and 12-Month Cessation Rates in Response to Web-Based Smoking Interventions Among Smokers Who Do and Do Not Screen Positive...


    Background: Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required. Objective: The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS. Methods: Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS—either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records. Results: Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%; P=.03), PTSD (294/1215, 24.19%; P=.03), PD (229/1003, 23.83%; P=.009), and two or more ADS (323/1332, 24.25%; P=.03). Post hoc analyses suggest the lower quit rates may be associated with differences in baseline nicotine dependence and levels of commitment to resist smoking in difficult situations. Website use did not explain the differential abstinence rates. Conclusions: Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS. Trial registration: Clinical NCT01812278; (Archived by WebCite at

  • Source: Unsplash; Copyright: Hannah Wei; URL:; License: Licensed by the authors.

    Not Just a Headache: Qualitative Study About Web-Based Self-Presentation and Social Media Use by People With Migraine


    Background: To help with a long-term but invisible medical condition such as migraine, many people seek information and support on social media. The effect of using social media for people with migraine is not fully understood and remains to be investigated. Objective: The aim of this study was to describe how people with migraine use social media and how social media use affects their identity and sense of self. Methods: A total of 20 participants who experienced migraine were recruited via migraine-specific charities. Semistructured interviews were conducted with questions based on a topic guide. Interviews were transcribed verbatim, and transcripts were analyzed using thematic analysis. Results: People with migraine are using social media to obtain information to better understand their condition and treatment options. Social media offers instant access to continuous information and social support. This exchange of social support and information was viewed as mutually beneficial. Participants viewed social media as an outlet to vent frustrations and validate the migraine experience. Several participants pointed out that the invisible and episodic nature of migraine can lead to societal misunderstanding of the impact and or severity of their condition. Some participants masked their online migraine-related behavior using different sites or closed online groups to control who saw their migraine-related content. Participating in closed social media groups sometimes changed Web-based behavior in other areas of the platform. This illustrates the complex relationship between migraine, social media, and identity. Conclusions: How migraine is part of an individual’s identity and how this is represented online can vary. Social media can provide people who experience migraine with instant and continuous access to support and information, from a group of empathic others with similar lived experiences. Social media is used to validate the illness experience, as well as provide reassurance and help reduce feelings of isolation.

  • Source: Flickr; Copyright: Marco Verch Professional Photographer and Speaker; URL:; License: Creative Commons Attribution (CC-BY).

    Associations of Social Media Use With Physical Activity and Sleep Adequacy Among Adolescents: Cross-Sectional Survey


    Background: Adolescents’ use of social media, which has increased considerably in the past decade, has both positive and negative influences on adolescents’ health and health behaviors. As social media is the most prominent communication tool of choice for adolescents, it is important to understand the relationship between the frequency of social media use and health behaviors among this population. Objective: The objective of our study was to examine the associations between the frequency of social media use and physical activity and sleep adequacy among middle and high school students. Methods: We used data from the Monitoring the Future survey (2014 and 2015), a nationally representative, annual, cross-sectional survey of American 8th-, 10th-, and 12th-grade students (N=43,994). Health behaviors examined were frequency of vigorous physical activity and frequency of getting 7 hours of sleep (never/seldom, sometimes, and every day/nearly every day). We measured frequency of social media use using a Likert-like scale (never, a few times a year, 1-2 times a month, once a week, or every day). Multivariable generalized ordered logistic regressions examined the association of social media use with different levels of physical activity and sleep. We estimated marginal effects (MEs) for the main independent variable (social media use frequency) by holding all other variables at their observed values. Results: The study population comprised 51.13% (21,276/42,067) female students, 37.48% (17,160/43,994) from the South, and 80.07% (34,953/43,994) from a metropolitan area, with 76.90% (33,831/43,994) reporting using social media every day. Among physically active students, frequent social media use was associated with a higher likelihood of vigorous daily exercise (ME 50.1%, 95% CI 49.2%-51.0%). Among sedentary students, frequent social media use was associated with a lower likelihood of vigorous daily exercise (ME 15.8%, 95% CI 15.1%-16.4%). Moderately active students who used social media once or twice a month had the highest likelihood of reporting vigorous daily exercise (ME 42.0%, 95% CI 37.6%-46.3%). Among those who normally got adequate sleep, daily social media users were least likely to report adequate sleep (ME 41.3%, 95% CI 40.4%-42.1%). Among those who were usually sleep deprived, daily social media users were more likely to report adequate sleep (ME 18.3%, 95% CI 17.6%-19.0%). Conclusions: Regular social media use every day was associated with a reinforcement of health behaviors at both extremes of health behaviors, whereas a medium intensity of social media use was associated with the highest levels of physical activity and lowest sleep adequacy among those with moderate health behaviors. Hence, finding an optimal level of social media use that is beneficial to a variety of health behaviors would be most beneficial to adolescents who are in the middle of the health behavior spectrum.

