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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; Copyright: Pixabay; URL:; License: Licensed by the authors.

    Smartphone Apps to Support Coordinated Specialty Care for Prodromal and Early Course Schizophrenia Disorders: Systematic Review


    Background: Demand for mental health services, especially for clinical high-risk and early psychosis, has increased, creating a need for new solutions to increase access to and quality of care. Smartphones and mobile technology are potential tools to support coordinated specialty care for early psychosis, given their potential to augment the six core roles of care: case management and team leadership, recovery-oriented psychotherapy, medication management, support for employment and education, coordination with primary care services, and family education and support. However, the services smartphones are actually offering specifically for coordinated specialty care and the level of evidence are unknown. Objective: This study aimed to review the published literature on smartphone technology to enhance care for patients with prodromal and early course psychosis and schizophrenia and to analyze studies by type, aligned with coordinated specialty care domains. Methods: A systematic literature search was conducted on August 16 and 17, 2019, using the PubMed, EMBASE, Web of Sciences, and PsycINFO electronic databases. The eligible studies were reviewed and screened based on inclusion and exclusion criteria. Results: The search uncovered 388 unique results, of which 32 articles met the initial inclusion criteria; 21 eligible studies on 16 unique app platforms were identified. Feasibility studies showed a high user engagement and interest among patients, monitoring studies demonstrated a correlation between app assessments and clinical outcomes, and intervention studies indicated that these apps have the potential to advance care. Eighteen studies reported on app use for the case management roles of coordinated specialty care. No app studies focused on employment and education, coordination with primary care services, and family education and support. Conclusions: Although the published literature on smartphone apps for prodromal and first-episode psychosis is small, it is growing exponentially and holds promise to augment both monitoring and interventions. Although the research results and protocols for app studies are not well aligned with all coordinated specialty care roles today, high rates of adoption and feasibility suggest the potential for future efforts. These results will be used to develop coordinated specialty care–specific app evaluation scales and toolkits.

  • Patient and pediatrician discussing Health-Related Quality of Life questionnaires. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Measurement Properties of the Online EuroQol-5D-Youth Instrument in Children and Adolescents With Type 1 Diabetes Mellitus: Questionnaire Study


    Background: The lack of continuity between health-related quality of life (HRQoL) instruments designed for children and adults hinders change analysis with a life course approach. To resolve this gap, EuroQol (EQ) developed the EQ-5D-Youth (EQ-5D-Y), derived from the EQ-5D for adults. Few studies have assessed the metric properties of EQ-5D-Y in children with specific chronic conditions, and none have done so for children with type I diabetes mellitus (T1DM). Objective: This study aimed to evaluate the acceptability, validity, reliability, and responsiveness of the EQ-5D-Y in children and adolescents with T1DM, when administered online. Methods: Participants with T1DM were consecutively recruited from July to December 2014, from a list of potential candidates aged 8-19 years, who attended outpatient pediatric endocrinology units. Before every quarterly routine visit, participants received an email/telephone reminder to complete the online version of two generic HRQoL questionnaires: EQ-5D-Y and KIDSCREEN-27. The EQ-5D-Y measures five dimensions, from which an equally weighted summary score was constructed (range: 0-100). Completion rate and distribution statistics were calculated. Construct validity was evaluated through known group comparisons based on general health, acute diabetic decompensations, mental health, family function, and a multitrait, multimethod matrix between EQ-5D-Y and KIDSCREEN by using Spearman correlations. Construct validity hypotheses were stated a priori. Reliability was assessed with the intraclass correlation coefficient and responsiveness by testing changes over time and calculating the effect size. Reliability and responsiveness were tested among the stable and improved subsamples defined by a KIDSCREEN-10 index change of <4.5 points or ≥4.5 points, respectively, from the first to the fourth visit. Results: Of the 136 participants, 119 (87.5%) responded to the EQ-5D-Y at the last visit. The dimensions that showed higher percentages of participants with problems were “having pain/discomfort” (34.6%) and “worried/sad/unhappy” (28.7%). The mean (SD) of the EQ-5D-Y summary score was 8.5 (10.9), with ceiling and floor effects of 50.7% and 0%, respectively. Statistically significant HRQoL differences between groups defined by their general health (excellent/very good and good/regular/bad) and mental health (Strengths and Difficulties Questionnaire score ≤15 and >16, respectively) were found in three EQ-5D-Y dimensions (“doing usual activities,” “having pain/discomfort,” and “feeling worried/sad/unhappy”), summary score (effect size for general health and mental health groups=0.7 and 1.5, respectively), and KIDSCREEN-10 index (effect size for general health and mental health groups=0.6 and 0.9, respectively). Significant differences in the EQ-5D-Y dimensions were also found according to acute diabetic decompensations in “looking after myself” (P=.005) and according to family function in “having pain/discomfort” (P=.03). Results of the multitrait, multimethod matrix confirmed three of the four relationships hypothesized as substantial (0.21, 0.58, 0.50, and 0.46). The EQ-5D-Y summary score presented an intraclass correlation coefficient of 0.83. Statistically significant change between visits was observed in the improved subsample, with an effect size of 0.7 (P<.001). Conclusions: These results support the use of the EQ-5D-Y administered online as an acceptable, valid, reliable, and responsive instrument for evaluating HRQoL in children and adolescents with T1DM.

