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Journal Description

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

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

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

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

 

Recent Articles:

  • Source: Freepik; Copyright: Freepik; URL: https://www.freepik.com/free-photo/senior-woman-glasses-browsing-tablet_2177215.htm; License: Licensed by JMIR.

    The Evidence Base for an Ideal Care Pathway for Frail Multimorbid Elderly: Combined Scoping and Systematic Intervention Review

    Abstract:

    Background: There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored. Objective: This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes. Methods: We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects. Results: Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects. Conclusions: Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care transformations for frail multimorbid elderly hinges on an individual care pathway, which reflects a synergetic PIP approach enabled by digital support.

  • Source: Rawpixel; Copyright: Rawpixel; URL: https://www.rawpixel.com/image/379138/black-woman-using-her-laptop; License: Licensed by JMIR.

    Racial, Ethnic, and Socioeconomic Disparities in Web-Based Patient Portal Usage Among Kidney and Liver Transplant Recipients: Cross-Sectional Study

    Abstract:

    Background: Kidney and liver transplant recipients must manage a complex care regimen after kidney transplant. Although the use of Web-based patient portals is known to improve patient-provider communication and health outcomes in chronic disease populations by helping patients manage posttransplant care, disparities in access to and use of portals have been reported. Little is known about portal usage and disparities among kidney and liver transplant recipients. Objective: The aim of this study was to examine patient racial/ethnic, socioeconomic, and clinical characteristics associated with portal usage among kidney and liver transplant recipients. Methods: The study included all adult kidney and liver transplant recipients (n=710) at a large academic transplant center in the Southeastern United States between March 2014 and November 2016. Electronic medical record data were linked with Cerner portal usage data. Patient portal use was defined as any portal activity (vs no activity) recorded in the Cerner Web-based portal, including viewing of health records, lab results, medication lists, and the use of secure messaging. Multivariable log-binomial regression was used to determine the patient demographic, clinical, and socioeconomic characteristics associated with portal usage, stratified by organ. Results: Among 710 transplant recipients (n=455 kidney, n=255 liver), 55.4% (252/455) of kidney recipients and 48.2% (123/255) of liver recipients used the patient portal. Black patients were less likely to use the portal versus white patients among both kidney (57% black vs 74% white) and liver (28% black vs 55% white) transplant recipients. In adjusted multivariable analyses, kidney transplant recipients were more likely to use the portal if they had higher education; among liver recipients, patients who were white versus black and had higher education were more likely to use the portal. Conclusions: Despite studies showing that patient portals have the potential to benefit transplant recipients as a tool for health management, racial and socioeconomic disparities should be considered before widespread implementation. Transplant centers should include portal training and support to all patients to encourage use, given its potential to improve outcomes.

  • Source: Freepik; Copyright: katemangostar; URL: https://www.freepik.com/free-photo/businessman-walking-with-bike-street-after-work_1355534.htm; License: Licensed by JMIR.

    Predicting Outcomes from Engagement With Specific Components of an Internet-Based Physical Activity Intervention With Financial Incentives: Process Analysis...

    Abstract:

