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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 2018: 4.945, ranked #1 out of 26 journals in the medical informatics category) 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 a 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 an open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as with 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:

  • Source: Pexels / Pixabay; Copyright: Pexels; URL:; License: Licensed by JMIR.

    A Comparison of Physical Activity Mobile Apps With and Without Existing Web-Based Social Networking Platforms: Systematic Review


    Background: Physical activity mobile apps present a unique medium to disseminate scalable interventions to increase levels of physical activity. However, the effectiveness of mobile apps has previously been limited by low levels of engagement. Existing Web-based social networking platforms (eg, Facebook and Twitter) afford high levels of popularity, reach, and sustain engagement and, thus, may present an innovative strategy to enhance the engagement, and ultimately the effectiveness of mobile apps. Methods: A systematic review was conducted by following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines. A systematic search of the following databases was conducted: Medline, PsycINFO, Web of Science, Scopus, CINAHL, ProQuest, SPORTDiscus, EMBASE, and Cochrane. According to the comparative objective of this review, 2 independent literature searches were conducted. The first incorporated terms related to apps and physical activity; the second also incorporated terms related to Web-based social networking. The results of the two searches were synthesized and compared narratively. Results: A total of 15 studies were identified, 10 incorporated a physical activity app alone and 5 incorporated an app in conjunction with an existing Web-based social networking platform. Overall, 10 of the 15 interventions were effective in improving one or more physical activity behaviors. Specifically, improvements in physical activity behaviors were reported in 7 of the 10 interventions incorporating physical activity apps alone and in 3 of the 5 interventions incorporating physical activity apps in conjunction with existing Web-based social networking platforms. Interventions incorporating physical activity apps alone demonstrated a decline in app engagement. In contrast, the physical activity apps in conjunction with existing Web-based social networking platforms showed increased and sustained intervention engagement. Conclusions: The interventions incorporating physical activity apps in conjunction with and without existing Web-based social networking platforms demonstrated effectiveness in improving physical activity behaviors. Notably, however, the interventions that incorporated existing Web-based social networking platforms achieved higher levels of engagement than those that did not. This review provides preliminary evidence that existing Web-based social networking platforms may be fundamental to increase engagement with physical activity interventions.

  • Source: Flickr; Copyright: Orbis - Giving the gift of sight; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Implementation and Evaluation of a Web-Based Distribution System For Anesthesia Department Guidelines and Standard Operating Procedures: Qualitative Study...


    Background: Digitization is spreading exponentially in medical care, with improved availability of electronic devices. Guidelines and standard operating procedures (SOPs) form an important part of daily clinical routine, and adherence is associated with improved outcomes. Methods: A content management system (CMS), WordPress, was set up in 2 tertiary-level hospitals within 1 year: the Department of Anesthesiology and Pain Medicine at the Kantonsspital Lucerne in Lucerne, Switzerland, as an open-access system, followed by a similar system for internal usage in the Department of Anaesthesiology and Pain Medicine of the Inselspital, Bern University Hospital, in Bern, Switzerland. We analyzed the requirements and implementation processes needed to successfully set up these systems, and we evaluated the systems’ impact by analyzing content and usage. Results: The systems’ generated exportable metadata, such as traffic and content. Analysis of the exported metadata showed that the Lucerne website had 269 pages managed by 44 users, with 88,124 visits per month (worldwide access possible), and the Bern website had 341 pages managed by 35 users, with 1765 visits per month (access only possible from within the institution). Creation of an open-access system resulted in third-party interest in the published guidelines and SOPs. The implementation process can be performed over the course of 1 year and setup and maintenance costs are low. Conclusions: A CMS, such as WordPress, is a suitable solution for distributing and managing guidelines and SOPs. Content is easily accessible and is accessed frequently. Metadata from the system allow live monitoring of usage and suggest that the system be accepted and appreciated by the users. In the future, Web-based solutions could be an important tool to handle guidelines and SOPs, but further studies are needed to assess the effect of these systems.

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Medium-Term Effects of a Tailored Web-Based Parenting Intervention to Reduce Adolescent Risk of Depression and Anxiety: 12-Month Findings From a Randomized...