  • Source: Shutterstock Inc; Copyright: xtock; URL:; License: Licensed by the authors.

    Cost Per Participant Recruited From Rural and Remote Areas Into a Smoking Cessation Trial Via Online or Traditional Strategies: Observational Study


    Background: Rural and remote residents are more likely to smoke than those who live in major cities; however, recruitment of research participants from rural and remote areas can be challenging. The cost per participant recruited from rural and remote areas via online (eg, social media) and traditional strategies (eg, print) has implications for researchers on how to allocate resources to maximize the number of participants recruited. Participant characteristics such as demographics, financial stress, mental health, and smoking-related factors may be associated with recruitment method (ie, online vs traditional), and so it is important to understand whether certain subgroups are more likely to be recruited via a particular strategy. Objective: This study aimed to determine the cost per participant recruited and examine whether characteristics such as demographics, financial stress, mental health, and smoking-related factors may be associated with the recruitment method (ie, online vs traditional). Methods: Participants were recruited into a randomized trial that provided smoking cessation support. Eligible participants were aged 18 years or older; used tobacco daily; had access to video communication software, internet, and telephone; had an email address; and lived in a rural or remote area of New South Wales, Australia. This study describes the natural (observed) experience of recruiting participants via online and traditional methods into a smoking cessation trial. Results: Over 17 months, 655 participants were recruited into the smoking cessation trial. A total of 88.7% (581/655) of the participants were recruited via online methods. Moreover, 1.8% (12/655) of the participants were recruited from remote locations and none from very remote areas. The cost per participant recruited by the various online strategies ranged from Aus $7.29 (US $4.96, £4.09, and €4.43) for Gumtree, a local online classified website, to Aus $128.67 (US $87.63, £72.20, and €78.28) for email. The cost per participant recruited using traditional strategies ranged from Aus $0 (US $0, £0, and €0) for word of mouth to Aus $3990.84 (US $2757.67, £2227.85, and €2477.11) for telephone. Women had greater odds of being recruited via online methods than men (odds ratio 2.50, 95% CI 1.42-4.40). No other characteristics were associated with the recruitment method. Conclusions: The cost per participant recruited via online and traditional strategies varied, with the range being smaller for online than traditional recruitment strategies. Women have greater odds of being recruited via online strategies into rural smoking cessation trials. Clinical Trial: Australian New Zealand Clinical Trials Registry ACTRN12617000514303;

  • Source: Creative Commons (Flickr); Copyright: Ministerio TIC Colombia; URL:; License: Creative Commons Attribution (CC-BY).

    Qualitative Synthesis of Young People’s Experiences With Technology-Assisted Cognitive Behavioral Therapy: Systematic Review


    Background: Cognitive behavioral therapy (CBT) for young people is increasingly being provided using technology-assisted formats. Although there is increasing evidence regarding the efficacy of such approaches, as illustrated by quantitative systematic reviews, the literature has also highlighted challenges with implementation factors, including high attrition rates and variable user engagement. Qualitative review methods can help to address the factors that impact young peoples’ experience of technology-assisted cognitive behavioral therapy (tech-assisted CBT) and, thus, enable us to better understand such implementation factors. To date, no such qualitative synthesis exists. Objective: The primary aim of this review was to systematically identify and synthesize the qualitative literature concerning the experiences of young people who have used tech-assisted CBT. Methods: This systematic review applied Thomas and Harden’s 2008 qualitative thematic synthesis approach. This involved line-by-line coding of the results sections of included studies and an inductive analysis on identified themes, followed by the generation of analytical themes through a process of iteration and interpretation of the descriptive themes. PsycINFO, ACM Digital Library, PubMed, EMBASE, and JMIR Publications databases were searched. The inclusion criteria were (1) studies involving school-aged young people over preschool age (6 years) but under the age of 18 years, (2) use of any form of tech-assisted CBT for any time period, (3) a stated focus of qualitative data to document the experiences of participants, and (4) studies published in English. The exclusion criteria were (1) interventions only provided face-to-face with no technological component, (2) only focused on the performance of the technology rather than participant experience, and (3) numerical data that sought to represent qualitative data. Results: A total of 14 studies were included in this review. Overall, these studies represented interventions for low mood and anxiety (n=10), trauma or self-harm (n=2), and physical difficulties (n=2). Overall, 5 analytical themes emerged on young people’s experiences with tech-assisted CBT: (1) helpfulness, (2) therapeutic process, (3) transferability, (4) gameplay experience, and (5) limitations. In addition, these analytical themes contained the following subthemes: positive experiences, tech-assisted CBT versus face-to-face CBT, understanding of a CBT model, process of change, skills development, application to everyday life settings, parental involvement, character relatedness, playability, negative experiences, and broad content. Conclusions: Overall, young people’s experiences with tech-assisted CBT were mostly positive. The use of gaming environments, relatable characters, concrete metaphors, and age-appropriate narratives contributed to these positive experiences. Evidence suggests that technology can help to mediate face-to-face relationships with therapists and help young people to understand the CBT model. Clear barriers also emerged, including over-reliance on reading and writing skills and dissatisfaction with overly generalized content and comparison with commercial technologies.