    Background: Investigating participant engagement and nonusage attrition can help identify the likely active ingredients of electronic health interventions. Research on engagement can identify which intervention components predict health outcomes. Research on nonusage attrition is important to make recommendations for retaining participants in future studies. Objective: This study aimed to investigate engagement and nonusage attrition in the Physical Activity Loyalty (PAL) scheme, a 6-month complex physical activity intervention in workplaces in Northern Ireland. The intervention included financial incentives with reward redemption and self-regulation techniques. Specific objectives were (1) to determine whether engagement in specific intervention components predicted physical activity at 6 months, (2) to determine whether engagement in specific intervention components predicted targeted mediators at 6 months, and (3) to investigate predictors of nonusage attrition for participants recording daily activity via the PAL scheme physical activity monitoring system and logging onto the website. Methods: Physical activity was assessed at baseline and 6 months using pedometers (Yamax Digiwalker CW-701, Japan). Markers of engagement and website use, monitoring system use, and reward redemption were collected throughout the scheme. Random-effects generalized least-squares regressions determined whether engagement with specific intervention components predicted 6-month physical activity and mediators. Cox proportional hazards regressions were used to investigate predictors of nonusage attrition (days until first 2-week lapse). Results: A multivariable generalized least-squares regression model (n=230) showed that the frequency of hits on the website’s monitoring and feedback component (regression coefficient [b]=50.2; SE=24.5; P=.04) and the percentage of earned points redeemed for financial incentives (b=9.1; SE=3.3; P=.005) were positively related to 6-month pedometer steps per day. The frequency of hits on the discussion forum (b=−69.3; SE=26.6; P=.009) was negatively related to 6-month pedometer steps per day. Reward redemption was not related to levels of more internal forms of motivation. Multivariable Cox proportional hazards regression models identified several baseline predictors associated with nonusage attrition. These included identified regulation (hazard ratio [HR] 0.88, 95% CI 0.81-0.97), recovery self-efficacy (HR 0.88, 95% CI 0.80-0.98), and perceived workplace environment safety (HR 1.07, 95% CI 1.02-1.11) for using the physical activity monitoring system. The EuroQoL health index (HR 0.33, 95% CI 0.12-0.91), financial motivation (HR 0.93, 95% CI 0.87-0.99), and perceived availability of physical activity opportunities in the workplace environment (HR 0.96, 95% CI 0.93-0.99) were associated with website nonusage attrition. Conclusions: Our results provide evidence opposing one of the main hypotheses of self-determination theory by showing that financial rewards are not necessarily associated with decreases in more internal forms of motivation when offered as part of a complex multicomponent intervention. Identifying baseline predictors of nonusage attrition can help researchers to develop strategies to ensure maximum intervention adherence. Trial Registration: ISRCTN Registry ISRCTN17975376; http://www.isrctn.com/ISRCTN17975376 (Archived by WebCite at http://www.webcitation.org/76VGZsZug)

  • Source: Image created by the Authors; Copyright: Cynthia Weijs; URL: http://www.jmir.org/2019/4/e12024/; License: Creative Commons Attribution (CC-BY).

    Effects of Mock Facebook Workday Comments on Public Perception of Professional Credibility: A Field Study in Canada

    Abstract:

    Background: There is considerable discussion of risks to health professionals’ reputations and employment from personal social media use, though its impacts on professional credibility and the health professional-client relationship are unknown. Objective: The aim of this study was to test the extent to which workday comments posted to health professionals’ personal Facebook profiles influence their credibility and affect the professional-client relationship. Methods: In a controlled field study, participants (members of the public) reviewed randomly assigned mock Facebook profiles of health professionals. The 2×2×2 factorial design of mock profiles included gender (female/male), health profession (physician/veterinarian), and workday comment type (evident frustration/ambiguous). Participants then rated the profile owner’s credibility on a visual analog scale. An analysis of variance test compared ratings. Mediation analyses tested the importance of credibility ratings on participants’ willingness to become a client of the mock health professional. Results: Participants (N=357) rated health professionals whose personal Facebook profile showed a comment with evident frustration rather than an ambiguous workday comment as less credible (P<.001; mean difference 11.18 [SE 1.28]; 95% CI 8.66 to 13.70). Furthermore, participants indicated they were less likely to become clients of the former when they considered credibility (standardized beta=.69; P<.001). Credibility explained 86% of the variation in the relationship between the type of workday comment and the participant’s willingness to become a client of the health professional. Conclusions: This study provides the first evidence of the impact of health professionals’ personal online disclosures on credibility and the health relationship. Public perceptions about professionalism and credibility are integral to developing the evidence base for e-professionalism guidelines and encouraging best practices in social media use.

  • Source: James Bueti Photography; Copyright: James Bueti Photography; URL: http://www.jmir.org/2019/4/e13404/; License: Licensed by the authors.