  • A young man performing a vape trick. Source: Flickr; Copyright: rpavich; URL:; License: Creative Commons Attribution (CC-BY).

    Promotion of Vape Tricks on YouTube: Content Analysis


    Background: The ability to perform vape tricks (ie, blowing large vapor clouds or shapes like rings) using e-cigarettes appeals to youth. Vape tricks are promoted on social media, but the promotion of vape tricks on social media is not well understood. Objective: The aim of this study was to examine how vape tricks were promoted on YouTube to youth. Methods: Videos on vape tricks that could be accessed by underage youth were identified. The videos were coded for number of views, likes, dislikes, and content (ie, description of vape tricks, e-cigarette devices used for this purpose, video sponsors [private or industry], brand marketing, and contextual characteristics [eg, model characteristics, music, and profanity]). Results: An analysis of 59 sample videos on vape tricks identified 25 distinct vape tricks. These videos had more likes than dislikes (11 to 1 ratio) and a 32,017 median view count. 48% (28/59) of the videos were posted by industry accounts (27% [16/59] provaping organizations, 15% [9/59] online shops, and 3% [2/59] vape shops) and 53% by private accounts (55% [17/31] private users, 26% [8/31] vape enthusiasts, and 19% [6/31] YouTube influencers); 53% (31/59) of the videos promoted a brand of e-cigarette devices, e-liquids, or online/vape shops, and 99% of the devices used for vape tricks were advanced generation devices. The models in the videos were 80.2% (160/198) male, 51.5% white (102/198), and 61.6% (122/198) aged 18 to 24 years; 85% (50/59) of the videos had electronic dance music and hip hop, and 32% (19/59) had profanity. Conclusions: Vape trick videos on YouTube, about half of which were industry sponsored, were accessible to youth. Restrictions of e-cigarette marketing on social media, such as YouTube, are needed.

  • MSM after HIV risk assessment is searching for an HIV testing service. Source: Image created by the Authors; Copyright: Ke Yun; URL:; License: Creative Commons Attribution (CC-BY).

    Development and Validation of a Personalized Social Media Platform–Based HIV Incidence Risk Assessment Tool for Men Who Have Sex With Men in China


    Background: Personalized risk assessments can help medical providers determine targeted populations for counseling and risk reduction interventions. Objective: The objective of this study was to develop a social media platform–based HIV risk prediction tool for men who have sex with men (MSM) in China based on an independent MSM cohort to help medical providers determine target populations for counseling and risk reduction treatments. Methods: A prospective cohort of MSM from Shenyang, China, followed from 2009 to 2016, was used to develop and validate the prediction model. The eligible MSM were randomly assigned to the training and validation dataset, and Cox proportional hazards regression modeling was conducted using predictors for HIV seroconversion selected by the training dataset. Discrimination and calibration were performed, and the related nomogram and social media platform–based HIV risk assessment tool were constructed. Results: The characteristics of the sample between the training dataset and the validation dataset were similar. The risk prediction model identified the following predictors for HIV seroconversion: the main venue used to find male sexual partners, had condomless receptive or insertive anal intercourse, and used rush poppers. The model was well calibrated. The bootstrap C-index was 0.75 (95% CI 0.65-0.85) in the training dataset, and 0.60 (95% CI 0.45-0.74) in the validation dataset. The calibration plots showed good agreement between predicted risk and the actual proportion of no HIV infection in both the training and validation datasets. Nomogram and WeChat-based HIV incidence risk assessment tools for MSM were developed. Conclusions: This social media platform–based HIV infection risk prediction tool can be distributed easily, improve awareness of personal HIV infection risk, and stratify the MSM population based on HIV risk, thus informing targeted interventions for MSM at greatest risk for HIV infection.