    Background: Prevention of depression and anxiety disorders early in life is a global health priority. Evidence on risk and protective factors for youth internalizing disorders indicates that the family represents a strategic setting to target preventive efforts. Despite this evidence base, there is a lack of accessible, cost-effective preventive programs for parents of adolescents. To address this gap, we recently developed the Partners in Parenting (PiP) program—an individually tailored Web-based parenting program targeting evidence-based parenting risk and protective factors for adolescent depression and anxiety disorders. We previously reported the postintervention outcomes of a single-blinded parallel-group superiority randomized controlled trial (RCT) in which PiP was found to significantly improve self-reported parenting compared with an active-control condition (educational factsheets). Objective: This study aimed to evaluate the effects of the PiP program on parenting risk and protective factors and symptoms of adolescent depression and anxiety using data from the final assessment time point (12-month follow-up) of this RCT. Methods: Parents (n=359) and adolescents (n=332) were recruited primarily from secondary schools and completed Web-based assessments of parenting and adolescent depression and anxiety symptoms at baseline, postintervention (3 months later), and 12-month follow-up (317 parents, 287 adolescents). Parents in the PiP intervention condition received personalized feedback about their parenting and were recommended a series of up to 9 interactive modules. Control group parents received access to 5 educational factsheets about adolescent development and mental health. Both groups received a weekly 5-min phone call to encourage progress through their program. Results: Intervention group parents completed an average of 73.7% of their intended program. For the primary outcome of parent-reported parenting, the intervention group showed significantly greater improvement from baseline to 12-month follow-up compared with controls, with a medium effect size (Cohen d=0.51; 95% CI 0.30 to 0.72). When transformed data were used, greater reduction in parent-reported adolescent depressive symptoms was observed in the intervention group (Cohen d=−0.21; 95% CI −0.42 to −0.01). Mediation analyses revealed that these effects were mediated by improvements in parenting (indirect effect b=−0.08; 95% CI −0.16 to −0.01). No other significant intervention effects were found for adolescent-reported parenting or adolescent depression or anxiety symptoms. Both groups showed significant reductions in anxiety (both reporters) and depressive (parent reported) symptoms. Conclusions: PiP improved self-reported parenting for up to 9 months postintervention, but its effects on adolescent symptoms were less conclusive, and parent-reported changes were not perceived by adolescents. Nonetheless, given its scalability, PiP may be a useful low-cost, sustainable program to empower parents of adolescents. Trial Registration: Australian Clinical Trials Registration Number (ACTRN): 12615000328572; (Archived by WebCite at

  • To produce own health data in any context. Source: Image created by the Authors; Copyright: Therese Scott Duncan; URL:; License: Creative Commons Attribution (CC-BY).

    From Information Seekers to Innovators: Qualitative Analysis Describing Experiences of the Second Generation of E-Patients


    Background: Current health care systems are rarely designed to meet the needs of people living with chronic conditions. However, some patients and informal caregivers are not waiting for the health care system to redesign itself. These individuals are sometimes referred to as e-patients. The first generation of e-patients used the internet for finding information and for communicating with peers. Compared with the first generation, the second generation of e-patients collects their own health data and appears to be more innovative. Objective: The aim of this study was to describe the second generation of e-patients through exploration of their active engagement in their self-care and health care. Methods: Semistructured interviews were conducted with 10 patients with chronic conditions and 5 informal caregivers. They were all recruited through a Web-based advertisement. Data were analyzed according to the framework analysis approach, using the 3 concepts of the self-determination theory—autonomy, relatedness, and competence—at the outset. Results: Study participants were actively engaged in influencing their self-care and the health care system to improve their own health, as well as the health of others. This occurred at different levels, such as using their own experience when giving presentations and lectures to health care professionals and medical students, working as professional peers in clinical settings, performing self-tracking, contributing with innovations, and being active on social media. When interaction with health care providers was perceived as being insufficient, the participants sought support through their peers, which showed strong relatedness. Competence increased through the use of technology and learning experiences with peers. Their autonomy was important but was sometimes described as involuntary and to give up was not an option for them. Conclusions: Like the first generation of e-patients, the participants frequently searched for Web-based information. However, the second generation of e-patients also produce their own health data, which they learn from and share. They also engage in the innovation of digital tools to meet health-related needs. Utilizing technological developments comes naturally to the second generation of e-patients, even if the health care system is not prepared to support them under these new circumstances.

  • The BENECA app (montage). Source: The Authors / Freepik (; Copyright: The Authors; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Association Between the Use of a Mobile Health Strategy App and Biological Changes in Breast Cancer Survivors: Prospective Pre-Post Study