    Wearable Sensors Reveal Menses-Driven Changes in Physiology and Enable Prediction of the Fertile Window: Observational Study

    Abstract:

    Background: Previous research examining physiological changes across the menstrual cycle has considered biological responses to shifting hormones in isolation. Clinical studies, for example, have shown that women’s nightly basal body temperature increases from 0.28 to 0.56 ˚C following postovulation progesterone production. Women’s resting pulse rate, respiratory rate, and heart rate variability (HRV) are similarly elevated in the luteal phase, whereas skin perfusion decreases significantly following the fertile window’s closing. Past research probed only 1 or 2 of these physiological features in a given study, requiring participants to come to a laboratory or hospital clinic multiple times throughout their cycle. Although initially designed for recreational purposes, wearable technology could enable more ambulatory studies of physiological changes across the menstrual cycle. Early research suggests that wearables can detect phase-based shifts in pulse rate and wrist skin temperature (WST). To date, previous work has studied these features separately, with the ability of wearables to accurately pinpoint the fertile window using multiple physiological parameters simultaneously yet unknown. Objective: In this study, we probed what phase-based differences a wearable bracelet could detect in users’ WST, heart rate, HRV, respiratory rate, and skin perfusion. Drawing on insight from artificial intelligence and machine learning, we then sought to develop an algorithm that could identify the fertile window in real time. Methods: We conducted a prospective longitudinal study, recruiting 237 conception-seeking Swiss women. Participants wore the Ava bracelet (Ava AG) nightly while sleeping for up to a year or until they became pregnant. In addition to syncing the device to the corresponding smartphone app daily, women also completed an electronic diary about their activities in the past 24 hours. Finally, women took a urinary luteinizing hormone test at several points in a given cycle to determine the close of the fertile window. We assessed phase-based changes in physiological parameters using cross-classified mixed-effects models with random intercepts and random slopes. We then trained a machine learning algorithm to recognize the fertile window. Results: We have demonstrated that wearable technology can detect significant, concurrent phase-based shifts in WST, heart rate, and respiratory rate (all P<.001). HRV and skin perfusion similarly varied across the menstrual cycle (all P<.05), although these effects only trended toward significance following a Bonferroni correction to maintain a family-wise alpha level. Our findings were robust to daily, individual, and cycle-level covariates. Furthermore, we developed a machine learning algorithm that can detect the fertile window with 90% accuracy (95% CI 0.89 to 0.92). Conclusions: Our contributions highlight the impact of artificial intelligence and machine learning’s integration into health care. By monitoring numerous physiological parameters simultaneously, wearable technology uniquely improves upon retrospective methods for fertility awareness and enables the first real-time predictive model of ovulation.

  • Source: Image created by the Authors; Copyright: The Authors; URL: http://www.jmir.org/2019/4/e12368/; License: Licensed by JMIR.

    Augmented Reality in Emergency Medicine: A Scoping Review

    Abstract:

    Background: Augmented reality is increasingly being investigated for its applications to medical specialties as well as in medical training. Currently, there is little information about its applicability to training and care delivery in the context of emergency medicine. Objective: The objective of this article is to review current literature related to augmented reality applicable to emergency medicine and its training. Methods: Through a scoping review utilizing Scopus, MEDLINE, and Embase databases for article searches, we identified articles involving augmented reality that directly involved emergency medicine or was in an area of education or clinical care that could be potentially applied to emergency medicine. Results: A total of 24 articles were reviewed in detail and were categorized into three groups: user-environment interface, telemedicine and prehospital care, and education and training. Conclusions: Through analysis of the current literature across fields, we were able to demonstrate that augmented reality has utility and feasibility in clinical care delivery in patient care settings, in operating rooms and inpatient settings, and in education and training of emergency care providers. Additionally, we found that the use of augmented reality for care delivery over distances is feasible, suggesting a role in telehealth. Our results from the review of the literature in emergency medicine and other specialties reveal that further research into the uses of augmented reality will have a substantial role in changing how emergency medicine as a specialty will deliver care and provide education and training.

  • Source: The Authors; Copyright: The Authors; URL: https://www.jmir.org/2019/4/e12772/; License: Creative Commons Attribution (CC-BY).