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

    Mobile Apps for Increasing Treatment Adherence: Systematic Review


    Background: It is estimated that 20% to 50% of patients do not take their medication correctly, and this leads to increased morbidity and inefficacy of therapeutic approaches. Fostering treatment adherence is a priority objective for all health systems. The growth of mobile apps to facilitate therapeutic adherence has significantly increased in recent years. However, the effectiveness of the apps for this purpose has not been evaluated. Objective: This study aimed to analyze whether mobile apps are perceived as useful for managing medication at home and if they actually contribute to increasing treatment adherence in patients. Methods: We carried out a systematic review of research published using Scopus, Cochrane Library, ProQuest, and MEDLINE databases and analyzed the information about their contribution to increasing therapeutic adherence and the perceived usefulness of mobile apps. This review examined studies published between 2000 and 2017. Results: Overall, 11 studies fulfilled the inclusion criteria. The sample sizes of these studies varied between 16 and 99 participants. In addition, 7 studies confirmed that the mobile app increased treatment adherence. In 5 of them, the before and after adherence measures suggested significant statistical improvements, when comparing self-reported adherence and missed dose with a percentage increase ranging between 7% and 40%. The users found mobile apps easy to use and useful for managing their medication. The patients were mostly satisfied with their use, with an average score of 8.1 out of 10. Conclusions: The use of mobile apps helps increase treatment adherence, and they are an appropriate method for managing medication at home.

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

    Implementation of a Web-Based Work-Related Psychological Aftercare Program Into Clinical Routine: Results of a Longitudinal Observational Study


    Background: As inpatient medical rehabilitation serves to promote work ability, vocational reintegration is a crucial outcome. However, previous Web-based trials on coping with work-related stress have been limited to Web-based recruitment of study participants. Objective: The aim of our study was to evaluate the implementation of an empirically supported transdiagnostic psychodynamic Web-based aftercare program GSA (Gesund und Stressfrei am Arbeitsplatz [Healthy and stress-less at the workplace])-Online plus into the clinical routine of inpatient medical rehabilitation, to identify characteristics of patients who have received the recommendation for GSA-Online plus, and to determine helpfulness of the intervention and satisfaction of the participants as well as improvement in quality of life and mental health status of the regular users of GSA-Online plus. Methods: GSA-Online plus was prescribed by physicians at termination of orthopedic psychosomatic inpatient rehabilitation. Participants’ use of the program, work-related attitudes, distress, and quality of life were assessed on the Web. Results: In 2 rehabilitation centers, 4.4% (112/2562) of rehabilitants got a recommendation for GSA-Online plus during inpatient rehabilitation. Compared with usual person aftercare, the Web-based aftercare program was rarely recommended by physicians. Recommendations were made more frequently in psychosomatic (69/1172, 5.9%) than orthopedic (43/1389, 3.1%) rehabilitation (χ2 1=11.845, P=.001, Cramér V=−0.068) and to younger patients (P=.004, d=0.28) with longer inpatient treatment duration (P<.001, r=−0.12) and extended sick leaves before inpatient medical rehabilitation (P=.004; Cramér V=0.072). Following recommendation, 77% (86/112) of rehabilitants participated in Web-based aftercare. Completers (50/86, 58%) reported statistically significant improvements between discharge of inpatient treatment and the end of the aftercare program for subjective work ability (P=.02, d=0.41), perceived stress (P=.01, d=−0.38), functioning (P=.002, d=−0.60), and life satisfaction (P=.008, d=0.42). Conclusions: Physicians’ recommendations of Web-based aftercare are well accepted by patients who derive considerable benefits from participation. However, a low rate of prescription compared with other usual aftercare options points to barriers among physicians to prescribing Web-based aftercare.