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

    Investigating Software Requirements for Systems Supporting Task-Shifted Interventions: Usability Study


    Background: There is a considerable shortfall in specialized health care professionals worldwide to deliver health services, and this shortfall is especially pronounced in low-middle-income countries. This has led to the implementation of task-shifted interventions, in which specific tasks are moved away from highly qualified health workers to health workers with less training. The World Health Organization (WHO) has published recommendations for such interventions, but guidelines for software and systems supporting such interventions are not included. Objective: The objective of this study was to formulate a number of software requirements for computer systems supporting task-shifted interventions. As the treatment of mental health problems is generally considered to be a task for highly trained health care professionals, it poses interesting case studies for task-shifted interventions. Therefore, we illustrated the use of the identified software requirements in a mobile system created for a task-shifted depression intervention to be provided to older adults in deprived areas of São Paulo, Brazil. Methods: Using a set of recommendations based on the WHO’s guidance documentation for task-shifted interventions, we identified 9 software requirements that aim to support health workers in management and supervision, training, good relationship with other health workers, and community embeddedness of the intervention. These 9 software requirements were used to implement a system for the provision of a psychosocial depression intervention with mobile Android interfaces to structure interventions and collect data, and Web interfaces for supervision and support of the health care workers delivering the intervention. The system was tested in a 2-arm pilot study with 33 patients and 11 health workers. In all, 8 of these 11 health workers participated in a usability study subsequent to the pilot. Results: The qualitative and quantitative feedback obtained with the System Usability Scale suggest that the system was deemed to have a usability of between OK and Good. Nevertheless, some participants’ responses indicated that they felt they needed technical assistance to use the system. This was reinforced by answers obtained with perceived usefulness and ease of use questionnaires, which indicated some users felt that they had issues around correct use of the system and perceived ability to become skillful at using the system. Conclusions: Overall, these high-level requirements adequately captured the functionality required to enable the health workers to provide the intervention successfully. Nevertheless, the analysis of results indicated that some improvements were required for the system to be useable in a task-shifted intervention. The most important of these were better access to a training environment, access for supervisors to metadata such as duration of sessions or exercises to identify issues, and a more robust and human-error–proof approach to the availability of patient data on the mobile devices used during the intervention.

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Licensed by JMIR.

    The Service of Research Analytics to Optimize Digital Health Evidence Generation: Multilevel Case Study


    Background: The widespread adoption of digital health interventions for chronic disease self-management has catalyzed a paradigm shift in the selection of methodologies used to evidence them. Recently, the application of digital health research analytics has emerged as an efficient approach to evaluate these data-rich interventions. However, there is a growing mismatch between the promising evidence base emerging from analytics mediated trials and the complexity of introducing these novel research methods into evaluative practice. Objective: This study aimed to generate transferable insights into the process of implementing research analytics to evaluate digital health interventions. We sought to answer the following two research questions: (1) how should the service of research analytics be designed to optimize digital health evidence generation? and (2) what are the challenges and opportunities to scale, spread, and sustain this service in evaluative practice? Methods: We conducted a qualitative multilevel embedded single case study of implementing research analytics in evaluative practice that comprised a review of the policy and regulatory climate in Ontario (macro level), a field study of introducing a digital health analytics platform into evaluative practice (meso level), and interviews with digital health innovators on their perceptions of analytics and evaluation (microlevel). Results: The practice of research analytics is an efficient and effective means of supporting digital health evidence generation. The introduction of a research analytics platform to evaluate effective engagement with digital health interventions into a busy research lab was ultimately accepted by research staff, became routinized in their evaluative practice, and optimized their existing mechanisms of log data analysis and interpretation. The capacity for research analytics to optimize digital health evaluations is highest when there is (1) a collaborative working relationship between research client and analytics service provider, (2) a data-driven research agenda, (3) a robust data infrastructure with clear documentation of analytic tags, (4) in-house software development expertise, and (5) a collective tolerance for methodological change. Conclusions: Scientific methods and practices that can facilitate the agile trials needed to iterate and improve digital health interventions warrant continued implementation. The service of research analytics may help to accelerate the pace of digital health evidence generation and build a data-rich research infrastructure that enables continuous learning and evaluation.