    Background: There is a bidirectional relationship between chronic low-grade inflammation and cancer. Inflammatory markers, such as interleukin-6 (IL-6), have been associated with both the malignant transformation of epithelial cells and tumor progression, thus linking low-grade inflammation with a higher risk of cancer and recurrence in the survival phase. Therefore, they are considered valuable prognostic biomarkers. Knowing and finding appropriate primary prevention strategies to modify these parameters is a major challenge in reducing the risk of cancer recurrence and increasing survival. Different therapeutic strategies have shown efficacy in the modification of these and other biological parameters, but with contradictory results. There are apparently no strategies in which telemedicine, and specifically mobile health (mHealth), are used as a means to potentially cause biological changes. Objective: The objectives of this study were to: (1) check whether it is feasible to find changes in inflammation biomarkers through an mHealth strategy app as a delivery mechanism of an intervention to monitor energy balance; and (2) discover potential predictors of change of these markers in breast cancer survivors (BCSs). Methods: A prospective quasi-experimental pre-post study was conducted through an mHealth energy balance monitoring app with 73 BCSs, defined as stage I-IIIA of breast cancer and at least six months from the completion of the adjuvant therapy. Measurements included were biological salivary markers (IL-6 and C-reactive protein [CRP]), self-completed questionnaires (the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, the user version of the Mobile Application Rating Scale [uMARS] and an ad hoc clinical and sociodemographic questionnaire) and physical objective measures (accelerometry, weight and height). In addition, using the logging data of the mHealth app, the rate of use (in days) was recorded during the entire experimental phase of the study. Using Stata software, a paired two-tailed t test, Pearson and Spearman correlations, and a stepwise multiple regression analysis were used to interpret the data. Results: Analyzing changes in inflammatory biomarker concentrations after using the mHealth app, differences between preassessment CRP (4899.04 pg/ml; SD 1085.25) and IL-6 (87.15 pg/ml; SD 33.59) and postassessment CRP (4221.24 pg/ml; SD 911.55) and IL-6 (60.53 pg/ml; SD 36.31) showed a significant decrease in both markers, with a mean difference of –635.25 pg/ml (95% CI –935.65 to –334.85; P<.001) in CRP and –26.61 pg/ml (95% CI –42.51 to –10.71; P=.002) in IL-6. Stepwise regression analyses revealed that changes in global quality of life, as well as uMARS score and hormonal therapy, were possible predictors of change in CRP concentration after using the mHealth app. In the same way, the type of tumor removal surgery conducted, as well as changes in weight and pain score, were possible predictors of change in IL-6 concentration after using the app. Conclusions: In conclusion, through the results of this study, we hypothesize that there is a possible association between an mHealth energy balance monitoring strategy and biological changes in BCSs. These changes could be explained by different biopsychosocial parameters, such as the use of the application itself, quality of life, pain, type of tumor removal surgery, hormonal treatment or obesity.

  • Source: Pexels; Copyright:; URL:; License: Licensed by JMIR.

    Adherence Reporting in Randomized Controlled Trials Examining Manualized Multisession Online Interventions: Systematic Review of Practices and Proposal for...


    Background: Adherence reflects the extent to which individuals experience or engage with the content of online interventions and poses a major challenge. Neglecting to examine and report adherence and its relation to outcomes can compromise the interpretation of research findings. Objective: The aim of this systematic review is to analyze how adherence is accounted for in publications and to propose standards for measuring and reporting adherence to online interventions. Methods: We performed a systematic review of randomized controlled trials on online interventions for the prevention and treatment of common mental disorders (depression, anxiety disorders, substance related disorders, and eating disorders) published between January 2006 and May 2018 and indexed in Medline and Web of Science. We included primary publications on manualized online treatments (more than 1 session and successive access to content) and examined how adherence was reported in these publications. Results: We identified 216 publications that met our inclusion criteria. Adherence was addressed in 85% of full-text manuscripts, but only in 31% of abstracts. A median of three usage metrics were reported; the most frequently reported usage metric (61%) was intervention completion. Manuscripts published in specialized electronic health journals more frequently included information on the relation of adherence and outcomes. Conclusions: We found substantial variety in the reporting of adherence and the usage metrics used to operationalize adherence. This limits the comparability of results and impedes the integration of findings from different studies. Based on our findings, we propose reporting standards for future publications on online interventions.

  • Source: Unsplash; Copyright: Kelsey Knight; URL:; License: Licensed by the authors.

    Privacy-Preserving Methods for Feature Engineering Using Blockchain: Review, Evaluation, and Proof of Concept