    Validation of Two Automatic Blood Pressure Monitors With the Ability to Transfer Data via Bluetooth

    Abstract:

    Background: Patients with chronic diseases are in need of regular health controls. Diabetes mellitus type 2 is currently the most prevalent chronic metabolic disease. A majority of diabetic patients have at least one comorbid chronic disease, where hypertension is the most common. The standard for blood pressure (BP) measurement is manual BP monitoring at health care clinics. Nevertheless, several advantages of self-measured BP have been documented. With BP data transfer from an automatic BP monitor via Bluetooth to software, for example, a smartphone app, home measurement could effectively be integrated into regular care. Objective: The aim of this study was to validate two commercially available automatic BP monitors with the ability to transfer BP data via Bluetooth (Beurer BM 85 and Andersson Lifesense BDR 2.0), against manual BP monitoring in patients with type 2 diabetes. Methods: A total of 181 participants with type 2 diabetes were recruited from 6 primary care centers in Stockholm, Sweden. BP was first measured using a manual BP monitor and then measured using the two automatic BP monitors. The mean differences between the automatic and manual measurements were calculated by subtracting the manual BP monitor measurement from the automatic monitor measurement. Validity of the two automatic BP monitors was further assessed using Spearman rank correlation coefficients and the Bland-Altman method. Results: In total, 180 participants, 119 men and 61 women, were included. The mean age was 60.1 (SD 11.4) years and the mean body mass index was 30.4 (SD 5.4) kg/m2. The mean difference between the Beurer BM 85 and the manual BP monitor was 11.1 (SD 11.2) mmHg for systolic blood pressure (SBP) and 8.0 (SD 8.1) mmHg for diastolic blood pressure (DBP). The mean difference between the Andersson Lifesense BDR 2.0 and the manual BP monitor was 3.2 (SD 10.8) mmHg for SBP and 4.2 (SD 7.2) mmHg for DBP. The automatic BP measurements were significantly correlated (P<.001) with the manual BP measurement values (Andersson Lifesense BDR 2.0: r=0.78 for SBP and r=0.71 for DBP; Beurer BM 85: r=0.78 for SBP and r=0.69 for DBP). Conclusions: The two automatic BP monitors validated measure sufficiently accurate on a group level, with the Andersson Lifesense BDR 2.0 more often falling within the ranges for what is acceptable in clinical practice compared with the Beurer BM 85.

  • Source: Wikimedia Commons; Copyright: NEALnz; URL: https://commons.wikimedia.org/wiki/File:Laptopboy_1.JPG; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Comparison of Smartphone Ownership, Social Media Use, and Willingness to Use Digital Interventions Between Generation Z and Millennials in the Treatment of...

    Abstract:

    Background: Problematic substance use in adolescence and emerging adulthood is a significant public health concern in the United States due to high recurrence of use rates and unmet treatment needs coupled with increased use. Consequently, there is a need for both improved service utilization and availability of recovery supports. Given the ubiquitous use of the internet and social media via smartphones, a viable option is to design digital treatments and recovery support services to include internet and social media platforms. Objective: Although digital treatments delivered through social media and the internet are a possibility, it is unclear how interventions using these tools should be tailored for groups with problematic substance use. There is limited research comparing consumer trends of use of social media platforms, use of platform features, and vulnerability of exposure to drug cues online. The goal of this study was to compare digital platforms used among adolescents (Generation Zs, age 13-17) and emerging adults (Millennials, age 18-35) attending outpatient substance use treatment and to examine receptiveness toward these platforms in order to support substance use treatment and recovery. Methods: Generation Zs and Millennials enrolled in outpatient substance use treatment (n=164) completed a survey examining social media use, digital intervention acceptability, frequency of substance exposure, and substance use experiences. Generation Zs (n=53) completed the survey in July 2018. Millennials (n=111) completed the survey in May 2016. Results: Generation Zs had an average age of 15.66 (SD 1.18) years and primarily identified as male (50.9%). Millennials had an average age of 27.66 (SD 5.12) years and also primarily identified as male (75.7%). Most participants owned a social media account (Millennials: 82.0%, Generation Zs: 94.3%) and used it daily (Millennials: 67.6%, Generation Zs: 79.2%); however, Generation Zs were more likely to use Instagram and Snapchat, whereas Millennials were more likely to use Facebook. Further, Generation Zs were more likely to use the features within social media platforms (eg, instant messaging: Millennials: 55.0%, Generation Zs: 79.2%; watching videos: Millennials: 56.8%, Generation Zs: 81.1%). Many participants observed drug cues on social media (Millennials: 67.5%, Generation Zs: 71.7%). However, fewer observed recovery information on social media (Millennials: 30.6%, Generation Zs: 34.0%). Participants felt that social media (Millennials: 55.0%, Generation Zs: 49.1%), a mobile phone app (Millennials: 36.9%, Generation Zs: 45.3%), texting (Millennials: 28.8%, Generation Zs: 45.3%), or a website (Millennials: 39.6%, Generation Zs: 32.1%) would be useful in delivering recovery support. Conclusions: Given the high rates of exposure to drug cues on social media, disseminating recovery support within a social media platform may be the ideal just-in-time intervention needed to decrease the rates of recurrent drug use. However, our results suggest that cross-platform solutions capable of transcending generational preferences are necessary and one-size-fits-all digital interventions should be avoided.