  • Source: iStock by Getty Images; Copyright: utah778; URL:; License: Licensed by the authors.

    Effects of Three Antecedents of Patient Compliance for Users of Peer-to-Peer Online Health Communities: Cross-Sectional Study


    Background: Over the past 50 years, patient noncompliance has appeared as a major public health concern and focus of a great deal of research because it endangers patient recovery and imposes a considerable financial burden on health care systems. Meanwhile, online health communities (OHCs) are becoming more common and are commonly used by individuals with health problems, and they may have a role in facilitating compliance. Despite this growing popularity, little is known about patient compliance predictors for OHCs’ users. Objective: This study aimed to investigate the extent to which participating in OHCs may trigger higher levels of compliance. It identified 3 interrelated predictors that may affect patient compliance: patient empowerment gained through peer-to-peer OHCs, satisfaction with the physician, and commitment to the physician. Methods: A Web-based survey tested the conceptual model and assessed the effects of patient empowerment gained through OHCs on patient satisfaction and commitment to the physician, as well as the effects of these 3 predictors on patient compliance with the proposed treatment. Members of peer-to-peer OHCs were asked to answer an online questionnaire. A convenience sample of 420 patients experiencing chronic illness and using peer-to-peer OHCs was surveyed in August 2018 in Québec, Canada. A path analysis using structural equation modeling tested the proposed relationships between the predictors and their respective paths on patient compliance. The mediation effects of these predictor variables on patient compliance were estimated with the PROCESS macro in SPSS. Results: The findings indicated that patient empowerment gained through OHCs was positively related to patient commitment to the physician (beta=.69; P<.001) and patient compliance with the proposed treatment (beta=.35; P<.001). Patient commitment also positively influenced patient compliance (beta=.74; P<.001). Patient empowerment did not exert a significant influence on patient satisfaction with the physician (beta=.02; P=.76), and satisfaction did not affect compliance (beta=−.07; P=.05); however, patient satisfaction was positively related to patient commitment to the physician (beta=.14; P<.01). The impact of empowerment on compliance was partially mediated by commitment to the physician (beta=.32; 95% CI 0.22-0.44) but not by satisfaction. Conclusions: This study highlights the importance of peer-to-peer OHCs for two main reasons. The primary reason is that patient empowerment gained through peer-to-peer OHCs both directly and indirectly enhances patient compliance with the proposed treatment. The underlying mechanisms of these effects were shown. Second, commitment to the physician was found to play a more critical role than satisfaction with the physician in determining patient-physician relationship quality. Overall, our findings support the assumption that health care stakeholders should encourage the use of peer-to-peer OHCs to favor patient empowerment and patient commitment to the physician to increase patient compliance with the proposed treatment.

  • Source: Image created by the Authors; Copyright: Just Eekhof; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Patients’ Use of the Internet to Find Reliable Medical Information About Minor Ailments: Vignette-Based Experimental Study


    Background: Little is known about the exact process of how patients search for medical information on the internet and what they retrieve. There is especially a paucity of literature on browsing for information on minor ailments, a term used for harmless diseases that are very common in the general population and thus have a significant impact on health care. Objective: This vignette-based experimental study aimed to explore what kind of Web-based search strategies are applied and how search strategies, demographic characteristics, and the quality of the visited websites relate to finding the right diagnosis. Additional goals were to describe how searching on the Web influences one’s perception of the severity of the potential diagnosis and whether or not the participants would discuss the information they found on the internet with their doctors. Methods: Out of 1372 survey participants, 355 were randomly sampled, and 155 of them were recruited and assigned to one of four clinical scenarios. Each search term they used was classified as one of three search strategies: (1) hypothesis testing, (2) narrowing within the general hypothesis area, and (3) symptom exploration. The quality of the websites used was determined by using the DISCERN instrument. To compare the diagnostic accuracy of the participants before and after the internet search, a McNemar test was used. Chi-square tests were used to describe which factors are related to the chosen search strategy. A multivariate binary logistic regression model was constructed to predict which factors are related to finding a sound diagnosis after searching the internet for health information. Results: Most participants (65.8%, 102/155) used the symptom exploration strategy. However, this depends on the assigned scenario (P<.001) and the self-estimated severity score of the symptoms before the internet search (P=.001). A significant relation was found between choosing an accurate diagnosis and age (odds ratio [OR] 0.94, 95% CI 0.90 to 0.98) and the clinical scenario, as well as the use of high-quality websites (OR 7.49, 95% CI 1.85 to 30.26). Browsing the internet did not lead to a statistically significant change in participants’ beliefs about the severity of the condition (McNemar test, P=.85). Most participants (65%) shared their retrieved information with their physician and most of them (75%) received a positive response. Conclusions: Our findings suggest that most patients use a symptom-based approach; however, if patients expect the potential diagnosis to be severe, they tend to use a hypothesis verification strategy more often and are therefore prone to certain forms of bias. In addition, self-diagnosing accuracy is related to younger age, the symptom scenario, and the use of high-quality websites. We should find ways to guide patients toward search strategies and websites that may more likely lead to accurate decision making.