    Background: The protection of private data is a key responsibility for research studies that collect identifiable information from study participants. Limiting the scope of data collection and preventing secondary use of the data are effective strategies for managing these risks. An ideal framework for data collection would incorporate feature engineering, a process where secondary features are derived from sensitive raw data in a secure environment without a trusted third party. Objective: This study aimed to compare current approaches based on how they maintain data privacy and the practicality of their implementations. These approaches include traditional approaches that rely on trusted third parties, and cryptographic, secure hardware, and blockchain-based techniques. Methods: A set of properties were defined for evaluating each approach. A qualitative comparison was presented based on these properties. The evaluation of each approach was framed with a use case of sharing geolocation data for biomedical research. Results: We found that approaches that rely on a trusted third party for preserving participant privacy do not provide sufficiently strong guarantees that sensitive data will not be exposed in modern data ecosystems. Cryptographic techniques incorporate strong privacy-preserving paradigms but are appropriate only for select use cases or are currently limited because of computational complexity. Blockchain smart contracts alone are insufficient to provide data privacy because transactional data are public. Trusted execution environments (TEEs) may have hardware vulnerabilities and lack visibility into how data are processed. Hybrid approaches combining blockchain and cryptographic techniques or blockchain and TEEs provide promising frameworks for privacy preservation. For reference, we provide a software implementation where users can privately share features of their geolocation data using the hybrid approach combining blockchain with TEEs as a supplement. Conclusions: Blockchain technology and smart contracts enable the development of new privacy-preserving feature engineering methods by obviating dependence on trusted parties and providing immutable, auditable data processing workflows. The overlap between blockchain and cryptographic techniques or blockchain and secure hardware technologies are promising fields for addressing important data privacy needs. Hybrid blockchain and TEE frameworks currently provide practical tools for implementing experimental privacy-preserving applications.

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

    Factors Influencing Patients’ Intentions to Use Diabetes Management Apps Based on an Extended Unified Theory of Acceptance and Use of Technology Model:...


    Background: Diabetes poses heavy social and economic burdens worldwide. Diabetes management apps show great potential for diabetes self-management. However, the adoption of diabetes management apps by diabetes patients is poor. The factors influencing patients’ intention to use these apps are unclear. Understanding the patients’ behavioral intention is necessary to support the development and promotion of diabetes app use. Objective: This study aimed to identify the determinants of patients’ intention to use diabetes management apps based on an integrated theoretical model. Methods: The hypotheses of our research model were developed based on an extended Unified Theory of Acceptance and Use of Technology (UTAUT). From April 20 to May 20, 2019, adult patients with diabetes across China, who were familiar with diabetes management apps, were surveyed using the Web-based survey tool Sojump. Structural equation modeling was used to analyze the data. Results: A total of 746 participants who met the inclusion criteria completed the survey. 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=0.482; P=.001). Performance expectancy (β=0.482; P=.001), social influence (β=0.223; P=.003), facilitating conditions (β=0.17; P=.006), perceived disease threat (β=0.073; P=.005), and perceived privacy risk (β=–0.073; 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=0.259; P=.001). Conclusions: Performance expectancy and social influence are the most important determinants of the intention to use diabetes management apps. Health care technology companies should 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 apps. Context-related determinants should also be taken into consideration.

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

    Using Facebook for Qualitative Research: A Brief Primer


    As Facebook continues to grow its number of active users, the potential to harness data generated by Facebook users also grows. As much of Facebook users’ activity consists of creating (and commenting on) written posts, the potential use of text data for research is enormous. However, conducting a content analysis of text from Facebook users requires adaptation of research methods used for more traditional sources of qualitative data. Furthermore, best practice guidelines to assist researchers interested in conducting qualitative studies using data derived from Facebook are lacking. The purpose of this primer was to identify opportunities, as well as potential pitfalls, of conducting qualitative research with Facebook users and their activity on Facebook and provide potential options to address each of these issues. We begin with an overview of information obtained from a literature review of 23 studies published between 2011 and 2018 and our own research experience to summarize current approaches to conducting qualitative health research using data obtained from Facebook users. We then identify potential strategies to address limitations related to current approaches and propose 5 key considerations for the collection, organization, and analysis of text data from Facebook. Finally, we consider ethical issues around the use and protection of Facebook data obtained from research participants. In this primer, we have identified several key considerations that should aid health researchers in the planning and execution of qualitative studies involving content analysis of text data from Facebook users.

  • Source: Unsplash; Copyright: Robin Worrall; URL:; License: Licensed by JMIR.

    Using Twitter to Understand the Human Bowel Disease Community: Exploratory Analysis of Key Topics