  • Source: Pixabay; Copyright: StartupStockPhotos; URL: https://pixabay.com/nl/photos/student-te-typen-toetsenbord-tekst-849825/; License: Licensed by the authors.

    Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis

    Abstract:

    Background: Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects. Objective: This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome. Methods: We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials. Results: We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls. Conclusions: iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients’ greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

  • The wearable device, smartphone, and eMoodchart used in this study. A passive digital phenotype was acquired through a wearable device and a smartphone, and a mood prediction algorithm using machine learning was constructed and verified using real-time mood recording through eMoodchart. Source: Image created by the Authors; Copyright: The Authors; URL: http://www.jmir.org/2019/4/e11029/; License: Creative Commons Attribution (CC-BY).

    Mood Prediction of Patients With Mood Disorders by Machine Learning Using Passive Digital Phenotypes Based on the Circadian Rhythm: Prospective Observational...

    Abstract:

    Background: Virtually, all organisms on Earth have their own circadian rhythm, and humans are no exception. Circadian rhythms are associated with various human states, especially mood disorders, and disturbance of the circadian rhythm is known to be very closely related. Attempts have also been made to derive clinical implications associated with mood disorders using the vast amounts of digital log that is acquired by digital technologies develop and using computational analysis techniques. Objective: This study was conducted to evaluate the mood state or episode, activity, sleep, light exposure, and heart rate during a period of about 2 years by acquiring various digital log data through wearable devices and smartphone apps as well as conventional clinical assessments. We investigated a mood prediction algorithm developed with machine learning using passive data phenotypes based on circadian rhythms. Methods: We performed a prospective observational cohort study on 55 patients with mood disorders (major depressive disorder [MDD] and bipolar disorder type 1 [BD I] and 2 [BD II]) for 2 years. A smartphone app for self-recording daily mood scores and detecting light exposure (using the installed sensor) were provided. From daily worn activity trackers, digital log data of activity, sleep, and heart rate were collected. Passive digital phenotypes were processed into 130 features based on circadian rhythms, and a mood prediction algorithm was developed by random forest. Results: The mood state prediction accuracies for the next 3 days in all patients, MDD patients, BD I patients, and BD II patients were 65%, 65%, 64%, and 65% with 0.7, 0.69, 0.67, and 0.67 area under the curve (AUC) values, respectively. The accuracies of all patients for no episode (NE), depressive episode (DE), manic episode (ME), and hypomanic episode (HME) were 85.3%, 87%, 94%, and 91.2% with 0.87, 0.87, 0.958, and 0.912 AUC values, respectively. The prediction accuracy in BD II patients was distinctively balanced as high showing 82.6%, 74.4%, and 87.5% of accuracy (with generally good sensitivity and specificity) with 0.919, 0.868, and 0.949 AUC values for NE, DE, and HME, respectively. Conclusions: On the basis of the theoretical basis of chronobiology, this study proposed a good model for future research by developing a mood prediction algorithm using machine learning by processing and reclassifying digital log data. In addition to academic value, it is expected that this study will be of practical help to improve the prognosis of patients with mood disorders by making it possible to apply actual clinical application owing to the rapid expansion of digital technology.