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

    A Revised Model of Trust in Internet-Based Health Information and Advice: Cross-Sectional Questionnaire Study


    Background: The internet continues to offer new forms of support for health decision making. Government, charity, and commercial websites increasingly offer a platform for shared personal health experiences, and these are just some of the opportunities that have arisen in a largely unregulated arena. Understanding how people trust and act on this information has always been an important issue and remains so, particularly as the design practices of health websites continue to evolve and raise further concerns regarding their trustworthiness. Objective: The aim of this study was to identify the key factors influencing US and UK citizens’ trust and intention to act on advice found on health websites and to understand the role of patient experiences. Methods: A total of 1123 users took part in an online survey (625 from the United States and 498 from the United Kingdom). They were asked to recall their previous visit to a health website. The online survey consisted of an updated general Web trust questionnaire to account for personal experiences plus questions assessing key factors associated with trust in health websites (information corroboration and coping perception) and intention to act. We performed principal component analysis (PCA), then explored the relationship between the factor structure and outcomes by testing the fit to the sampled data using structural equation modeling (SEM). We also explored the model fit across US and UK populations. Results: PCA of the general Web trust questionnaire revealed 4 trust factors: (1) personal experiences, (2) credibility and impartiality, (3) privacy, and (4) familiarity. In the final SEM model, trust was found to have a significant direct effect on intention to act (beta=.59; P<.001), and of the trust factors, only credibility and impartiality had a significant direct effect on trust (beta=.79; P<.001). The impact of personal experiences on trust was mediated through information corroboration (beta=.06; P=.04). Variables specific to electronic health (eHealth; information corroboration and coping) were found to substantially improve the model fit, and differences in information corroboration were found between US and UK samples. The final model accounting for all factors achieved a good fit (goodness-of-fit index [0.95], adjusted goodness-of-fit index [0.93], root mean square error of approximation [0.50], and comparative fit index [0.98]) and explained 65% of the variance in trust and 41% of the variance in intention to act. Conclusions: Credibility and impartiality continue to be key predictors of trust in eHealth websites. Websites with patient experiences can positively influence trust but only if users first corroborate the information through other sources. The need for corroboration was weaker in the United Kingdom, where website familiarity reduced the need to check information elsewhere. These findings are discussed in relation to existing trust models, patient experiences, and health literacy.

  • Source: Pixabay; Copyright: Jan Alexander; URL:; License: Licensed by the authors.

    Unlocking the Power of Artificial Intelligence and Big Data in Medicine

    Authors List:


    unstructured: Data-driven science and its corollaries in machine learning and the wider field of artificial intelligence have the potential to drive important changes in medicine. However, medicine is not a science like any other: It is deeply and tightly bound, with a large and wide network of legal, ethical, regulatory, economical, and societal dependencies. As a consequence, the scientific and technological progresses in handling information and its further processing and cross-linking for decision support and predictive systems must be accompanied by parallel changes in the global environment, with numerous stakeholders, including citizen and society. What can be seen at the first glance as a barrier and mechanism slowing down the progression of data science must, however, be considered an important asset. Only global adoption can transform the potential of big data and artificial intelligence into an effective breakthroughs in handling health and medicine. This requires science and society, scientists and citizens, to progress together.

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

    The Last Mile: Where Artificial Intelligence Meets Reality

    Authors List:


    Although much effort is focused on improving the technical performance of artificial intelligence, there are compelling reasons to focus more on the implementation of this technology class to solve real-world applications. In this “last mile” of implementation lie many complex challenges that may make technically high-performing systems perform poorly. Instead of viewing artificial intelligence development as a linear one of algorithm development through to eventual deployment, there are strong reasons to take a more agile approach, iteratively developing and testing artificial intelligence within the context in which it finally will be used.

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

    Validation of an Independent Web-Based Tool for Measuring Visual Acuity and Refractive Error (the Manifest versus Online Refractive Evaluation Trial):...