  • Source: Freepik; Copyright: freepik; URL:; License: Licensed by JMIR.

    The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review


    Background: With the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model–based health technology assessment approach. Objective: The aim of this study was to perform a systematic review of the decision analytic model–based studies evaluating the cost-effectiveness of DHIs on the management of CVDs. Methods: A literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients’ cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards. Results: A total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50%) and stroke (4/14, 29%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64%) studies were published between 2015 and 2018 and 5 (36%) published between 2011 and 2014. The time horizon was ≤1 year in 3 studies (21%), >1 year in 10 studies (71%), and 1 study (7%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7%), telephone support (1/14, 7%), mobile app (1/14, 7%), video conferencing system (5/14, 36%), digital transmission of physiologic data (telemonitoring; 5/14, 36%), and wearable medical device (1/14, 7%). The DHIs gained higher QALYs with cost saving in 43% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57% (8/14) of studies. The studies were classified as excellent (0/14, 0%), good (9/14, 64%), moderate (4/14, 29%), and low (1/14, 7%) quality. Conclusions: This study is the first systematic review of decision analytic model–based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective.

  • Source: Flickr; Copyright: Tim Samoff; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Context-Aware Systems for Chronic Disease Patients: Scoping Review


    Background: Context-aware systems, also known as context-sensitive systems, are computing applications designed to capture, interpret, and use contextual information and provide adaptive services according to the current context of use. Context-aware systems have the potential to support patients with chronic conditions; however, little is known about how such systems have been utilized to facilitate patient work. Objective: This study aimed to characterize the different tasks and contexts in which context-aware systems for patient work were used as well as to assess any existing evidence about the impact of such systems on health-related process or outcome measures. Methods: A total of 6 databases (MEDLINE, EMBASE, CINAHL, ACM Digital, Web of Science, and Scopus) were scanned using a predefined search strategy. Studies were included in the review if they focused on patients with chronic conditions, involved the use of a context-aware system to support patients’ health-related activities, and reported the evaluation of the systems by the users. Studies were screened by independent reviewers, and a narrative synthesis of included studies was conducted. Results: The database search retrieved 1478 citations; 6 papers were included, all published from 2009 onwards. The majority of the papers were quasi-experimental and involved pilot and usability testing with a small number of users; there were no randomized controlled trials (RCTs) to evaluate the efficacy of a context-aware system. In the included studies, context was captured using sensors or self-reports, sometimes involving both. Most studies used a combination of sensor technology and mobile apps to deliver personalized feedback. A total of 3 studies examined the impact of interventions on health-related measures, showing positive results. Conclusions: The use of context-aware systems to support patient work is an emerging area of research. RCTs are needed to evaluate the effectiveness of context-aware systems in improving patient work, self-management practices, and health outcomes in chronic disease patients.

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  • Randomized, Controlled Trial of an Information and Communication Technology-based Health Management Program for Patients with Cardiovascular Risk

    Date Submitted: Jun 16, 2019

    Open Peer Review Period: Jun 19, 2019 - Aug 14, 2019

    Background: In addition to medication, the management of health behavior is crucial in patients with multiple risks of cardiovascular mortality. Objective: This study aimed to examine the efficacy of...