    Background: Nowadays, the use of social media is part of daily life, with more and more people, including governments and health organizations, using at least one platform regularly. Social media enables users to interact among large groups of people that share the same interests and suffer the same afflictions. Notably, these channels promote the ability to find and share information about health and medical conditions. Methods: To answer these questions, a dataset of tweets containing terms related to BD conditions was collected from February to August 2018, accounting for a total of 24,634 tweets from 13,295 different users. Tweet preprocessing entailed the extraction of textual contents, hyperlinks, hashtags, time, location, and user information. Missing and incomplete information about the user profiles was completed using different analysis techniques. Semantic tweet topic analysis was supported by a lexicon-based entity recognizer. Furthermore, sentiment analysis enabled a closer look into the opinions expressed in the tweets, namely, gaining a deeper understanding of patients’ feelings and experiences. Results: Health organizations received most of the communication, whereas BD patients and experts in bowel conditions and nutrition were among those tweeting the most. In general, the BD community was mainly discussing symptoms, BD-related diseases, and diet-based treatments. Diarrhea and constipation were the most commonly mentioned symptoms, and cancer, anxiety disorder, depression, and chronic inflammations were frequently part of BD-related tweets. Most patient tweets discussed the bad side of BD conditions and other related conditions, namely, depression, diarrhea, and fibromyalgia. In turn, gluten-free diets and probiotic supplements were often mentioned in patient tweets expressing positive emotions. However, for the most part, tweets containing mentions to foods and diets showed a similar distribution of negative and positive sentiments because the effects of certain food components (eg, fiber, iron, and magnesium) were perceived differently, depending on the state of the disease and other personal conditions of the patients. The benefits of medical cannabis for the treatment of different chronic diseases were also highlighted. Conclusions: This study evidences that Twitter is becoming an influential space for conversation about bowel conditions, namely, patient opinions about associated symptoms and treatments. So, further qualitative and quantitative content analyses hold the potential to support decision making among health-related stakeholders, including the planning of awareness campaigns.

  • Source: Pexels; Copyright: Tracy Le Blanc; URL:; License: Licensed by JMIR.

    Association of Social Media Presence with Online Physician Ratings and Surgical Volume Among California Urologists: Observational Study


    Background: Urologists are increasingly using various forms of social media to promote their professional practice and attract patients. Currently, the association of social media on a urologists’ practice is unknown. Objectives: We aimed to determine whether social media presence is associated with higher online physician ratings and surgical volume among California urologists. Methods: We sampled 195 California urologists who were rated on the ProPublica Surgeon Scorecard website. We obtained information on professional use of online social media (Facebook, Instagram, Twitter, blog, and YouTube) in 2014 and defined social media presence as a binary variable (yes/no) for use of an individual platform or any platform. We collected data on online physician ratings across websites (Yelp, Healthgrades, Vitals, RateMD, and UCompareHealthcare) and calculated the mean physician ratings across all websites as an average weighted by the number of reviews. We then collected data on surgical volume for radical prostatectomy from the ProPublica Surgeon Scorecard website. We used multivariable linear regression to determine the association of social media presence with physician ratings and surgical volume. Results: Among our sample of 195 urologists, 62 (32%) were active on some form of social media. Social media presence on any platform was associated with a slightly higher mean physician rating (β coefficient: .3; 95% CI 0.03-0.5; P=.05). However, only YouTube was associated with higher physician ratings (β coefficient: .3; 95% CI 0.2-0.5; P=.04). Social media presence on YouTube was strongly associated with increased radical prostatectomy volume (β coefficient: 7.4; 95% CI 0.3-14.5; P=.04). Social media presence on any platform was associated with increased radical prostatectomy volume (β coefficient: 7.1; 95% CI –0.7 to 14.2; P=.05). Conclusions: Urologists’ use of social media, especially YouTube, is associated with a modest increase in physician ratings and prostatectomy volume. Although a majority of urologists are not currently active on social media, patients may be more inclined to endorse and choose subspecialist urologists who post videos of their surgical technique.

  • Mapping the Access of Future Doctors to Health Information Technologies Training in the European Union: Cross-Sectional Descriptive Study


    Background: Health information technologies (HITs) such as electronic health records (EHR) and telemedicine services are currently used to assist clinicians provide care to patients. There are many barriers to HIT adoption, including mismatches between investments and benefits, disruptions in the workflow, and concerns about privacy and confidentiality. The lack of HIT training of health professionals as a workforce is an increasingly recognized and understudied barrier. Objective: The purpose of this study is to describe what courses on HIT topics are available at the graduate level for future health professionals in the European Union (EU) and to explore possible determining factors for their exposure to these courses. Methods: A cross-sectional descriptive study of EU medical schools was performed to explore the prevalence of HIT courses. The curricula of all identified higher learning institutions that offer a medical degree were manually explored to identify graduate-level courses that offer specific training on HIT topics. HIT topics were defined as courses or subjects that provided knowledge on the design, development, use, and implementation of HIT. Associations among potential factors such as population, yearly medical graduates, total number of physicians, EHR presence, and gross domestic product (GDP) were explored. Results: A total of 302 medical schools from the 28 member states of the EU were explored. Only about one-third (90/302, 29.80%) of all medical degree curricula offered any kind of HIT course at the graduate level; in the medical schools that offered HIT courses, the courses were often mandatory (58/90, 64.44%). In most EU countries, HIT courses are offered in less than half of the medical schools, regardless of the country’s GDP per capita. Countries with the highest percentages of HIT course presence have the lowest GDP per capita. There seems to be a weak inverse correlation (–0.49) between the two variables (GDP per capita and HIT course presence). There is a trend between the availability of medical human resources and an increase in the presence of HIT courses, with Romania, Croatia, and Greece as outliers in this respect. Conclusions: The current state of medical training in the EU leaves much room for improvement. Further studies are required for in-depth analysis of the content and manner of instruction that would fit present and future needs of HIT.