    Background: Digital tools provide a unique opportunity to increase access to eye care. We developed a Web-based test that measures visual acuity and both spherical and cylindrical refractive errors. This test is Conformité Européenne marked and available on the Easee website. The purpose of this study was to compare the efficacy of this Web-based tool with traditional subjective manifest refraction in a prospective open-label noninferiority clinical trial. Objective: The aim of this study was to evaluate the outcome of a Web-based refraction compared with a manifest refraction (golden standard). Methods: Healthy volunteers from 18 to 40 years of age, with a refraction error between –6 and +4 diopter (D), were eligible. Each participant performed the Web-based test, and the reference test was performed by an optometrist. An absolute difference in refractive error of <0.5 D was considered noninferior. Reliability was assessed by using an intraclass correlation coefficient (ICC). Both uncorrected and corrected visual acuity were measured. Results: A total of 200 eyes in 100 healthy volunteers were examined. The Web-based assessment of refractive error had excellent correlation with the reference test (ICC=0.92) and was considered noninferior to the reference test. Uncorrected visual acuity was similar with the Web-based test and the reference test (P=.21). Visual acuity was significantly improved using the prescription obtained by using the Web-based tool (P<.01). The Web-based test provided the best results in participants with mild myopia (ie, <3 D), with a mean difference of 0.02 (SD 0.49) D (P=.48) and yielding a corrected visual acuity of >1.0 in 90% (n=77) of participants. Conclusions: Our results indicate that Web-based eye testing is a valid and safe method for measuring visual acuity and refractive error in healthy eyes, particularly for mild myopia. This tool can be used for screening purposes, and it is an easily accessible alternative to the subjective manifest refraction test. Clinical Trial: NCT03313921;

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  • Communicating Uncertainty from Limitations in Quality of Evidence to the Public in Written Consumer Health Information: a Parallel-group, Web-based Randomized Controlled Trial

    Date Submitted: Nov 8, 2019

    Open Peer Review Period: Nov 8, 2019 - Jan 3, 2020

    Background: Uncertainty is integral to evidence-informed decision making and is of particular importance for preference-sensitive decisions. Communicating uncertainty to patients and the public has lo...

    Background: Uncertainty is integral to evidence-informed decision making and is of particular importance for preference-sensitive decisions. Communicating uncertainty to patients and the public has long been identified as a goal in the informed and shared decision-making movement. Despite this, there is little quantitative research on how uncertainty in health information is perceived by readers. Objective: The aim of this study was to examine the impact of different uncertainty descriptions regarding the evidence for a treatment effect in a written research summary for the public. Methods: We developed 8 versions of a research summary on a fictitious tinnitus drug with varying degrees (Q1), sources (Q2) and magnitudes of uncertainty (Q3). We recruited 2099 members of the German public from a web-based research panel. Of these, 1727 fulfilled the inclusion criteria and were randomly presented with one of these research summaries. Randomization was conducted by a centralized computer using a random number generator. Web-based recruitment and data collection were fully automated. Participants were not aware of the purpose of the study and alternative presentations. We measured the following outcomes: perception of the treatment effectiveness (primary); certainty in the judgement of treatment effectiveness; perception of the body of evidence; text quality; intended decision. Outcomes were self-assessed. Results: We did not find a global effect for Q1 and Q2 (p=.25 and p=.73), but for Q3 (p=.048). Pairwise comparisons showed a weaker perception of the treatment effectiveness for the research summary with 3 sources of uncertainty compared to a version with 2 sources of uncertainty (p=.037). Specifically, 9% less participants perceived the tinnitus drug as possibly beneficial, while 8% more considered it to be of unclear benefit in the group with 3 sources of uncertainty. There was no difference compared to a version with 1 source of uncertainty (p=.31), however. We did not find any meaningful differences between the research summaries for the secondary outcomes. Conclusions: Communicating even a large magnitude of uncertainty for a treatment effect had little impact on perceived effectiveness. Efforts to improve public understanding of research are needed to improve understanding of evidence based health information. Clinical Trial: German Clinical Trials Register DRKS00015911,

  • Adopting patient portals in hospitals: a qualitative study

    Date Submitted: Nov 5, 2019

    Open Peer Review Period: Nov 5, 2019 - Dec 31, 2019

    Background: Theoretical models help to explain or predict the adoption of eHealth technology and illustrate the complexity of the adoption process. Various models provide insights into general factors...