  • Source: Andrew Neel; Copyright: Unsplash; URL: https://unsplash.com/photos/wClUbRMCBD8; License: Licensed by the authors.

    Designing a Chatbot for a Brief Motivational Interview on Stress Management: Qualitative Case Study

    Abstract:

    Background: In addition to addiction and substance abuse, motivational interviewing (MI) is increasingly being integrated in treating other clinical issues such as mental health problems. Most of the many technological adaptations of MI, however, have focused on delivering the action-oriented treatment, leaving its relational component unexplored or vaguely described. This study intended to design a conversational sequence that considers both technical and relational components of MI for a mental health concern. Objective: This case study aimed to design a conversational sequence for a brief motivational interview to be delivered by a Web-based text messaging application (chatbot) and to investigate its conversational experience with graduate students in their coping with stress. Methods: A brief conversational sequence was designed with varied combinations of MI skills to follow the 4 processes of MI. A Web-based text messaging application, Bonobot, was built as a research prototype to deliver the sequence in a conversation. A total of 30 full-time graduate students who self-reported stress with regard to their school life were recruited for a survey of demographic information and perceived stress and a semistructured interview. Interviews were transcribed verbatim and analyzed by Braun and Clarke’s thematic method. The themes that reflect the process of, impact of, and needs for the conversational experience are reported. Results: Participants had a high level of perceived stress (mean 22.5 [SD 5.0]). Our findings included the following themes: Evocative Questions and Clichéd Feedback; Self-Reflection and Potential Consolation; and Need for Information and Contextualized Feedback. Participants particularly favored the relay of evocative questions but were less satisfied with the agent-generated reflective and affirming feedback that filled in-between. Discussing the idea of change was a good means of reflecting on themselves, and some of Bonobot’s encouragements related to graduate school life were appreciated. Participants suggested the conversation provide informational support, as well as more contextualized feedback. Conclusions: A conversational sequence for a brief motivational interview was presented in this case study. Participant feedback suggests sequencing questions and MI-adherent statements can facilitate a conversation for stress management, which may encourage a chance of self-reflection. More diversified sequences, along with more contextualized feedback, should follow to offer a better conversational experience and to confirm any empirical effect.

  • Source: iStock by Getty Images; Copyright: coffeekai; URL: https://www.istockphoto.com/ca/photo/facebook-app-on-iphone-with-computer-laptop-background-closeup-male-hand-hold-social-gm847576432-139205449; License: Licensed by the authors.

    Using a Facebook Forum to Cope With Narcolepsy After Pandemrix Vaccination: Infodemiology Study

    Abstract:

    Background: In 2010, newly diagnosed narcolepsy cases among children and adolescents were seen in several European countries as a consequence of comprehensive national vaccination campaigns with Pandemrix against H1N1 influenza. Since then, a large number of people have had to live with narcolepsy and its consequences in daily life, such as effects on school life, social relationships, and activities. Initially, the adverse effects were not well understood and there was uncertainty about whether there would be any financial compensation. The situation remained unresolved until 2016, and during these years affected people sought various ways to join forces to handle the many issues involved, including setting up a social media forum. Objective: Our aim was to examine how information was shared, and how opinions and beliefs about narcolepsy as a consequence of Pandemrix vaccination were formed through discussions on social media. Methods: We used quantitative and qualitative methods to investigate a series of messages posted in a social media forum for people affected by narcolepsy after vaccination. Results: Group activity was high throughout the years 2010 to 2016, with peaks corresponding to major narcolepsy-related events, such as the appearance of the first cases in 2010, the first payment of compensation in 2011, and passage of a law on compensation in July 2016. Unusually, most (462/774, 59.7%) of the group took part in discussions and only 312 of 774 (40.3%) were lurkers (compared with the usual 90% rule of thumb for participation in an online community). The conversation in the group was largely factual and had a civil tone, even though there was a long struggle for the link between the vaccine and narcolepsy to be acknowledged and regarding the compensation issue. Radical, nonscientific views, such as those expounded by the antivaccination movement, did not shape the discussions in the group but were being actively expressed elsewhere on the internet. At the outset of the pandemic, there were 18 active Swedish discussion groups on the topic, but most dissolved quickly and only one Facebook group remained active throughout the period. Conclusions: The group studied is a good example of social media use for self-help through a difficult situation among people affected by illness and disease. This shows that social media do not by themselves induce trench warfare but, given a good group composition, can provide a necessary forum for managing an emergency situation where health care and government have failed or are mistrusted, and patients have to organize themselves so as to cope.