    Background: In addition to medication, the management of health behavior is crucial in patients with multiple risks of cardiovascular mortality. Objective: This study aimed to examine the efficacy of a self-management strategy-based information and communication technology (ICT) program. Methods: Methods: This was a randomized, controlled trial of a self-management strategy-based ICT program (n = 53) versus an attention control (n = 53) in 106 patients with at least one indicator of poor disease control and who had hypertension, diabetes, or hypercholesterolemia. Intervention group were provided with the program. Control subjects received basic educational material concerning disease content. The primary outcome was the percentage of patients achieving three clinical indicators after 3 months: HbA1c < 7.0%, systolic blood pressure (SBP) < 130 mmHg, or LDL cholesterol < 130 mg/dL. Results: Results: The intervention group showed a significantly high success rate for achieving all three clinical indicators (p = 0.016). Only patients with hypertension showed a significant improvement in SBP from baseline as compared to controls (72.8% vs 35.7%, p = 0.035). There was a significant reduction in HbA1c in the intervention group compared to controls (difference = 0.54%, p = 0.014). In the intervention group, 20% of patients with diabetes exhibited a ≥ 1% decrease in HbA1c (vs. 0% among controls, p = 0.038). Conclusions: Conclusion: A short-term self-management strategy-based ICT intervention may improve clinical outcomes among patients with cardiovascular risk. Clinical Trial: NCT03294044

  • Developing and applying a formative evaluation framework for health information technology implementations – The Technology, People, Organizations and Macro-environmental factors (TPOM) Framework

    Date Submitted: Jun 17, 2019

    Open Peer Review Period: Jun 18, 2019 - Aug 13, 2019

    Background: There is currently a lack of comprehensive, yet intuitive and usable formative evaluation frameworks of health information technology (HIT) implementations. Objective: We therefore sought...

    Background: There is currently a lack of comprehensive, yet intuitive and usable formative evaluation frameworks of health information technology (HIT) implementations. Objective: We therefore sought to develop and apply such a framework: the Technology, People, Organizations and Macro-environmental factors (TPOM) Framework. Methods: We drew on qualitative data from three national formative evaluations of different HIT (i.e. electronic health record, electronic prescribing and clinical decision support functionality) interventions. The combined dataset comprised 703 semi-structured interviews, 663 hours of observations and 864 documents gathered from a range of care settings across NHS England and NHS Scotland. Data analysis took place over a period of 10 years guided by a framework we iteratively developed that was informed by the existing evidence base. Results: TPOM dimensions are intimately related and each include a number of sub-themes that evaluators need to consider. Whilst technological functionalities are crucial in getting an initiative off the ground, system design needs to be cognizant of the accompanying social and organizational transformations required to ensure that technologies deliver the desired value for a variety of stakeholders. Wider structural changes, characterized by shifting policy landscapes and markets, influence technologies and the ways these are used by organizations and staff. Conclusions: The TPOM Framework supports formative evaluations of health IT implementation and digitally enabled transformation efforts. There is now a need for prospective application of the TOPM Framework to determine its value.

  • There’s more to the picture than meets the eye: the mechanisms responsible for improved information transfer in avatar-based patient monitoring explained by eye-tracking.

    Date Submitted: Jun 17, 2019

    Open Peer Review Period: Jun 18, 2019 - Aug 13, 2019

    Background: Patient monitoring is central to the safety of state-of-the-art perioperative and intensive care medicine. While current state-of-the-art patient monitors display vital signs in the form o...