    Background: Theoretical models help to explain or predict the adoption of eHealth technology and illustrate the complexity of the adoption process. Various models provide insights into general factors that influence the use of eHealth technology. However, they do not give hospitals much actionable knowledge on how to facilitate the adoption process. Objective: Our study aims to provide insights into patient portal adoption processes among patients and hospital staff (including healthcare professionals, managers and administrative clerks). Studying the experiences and views of stakeholders answers this question: How can hospitals encourage patients and healthcare professionals to adopt a patient portal? Methods: 22 semi-structured (group) interviews (N=69) in 12 hospitals and four focus groups with members of (semi)national organizations and patient portal suppliers (N=53). Results: The effort hospitals put into adopting patient portals can be split into three themes. First, informing patients and healthcare professionals about the portal. The communication strategy has four objectives: 1) knowing about the portal, 2) knowing how it works, 3) encouraging visits to the portal and 4) knowing where to get support. Second, embedding the patient portal in the daily routine of healthcare professionals and management with three forms of support: 1) hospital policy, 2) management by numbers, and 3) a structured implementation strategy that includes all staff of one department. This embedding requires changing work processes and routines. Third, adjusting the portal to meet patients’ needs in the effort to optimize user-friendliness in two ways: 1) using patient feedback, and 2) focusing on optimizing the portal for patients with special needs (e.g. low literacy,, low digital skills). Interestingly,hospitals are reluctant to involve patients in the continuous development of patient portals, because they have experienced that nothing can be done with the feedback received (e.g. technologically impossible or too expensive). Conclusions: Asking stakeholders what they have learned from their attempts to stimulate patient portal use in hospitals elicited rich insights into the adoption process. This practical knowledge helps to translate the relatively abstract success factors one finds in scientific adoption models to the everyday pragmatics of eHealth projects in hospitals.

  • Bringing Home Cognitive Assessment: Initial Validation of Unsupervised Web-based Cognitive Testing on the Cambridge Neuropsychological Test Automated Battery (CANTAB) using a within-subjects counterbalanced design

    Date Submitted: Oct 29, 2019

    Open Peer Review Period: Oct 29, 2019 - Dec 24, 2019

    Background: Computerised assessments already confer advantages for deriving accurate and reliable measures of cognitive function, including test standardisation, accuracy of response recordings and au...

    Background: Computerised assessments already confer advantages for deriving accurate and reliable measures of cognitive function, including test standardisation, accuracy of response recordings and automated scoring. Web-based cognitive assessment could improve accessibility and flexibility of research and clinical assessment, widen participation and promote research recruitment whilst simultaneously reducing costs. However, differences between lab-based and unsupervised cognitive assessment may influence task performance. Validation is required to establish reliability, equivalency and agreement with respect to gold-standard lab-based assessments. Objective: The current study validates an unsupervised web-based version of the Cambridge Neuropsychological Test Automated Battery (CANTAB) against a typical in-person lab-based assessment, using a within-subjects counterbalanced design. The study tests: 1) reliability, the correlation between measurements across participants, 2) equivalence, the extent to which test results in different settings produce similar, or by contrast, different overall results, and 3) agreement, by quantifying acceptable limits to bias and differences between the different measurement environments. Methods: Fifty-one healthy adults (32 women, 19 men; mean age 37 years) completed two testing sessions on average one week apart. Assessments included equivalent tests of emotion recognition (Emotion Recognition Task: ERT), visual recognition (Pattern Recognition Memory: PRM), episodic memory (Paired Associate Learning: PAL), working memory and spatial planning (Spatial Working Memory: SWM; One-Touch Stockings of Cambridge: OTS), and sustained attention (Rapid Visual Information Processing: RVP). Participants were randomly allocated to one of two groups, either assessed in-person first (n=33) or using web-based assessment first (n=18). Performance measures (errors, correct trials, response sensitivity), and median reaction times were extracted. Analyses included intra-class correlations (ICC) to examine reliability, linear mixed models and Bayesian paired samples t-tests to test for equivalence, and Bland Altman plots to examine agreement. Results: Intra-class correlation coefficients ranged from 0.23-0.67, with high correlations in three performance measures (from PAL, SWM and RVP tasks, ≥0.60). High intra-class correlations were also seen for reaction time measures from two tasks (PRM and ERT tasks, ≥0.60). However, reaction times were slower during web-based assessments, which undermined both equivalence and agreement for reaction time measures. Performance measures did not differ between assessment modalities, and generally showed satisfactory agreement. Conclusions: Our results support the use of CANTAB performance measures (errors, correct trials, response sensitivity) in unsupervised web-based assessments. Reaction times are not as easily translatable from in-person to web-based testing, likely due to variation in home computer hardware. Results underline the importance of examining more than one index to ascertain validity, since high correlations can be present in the context of consistent, systematic differences which are a product of differences between measurement environments. Further work is now needed validate web-based assessments in clinical populations, and in larger samples to improve sensitivity for detecting subtler differences between test settings.

  • Digital platforms for the self-management of noncommunicable disease: A systematic review

    Date Submitted: Oct 23, 2019

    Open Peer Review Period: Oct 23, 2019 - Dec 18, 2019

    Background: Digital interventions are effective for health behavior change as they enable the self-management of chronic, noncommunicable diseases (NCDs). However, they often fail to facilitate the sp...