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

    Background: This paper examines the development of the Connected Health research landscape with a view on providing a historical perspective on existing Connected Health research. Connected Health has...

    Background: This paper examines the development of the Connected Health research landscape with a view on providing a historical perspective on existing Connected Health research. Connected Health has become a rapidly growing research field as our healthcare system is facing pressured to become more proactive and patient centred. Objective: We aimed to identify the extent and coverage of the current body of knowledge in Connected Health. With this, we want to identify which topics have drawn the attention of Connected health researchers, and if there are gaps or interdisciplinary opportunities for further research. Methods: We used a systematic mapping study that combines scientific contributions from research on medicine, business, computer science and engineering. We analyse the papers with seven classification criteria, publication source, publication year, research types, empirical types, contribution types research topic and the condition studied in the paper. Results: Altogether, our search resulted in 208 papers which were analysed by a multidisciplinary group of researchers. Our results indicate a slow start for Connected Health research but a more recent steady upswing since 2013. The majority of papers proposed healthcare solutions (37%) or evaluated Connected Health approaches (23%). Case studies (28%) and experiments (26%) were the most popular forms of scientific validation employed. Diabetes, cancer, multiple sclerosis, and heart conditions are among the most prevalent conditions studied. Conclusions: We conclude that Connected Health research seems to be an established field of research, which has been growing strongly during the last five years. There seems to be more focus on technology driven research with a strong contribution from medicine, but business aspects of Connected health are not as much studied.

  • Title: Hacking 9-1-1: infrastructure vulnerabilities and attack vectors

    Date Submitted: Apr 14, 2019

    Open Peer Review Period: Apr 14, 2019 - Jun 9, 2019

    Background: 9-1-1 call centers are a critical component of prehospital care: they accept emergency calls, dispatch field responders such as EMS units, and provide callers with emergency medical instru...

    Background: 9-1-1 call centers are a critical component of prehospital care: they accept emergency calls, dispatch field responders such as EMS units, and provide callers with emergency medical instructions prior to their arrival. Objective: We aim to describe the technical structure of the 9-1-1 call taking system and describe its vulnerabilities that could lead to compromised patient care. Methods: 9-1-1 calls answered from mobile phones and land lines use a variety of technologies to provide information about caller location and other information. These interconnected technologies create potential cyber vulnerabilities. Results: A variety of attacks could be carried out on 9-1-1 infrastructure to various ends. Attackers could target individuals, groups, or entire municipalities. These attacks could result in anything from a nuisance, to increased loss of life in a physical attack, to worse overall outcomes due to delays in care for time sensitive conditions. Conclusions: Evolving 9-1-1 systems are increasingly connected and dependent on network technology. As implications of cybersecurity vulnerabilities loom large, future research should examine methods of hardening the 9-1-1 system against attack.

  • Barriers and enablers for successful implementation of the eHealth service Sisom for improved child participation in pediatric care - a multi-center study

    Date Submitted: Apr 8, 2019

    Open Peer Review Period: Apr 12, 2019 - Jun 7, 2019

    Background: Children’s participation in healthcare is one of the most important components in the management of their disease. eHealth services that are adapted to the needs of children have the pot...