    Background: Patient monitoring is central to the safety of state-of-the-art perioperative and intensive care medicine. While current state-of-the-art patient monitors display vital signs in the form of numbers and curve forms, Visual Patient technology creates an easy to interpret virtual patient avatar model, which, in a previous study, enabled anesthesia providers to perceive more vital sign information during short glances than conventional monitoring. Objective: In this study, we used eye-tracking technology to study the deeper mechanisms underlying information perception in both, conventional and avatar-based patient monitoring. Methods: In this prospective, multi-center study with a within subject design, we showed 32 anesthesia experts (physicians and nurse anesthetists) a total of four 3- and 10-second monitoring scenarios alternatingly as either routine conventional or avatar-based monitoring in random sequence. All participants observed the same scenarios with both monitoring technologies. After each scenario, we asked participants to report the status of the vital signs. Using an eye-tracker, we recorded the participants’ gaze paths as they observed the scenarios. From the eye-tracking recordings, we evaluated which vital signs the participants had visually fixated, how often and for how long during a scenario, and therefore, could have potentially read and perceived this vital sign. We compared the frequencies and durations with which the participants had visually fixated the vital signs between the two monitoring technologies. Results: Participants visually fixated more vital signs per scenario, median (IQR): 10 (9-11) vs. 6 (4-8), p<0.001 in avatar-based monitoring (median of differences: 3 vital signs (95% confidence interval [95%CI 3-4]). In all four scenarios, the participants visually fixated nine of the 11 total vital signs shown statistically significantly longer using the avatar. Four critical vital signs, i.e., pulse rate, blood pressure, oxygen saturation, and respiratory rate were visible almost the entire time of a scenario with avatar-based monitoring, while with conventional monitoring, these were only visible for fractions of the observations. Visual fixation of a certain vital sign was associated with the correct perception of that certain vital sign in both technologies. Phi coefficient for avatar: 0.358, for conventional monitoring: 0.515, both p<0.001. Conclusions: This study uncovered, by use of eye-tracking, one of the mechanisms responsible for the improved information transfer in avatar-based monitoring. The design of the avatar technology, which presents the information about multiple vital signs integrated into forms and colors of the corresponding anatomical parts of a patient avatar model results in more information being visible with every visual fixation. With this finding confirmed by eye-tracking, this study adds a new and higher level of empirical evidence as to why avatar-based monitoring improves the perception of vital sign information compared to conventional monitoring.

  • Implementing Clinical Genomic Sequencing Report in Electronic Health Record System Based on International Standards

    Date Submitted: Jun 14, 2019

    Open Peer Review Period: Jun 17, 2019 - Aug 12, 2019

    Background: Despite the rapid adoption of genomic sequencing in clinical practice, clinical sequencing reports in electronic health record (EHR) systems are currently being written in unstructured for...

    Background: Despite the rapid adoption of genomic sequencing in clinical practice, clinical sequencing reports in electronic health record (EHR) systems are currently being written in unstructured formats such as PDF or free text. These formats hinder the implementation of a clinical decision support system and secondary research applications. Therefore, there is an urgent need to standardize genomic sequencing reports in EHR systems. Objective: To implement standardized machine-processable clinical sequencing reports in an EHR system, the ISO/TS 20428 international standard was developed for a structured template. This study aims to verify the actual use of the ISO/TS 20428 standard in clinical practice settings. Methods: Here, we describe the practical implementation of ISO/TS 20428 using Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) genomics implementation guidance to efficiently deliver required genomic sequencing results to clinicians through an EHR system. Results: We successfully administered a structured genomic sequencing report in a tertiary hospital in Korea based on international standards. In total, 90 FHIR resources were used. Among 41 resources for the required fields, 26 were reused and 15 were extended. For the optional fields, 28 were reused and 21 were extended. Conclusions: To share and apply genomic sequencing data in both clinical practice and translational research, it is essential to identify the applicability of the standard based information system in a practical setting. This prototyping work proves that clinical genomics sequencing reporting data can be effectively implemented in an EHR system using the existing ISO/TS 20428 standard and FHIR resources.

  • Forecasting Mood in Bipolar Disorder from Smartphone
Self-assessments with Hierarchical Bayesian Models

    Date Submitted: Jun 13, 2019

    Open Peer Review Period: Jun 17, 2019 - Aug 12, 2019

    Background: Bipolar disorder is a prevalent mental disease imposing a high societal burden. Accurate forecasting of symptom scores can be used to improve disease monitoring, enable early intervention...