    Background: Digital interventions are effective for health behavior change as they enable the self-management of chronic, noncommunicable diseases (NCDs). However, they often fail to facilitate the specific or current needs and preferences of the individual. A proposed alternative is a digital platform, which would host a suite of discrete, already existing digital health interventions. A platform architecture would allow users to explore a range of evidence-based solutions over time to optimize their self-management and health behavior change. For this review, a digital platform has been defined as: a web-based host for numerous discrete, evidence-based digital health interventions, which are effective in supporting NCD self-management. Offers tool for guidance towards the interventions that are most suited to the user’s needs and preferences. Objective: This review aims to identify digital platforms and examine their potential for supporting NCD self-management and health behavior change. Methods: A literature search was conducted in August 2018 using EBSCOhost, PubMed, Scopus, and No digital platforms were identified, so criteria were broadened to include platform-like digital health interventions. Eligible interventions offered several health behavior change features to optimize NCD self-management in an adult population and provided digitally-supported guidance for the user towards the features best suited to them. Data collected on interventions was guided by the CONSORT-EHEALTH checklist. Evaluation data were collected on effectiveness and process outcomes. Results: Six interventions were included for review. Targeted NCDs included cardiovascular diseases (n=2), diabetes (n=3), and chronic obstructive pulmonary disease (n=1). All six used behavior change theories and frameworks to guide conceptualization. Development approaches were similar, with five of six implementing user-centered, iterative processes to optimize intervention relevance. Physical activity was the most targeted health behavior, addressed in all six interventions. Self-report measures and existing medical records were the main sources of data collection during evaluation. Four of the six interventions assessed changes in behavior. Just one demonstrated significant improvements in overall physical activity compared to the control group at 3-months (+4297 MET-minutes/week, P=.02). Significant improvements in diabetes-specific self-care behavior were observed for two of the six interventions at 1-month and 9-months. Older age, female, and lower baseline self-efficacy were associated with greater changes in self-care. One of the six studies reported significant improvements in disease-related quality of life of users at 9-months compared to non-users of the intervention. Adherence was based on the number of follow-up respondents and ranged from 27% to 83% across the six interventions (mean 65 ± SD 25). Initial log-in rates were high (84% ± 17%) and an average of 4 log-ins per user per month (± SD 2.5) was recorded for half of the interventions. User satisfaction was high and platform-like interventions were considered useful, especially the personal relevance to the user and the authoritative nature of the evidence-based components. Conclusions: This review suggests that, with guidance and support, a digital platform could effectively address the individual needs of users to affect positive behavior change. Drawing several evidence-based interventions together has the potential to engage a diverse user group and optimize engagement with existing interventions. This review highlights the need for comprehensive user-centered development and iterative evaluation of a digital platform for NCD self-management. Clinical Trial: PROSPERO 2018 CRD 420 1810 2095

  • Evaluating privacy-preserving record linkage within a public health surveillance system that uses anonymous records

    Date Submitted: Oct 21, 2019

    Open Peer Review Period: Oct 21, 2019 - Dec 16, 2019

    Background: The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) has been established to monitor national testing and test outcomes for blood borne viruses (BBV) and se...

    Background: The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) has been established to monitor national testing and test outcomes for blood borne viruses (BBV) and sexually transmissible infections (STI) in key populations. ACCESS extracts anonymous data from sentinel health services that include general practice, sexual health and infectious disease clinics, as well as public and private laboratories that conduct a large volume of BBV/STI testing. An important attribute of ACCESS is the ability to accurately link individual level records within and between the participating sites, as this enables the system to produce reliable epidemiological measures. Objective: GRHANITE® software is used in ACCESS to extract and link anonymous data from participating clinics and laboratories. Irreversible hashed linkage keys are generated based on patient identifying data captured in the patient electronic medical records (EMRs) at the site. The algorithms to produce the data linkage use probabilistic linkage principles to account for variability and completeness of the underlying patient identifiers, producing up to four linkage key types per EMR. Errors in the linkage process can arise from imperfect or missing identifiers, impacting on the systems integrity. Therefore, it is important to evaluate the quality of the linkages created and evaluate the outcome of the linkage for ongoing public health surveillance. Methods: While ACCESS data are de-identified we created two gold-standard data sets where true match status could be identified to compare against record linkage results arising from different approaches of the GRHANITE Linkage Tool. We report sensitivity, specificity and positive and negative predictive values where possible and estimate specificity by comparing a history of HIV and hepatitis C antibody results for linked EMRs. Results: Sensitivity and specificity was 100% when applying the GRHANITE Linkage Tool to a small gold-standard dataset of 3700 clinical medical records. Medical records in this dataset contained a very high level of data completeness by having name, date of birth, post code and Medicare number available for use in record linkage. In a larger gold standard dataset containing 86,538 medical records across clinics and pathology services, with a lower level of data completeness, sensitivity was over 94% and estimated specificity over 90% in 4 of the 6 different record linkage approaches. Conclusions: Our findings suggest the accuracy of record linkage using the GRHANITE Linkage Tool is high and can be used to make reliable population-based epidemiological assessments including disease incidence and prevalence using ACCESS data.