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  • Time trends during 15 years’ use of Patient-reported Outcome (PRO) measures at group and patient levels

    Date Submitted: Aug 14, 2019

    Open Peer Review Period: Aug 14, 2019 - Aug 22, 2019

    Background: Since 2004, we have collected patient-reported outcome (PRO) data from several Danish patient populations for use at group and patient levels. Objective: The aim of this paper is to highli...

    Background: Since 2004, we have collected patient-reported outcome (PRO) data from several Danish patient populations for use at group and patient levels. Objective: The aim of this paper is to highlight trends during the last 15 years with respect to patient inclusion, the methods for collection of PRO data, the processing of the data, and the actual applications and use of the PRO measurements. Methods: All PRO data have been collected using the WestChronic/AmbuFlex PRO system, which was developed by the author in 2004 and has been continuously updated since. The analysis of trends was based on a generic model applicable for any kind of clinical health data, according to which any application of clinical data may be divided into four processes: patient identification, data collection, data aggregation, and the actual data use. Data were generated by a specific application in the system and transferred to analysis in the R package. Results: During the 15-year period, 77,828 patients answered 253,998 questionnaires containing a total of 13,204,223 responses. A number of marked changes have taken place. 1) The creation of cohorts for clinical epidemiological research purposes has shifted towards cohorts defined by clinical use of PRO data at the patient level 2) The development of AmbuFlex, where PRO data are used as the entire basis for outpatient follow-up instead of fixed appointments, has undergone exponential growth, and the system is currently in use in 47 ICD groups, covering 16,000 patients and 94 departments throughout Denmark. 3) In the first part of the period, a combination of paper- and web-based questionnaires secured response rates above 90% and low attrition rates; while in 2005, 66.5% of questionnaires were paper-based, this is the case for only 4.3% in 2019. 4) The approach methods for questionnaires and reminders have changed dramatically from letter, e-mails, and text-messaging to a national, secure electronic mail system, through which 93.2% of the communication to patients took place in 2019. The combination of secure email and web-based answering has resulted in a low turnaround time in which half of the responses are now received within 5 days. Conclusions: Substantial changes have occurred in the PRO scene during the 15-year period. The demand for clinical use of PRO measurements has increased, driven by a wish among patients as well as clinicians to use PRO as a mean to promote better symptom assessment, more patient-centred care, and more efficient use of resources. Important technological changes have occurred, creating new opportunities and making PRO collection and use cheaper and more feasible. Also, a number of legal changes have occurred and may constitute a barrier for further development as well as a barrier for better utilisation of patients’ questionnaire data. In the future, clinical settings will be the primary source of PRO data, not only for clinical application but also for other purposes like research and quality surveillance, and new ways to conduct complementary data collection will be necessary. However, the current legal restrictions on the joint use of health data imposed by the EU’s General Data Protection Regulation makes no distinction between use and misuse, and steps should be taken to alleviate these restrictions on the joint use of PRO data.

  • Identifying Military Veterans in a Clinical Research Database using Natural Language Processing and Machine Learning

    Date Submitted: Aug 13, 2019

    Open Peer Review Period: Aug 13, 2019 - Oct 8, 2019

    Background: Electronic healthcare records (EHRs) are a rich source of health-related information, with huge potential for secondary research use. In the United Kingdom (UK), there is no national marke...

    Background: Electronic healthcare records (EHRs) are a rich source of health-related information, with huge potential for secondary research use. In the United Kingdom (UK), there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult. Objective: The aim of this study was to develop a tool to identify veterans from free-text clinical notes recorded in a psychiatric EHR database. Methods: Veterans were manually identified using the South London and Maudsley Biomedical Research Centre Clinical Record Interactive Search – a database holding secondary mental health care electronic records for the South London and Maudsley National Health Service Trust. An iteratively developed Natural Language Processing and machine learning approach called the Veteran Detection Tool (VDT) was created to identify if a patient was a civilian or veteran. Results: To develop the VDT, an iterative two-stage approach was undertaken. In the first stage, a Structured Query Language approach was developed to identify veterans using a keyword rule-based approach. This scoping approach obtained a precision of 0.81, and a recall of 0.75. This approach informed the second stage, which was the development of the VDT using machine learning. In total, 6672 gold standard free-text clinical notes were manually annotated by human coders, 66% were retained for training, and 34% for testing. Conclusions: The VDT has the potential to be used in identifying veterans in the UK from free-text clinical notes, providing new and unique insights into the health and well-being of this population and their use of mental healthcare services.