    Background: Bipolar disorder is a prevalent mental disease imposing a high societal burden. Accurate forecasting of symptom scores can be used to improve disease monitoring, enable early intervention and eventually help prevent costly hospitalizations. While several studies have examined the use of smartphone data to detect mood, only few studies deal with forecasting mood one or more days ahead of time. Objective: The objective of this work is to examine the feasibility of forecasting daily subjective mood based on daily self-assessments collected from bipolar disorder patients via a smartphone-based system in a randomized clinical trial. Methods: We apply hierarchical Bayesian regression models, a multi-task learning method, to account for individual differences and forecast mood up to seven days ahead based on 15,975 smartphone self-assessments from 84 bipolar disorder patients participating in a randomized clinical trial. We report the results of two time-series cross-validation one day ahead prediction experiments corresponding to two different real-world scenarios and compare the outcomes to commonly used baselines methods. We then apply the best model to evaluate a seven-day forecast. Results: The best performing model used a history of 4 days of self-assessments to predict future mood scores with historical mood being the most important predictor variable. The proposed hierarchical Bayesian regression model outperformed pooled and separate models in a one-day forecast time series cross-validation experiment and achieved predicted R^2=0.51 and RMSE=0.32 for mood scores on a scale of -3 to 3. When increasing the forecast horizon, forecast errors also increase and the forecast regresses towards the mean of the data distribution. Conclusions: We found that our proposed method can forecast mood several days ahead with low error compared to common baseline methods. The applicability of a mood forecast in clinical treatment of bipolar disorder is also discussed.

  • Exploring Factors Influencing Patients’ Intention to Use Diabetes Management Mobile Apps Based on an Integrated Theoretical Model—a Web-Based Survey in China

    Date Submitted: Jun 13, 2019

    Open Peer Review Period: Jun 13, 2019 - Jun 21, 2019

    Background: Diabetes poses heavy social and economic burdens on the world. Diabetes management mobile apps show great potential for diabetes self-management. However, the uptake of diabetes apps among...

    Background: Diabetes poses heavy social and economic burdens on the world. Diabetes management mobile apps show great potential for diabetes self-management. However, the uptake of diabetes apps among diabetes patients is poor. The factors influencing patients’ intention to use these apps are unclear. Understanding patients’ behavioral intention is necessary to support the development and promotion of diabetes app use. Objective: To identify the determinants of patients’ intention to use diabetes apps based on an integrated theoretical model. Methods: The hypotheses of our research model were developed based on the Unified Theory of Acceptance and Use of Technology (UTAUT) integrated with context-related hypotheses. From 20 April to 20 May 2019, adult diabetes patients across China who were familiar with diabetes management mobile apps were surveyed using the web-based survey tool Sojump (Changsha ran Xing InfoTech Ltd). Structural equation modeling was used to analyze the data. Results: A total of 746 qualified questionnaires were collected. The fitness indices suggested that the collected data fit well with the research model. The model explained 62.6% of the variance in performance expectancy and 57.1% of the variance in behavioral intention. Performance expectancy and social influence had the strongest total effects on behavioral intention (β=.482 p=0.001). Performance expectancy (β=.482 P=.001), social influence (β=.223 P=.003), facilitating conditions (β=.17 P=.006), perceived disease threat (β=.073 P=.005) and perceived privacy risk (β=-.073 P=.012) had direct effects on behavioral intention. Additionally, social influence, effort expectancy and facilitating conditions had indirect effects on behavioral intention that were mediated by performance expectancy. Social influence had the highest indirect effects among the three constructs (β=.259 P=.001). Conclusions: Performance expectancy and social influence are the most important determinants of the intention to use diabetes apps. Healthcare technology companies must improve the usefulness of apps and carry out research to provide clinical evidence for the apps’ effectiveness, which will benefit the promotion of these apps. Facilitating conditions and perceived privacy risk also have an impact on behavioral intention. Therefore, it is necessary to improve facilitating conditions and provide solid privacy protection. Our study supports the use of UTAUT in explaining patients’ intention to use diabetes management mobile apps. Context-related determinants should also be taken into consideration.