  • Internet-Based Cognitive Behavioral Therapy With Real-Time Therapist Support via Videoconference for Patients With Bulimia nervosa and Binge-eating disorder: Pilot Single-Arm Trial

    Date Submitted: Aug 12, 2019

    Open Peer Review Period: Aug 12, 2019 - Aug 20, 2019

    Background: A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of Inter...

    Background: A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of Internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa (BN) and binge-eating disorder (BED) at the same time in Japan. Objective: To evaluate the feasibility of ICBT via videoconference for patients with BN or BED. Methods: Five Japanese subjects (mean age 35.4 ± 9.2 years) with BN and BED received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination interview-16 (EDE 16) for BN and BED: the combined objective binge and purging episodes; objective binge episodes; purging episodes. The secondary outcomes were the EDE-Q, the Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, the Motivational Ruler for motivation to change, the EuroQol-5 Dimension for quality of life, the Patient Health Questionnaire-9 for depression, the Generalized Anxiety Disorder questionnaire-7 for anxiety, and the Working Alliance Inventory-Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and at weeks 8 (mid intervention), and 16 (post intervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and the 95% confidence intervals using the paired t-test. Results: Although the mean combined objective binge episodes and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen’s d, -0.76), there was no significant reduction in the combined these episodes (EDE 16D, -41; 95% confidence interval -2.089, 0.576; P = 0.17). There were no significant treatment-related changes in the secondary outcomes. The WAI-SF scores remained consistently high (64.8–66.0) during treatment. Conclusions: ICBT via videoconference is feasible in Japanese patients with BN and BED. Clinical Trial: UMIN000029426

  • Developing and Evaluating the Quality of a New Patient Education Video on Colonoscopy Preparation

    Date Submitted: Aug 8, 2019

    Open Peer Review Period: Aug 12, 2019 - Oct 7, 2019

    Background: Although several patient education materials on colonoscopy preparation exist, few studies have evaluated or compared them, and hence no professional consensus on recommended content or me...

    Background: Although several patient education materials on colonoscopy preparation exist, few studies have evaluated or compared them, and hence no professional consensus on recommended content or media to use. Objective: We aimed to address this need by developing and evaluating a new video on colonoscopy preparation. Methods: We developed a new video explaining split-dose bowel preparation for colonoscopy. Of similar content videos on the Internet (n=20), the most favourably reviewed video among patient and physician advisors was used as the comparator for the study. 232 individuals attending gastroenterology or urology clinics reviewed the new and comparator videos. The order of administration of the new and comparator videos was randomly counterbalanced to assess the impact of presentation order. Respondents rated each video along the following dimensions: information amount, clarity, trustworthiness, understandability, new or familiar information, reassurance, information learned, understanding from patient’s point of view, appeal, and likelihood to recommend the video to others. Results: Overall, 71.6% preferred the new video, 25.0% preferred the comparator video, and 3.4% were not sure. 64% of those who viewed the new video first, preferred it, while 78% who viewed the new video second preferred it. Multivariable logistic regression analysis also demonstrated that participants were more likely to prefer the new video if they had viewed it second. Participants who preferred the new video rated it as more clear and trustworthy compared with those who preferred the comparator video. Conclusions: This study developed and assessed the strengths of a newly developed colonoscopy educational video.

  • The Give And Take: Automated Classification of Types of Support Given and Received over an Autoimmune Hepatitis (AIH) Online Support Group

    Date Submitted: Aug 7, 2019

    Open Peer Review Period: Aug 12, 2019 - Oct 7, 2019

    Background: Autoimmune Hepatitis (AIH) is a rare disease involving the body attacking its own liver and affects fewer than 1.2 out of 100,000 people in the United States. Provider support for the di...

    Background: Autoimmune Hepatitis (AIH) is a rare disease involving the body attacking its own liver and affects fewer than 1.2 out of 100,000 people in the United States. Provider support for the disorder can be limited due to the frequency of provider appointments; as is the case with many rare diseases, AIH’s patients turn to peer support from online social media venues to supplement the advice of their providers. Objective: Here, we characterize the types and dynamics of support exchanged over an AIH-related Facebook™ page. Methods: Data from a coauthor-administered AIH-related Facebook™ page were downloaded from the browser front end. A brief literature review was performed to elucidate baseline types of support that could be exchanged over health-related social media venues. A portion of the resulting group user communications were qualitatively analyzed to determine the types of support exchanged within them, and key terms that indicated these types of support. Key terms were then used in dictionaries to drive a computational classification algorithm to classify the remaining user communications. The nature of communication (by type of support exchanged) was compared to various characteristics (sole poster; sole commenter; tenure at time of communication) of the user and the communication itself (post vs. comment status). Results: In the literature review, two directions (inbound/requesting and outbound/offering) and two content types (advice/information and emotional/social) of support were found. In addition to the 3 out of 4 permutations offered by these types and directions, three additional categories (asking the coauthor administrator [CSL] for advice; personal inquiry in providing support; grateful acknowledgement of support) were found directly from annotation of user communications. The search algorithms powered by the created dictionaries yielded reliability (F1) scores ranging from 0.308 (offering advice/information support) to 0.700 (offering emotional/social support). Significant differences existed across communication type (post vs. comment) when compared to support direction; the requesting of support primarily was seen in posts and the offering of support primarily in comments. Users who were deleted were more likely to have requested advice from CSL (OR 6.445, 95% CI 5.454-7.616, P<.001) but significantly less likely to offer emotional/social support (OR 0.155, 95% CI 0.069-0.348, P<.001). A longer tenure in the group correlated qualitatively with more offering of support; such tenure likewise correlated with less requesting of support, with the exception of requesting advice from CSL. Finally, CSL’s own support metrics revealed that he was significantly more likely to offer advice compared (OR 2.824, 95% CI 2.255-3.538, P<.001) to other group members, and less likely to perform personal inquiries in provision of support (OR 0.401, 95% CI 0.178-0.900, P=.022). Conclusions: The generated algorithm shows modest but reasonable gold standard comparison (F1)-based reliability in detecting support types by content type and direction. Conclusions drawn on correlations between user characteristics and detected communication types lend further intuition-based reliability to the algorithm. Future research is needed to more accurately detect the offering of advice/information and more importantly, to go beyond simply the types of support and to characterize the reasons of support.

  • A Smartphone-based Healthcare Chatbot to Promote Self-Management of Chronic Pain (SELMA): A Pilot Randomized Control Trial

    Date Submitted: Aug 9, 2019

    Open Peer Review Period: Aug 11, 2019 - Oct 11, 2019

    Background: Ongoing pain is one of the most common diseases and has a major physical psychological, social and economic impact. A mobile health intervention utilizing a fully-automated text-based heal...

    Background: Ongoing pain is one of the most common diseases and has a major physical psychological, social and economic impact. A mobile health intervention utilizing a fully-automated text-based healthcare chatbot (TBHC) may offer an innovative way not only to deliver coping strategies and psychoeducation for pain management but also to build a working alliance between participant and the THCB. Objective: The objectives of this paper are twofold: (1) to describe the design and implementation of SELMA (painSELfMAnagement), a 2-month smartphone-based Cognitive Behavior Therapy (CBT) TBHC intervention for pain self-management of patients with ongoing or cyclic pain, and (2) to present findings from a pilot randomized controlled trial, in which effectiveness, influence of intention to change behavior and pain duration, working alliance, acceptance and adherence were evaluated. Methods: Participants were recruited online and in collaboration with pain experts and randomized to interact with SELMA for 8 weeks, either every day or every other day, concerning CBT-based pain management (n=59), or weekly concerning content not related to pain management (n=43). Pain-related impairment (primary outcome), general well-being, pain intensity and the bond scale of working alliance were measured at baseline and post-intervention, intention to change behavior and pain duration at baseline only, and acceptance post- intervention via self-report instruments. Adherence was assessed objectively via usage data. Results: From May 2018 till August 2018, 311 adults downloaded the SELMA app, 102 consented to participate and met the inclusion criteria. The average age of the 88 female (86.4%) and 14 male (13.6%) participants was 43.7 (SD=12.7) years. Baseline group comparison did not differ in any demographic or clinical variables. Pain intensity was reduced significantly (P=.05) and general well-being increased significantly (P=.01) in both groups. The intervention group reported no significant change in pain-related impairment (P=.68) compared to the wait-list control group post-intervention. The intention to change behavior was related positively to pain-related impairment (P=.01) and pain intensity (P=.01). Working alliance with the THCB SELMA was comparable to working alliance in guided internet therapies with human coaches. Participants enjoyed using the app, perceived it as useful and easy to use, and would recommend it to others. Overall, 52% adhered to the program by self-selecting coaching modules actively. Participants’ comments revealed an appreciation of the empathic and responsible interaction with the THCB SELMA. A main criticism was that there was no option to enter free text for patients’ own comments. Conclusions: SELMA is feasible, revealed mainly positive feedback and valuable suggestions for future revisions. For example, participants’ intention to change behavior or a more homogenous sample (e.g. with a specific type of chronic pain) should be considered in further tailoring SELMA. Clinical Trial: German Clinical Trials Register DRKS00017147;, Swiss National Clinical Trial Portal: SNCTP000002712.