    Background: Children’s participation in healthcare is one of the most important components in the management of their disease. eHealth services that are adapted to the needs of children have the potential for restructuring how children and professionals work together. We have developed the digital interactive assessment and communication tool, Sisom, to give children between 6-12 years “a voice" in their own healthcare. However, the implementation of eHealth services such as Sisom in daily practice in pediatric healthcare is rarely investigated. Objective: The purpose of this study was to explore the process of implementing Sisom for children in pediatric care in Sweden. More specifically, to (1) evaluate whether the implementation strategy was conducted as planned; (2) understand the barriers and facilitators of the implementation strategy in pediatric care settings; (3) gain insight into how professionals work with the specific intervention; and (4) gain insight into the usefulness and effects of the intervention from the professionals’ perspectives. Methods: A process evaluation design was used to study the implementation of Sisom at four pediatric care centers in Sweden. An extensive amount of qualitative and quantitative data was collected before, during and after the intervention through self-report checklists, memos and interviews with professionals. In total, 46 children, age 6- 13 years, participated. The children used Sisom at two occasions during 6 months. When they have used Sisom, a printed report forms the basis for a forthcoming dialogue between professionals, children and their parents. Results: To our knowledge, this is the first implementation study of an eHealth communication tool aimed at strengthening children’s participation in pediatric healthcare. Key factors for successful implementation were alignment of the solution with the values and goals of the organization, healthcare professionals’ beliefs in the usefulness and usability of the solution and healthcare professionals’ willingness to change their professional roles guided by the solution. Conclusions: The results from the study shows that it is possible to restructure healthcare delivery towards a child-centered approach if there is a willingness and preparedness in the organization to implement an eHealth solution with the aim of restructuring the way of working with children’s participation.

  • Integrating Health technologies in Health Services for Syrian Refugees in Lebanon: a Qualitative study

    Date Submitted: Apr 8, 2019

    Open Peer Review Period: Apr 12, 2019 - Jun 7, 2019

    Background: Lebanon currently hosts around one million Syrian refugees. There has been an increasing interest in integrating eHealth and mHealth technologies into the provision of primary healthcare t...

    Background: Lebanon currently hosts around one million Syrian refugees. There has been an increasing interest in integrating eHealth and mHealth technologies into the provision of primary healthcare to refugees and Lebanese citizens. Objective: We aimed to gain a deeper understanding of the potential for technology integration in primary healthcare provision in the context of the protracted Syrian refugee crisis in Lebanon. Methods: A total of 18 face-to-face semi structured interviews were conducted with key informants (n=8) and healthcare providers (n=10) involved in the provision of health care to the Syrian refugee population in Lebanon. Interviews were audio recorded and directly translated and transcribed from Arabic to English. Thematic Analysis was conducted. Results: Study participants indicated that varying resources, primarily time and the availability of technologies, at primary healthcare clinics, to be one of the main challenges for integrating technologies for the provision of healthcare services for refugees. This challenge is compounded by refugees being viewed by participants as a mobile population thus making primary healthcare clinics less willing to invest in refugee health technologies. Lastly, participants’ perceptions of refugees’ technological capabilities and motivations regarding their health concerns were found to be challenges that need addressing for the successful integration of refugee health technologies. Conclusions: Our findings indicate that in the context of integrating technology into the provision of healthcare for refugees in a low or middle income country, such as Lebanon, some barriers for technology integration related to the availability of resources are common with those found elsewhere. However, we identified participants’ perceptions of refugees’ capabilities to be a challenge specific to the context of this refugee crisis. These perceptions needs addressing when considering refugee health technologies. This could be done by: a)increasing the visibility of refugee capabilities, and; b) configuring refugee health technologies so that they may create spaces in which refugees are empowered within the healthcare system and can work towards debunking the negative perceptions surfaced in this study.

  • A Research Roadmap: Connected Health as enabler of Cancer Patient Support

    Date Submitted: Apr 12, 2019

    Open Peer Review Period: Apr 12, 2019 - Jun 7, 2019

    Sustained improvements in cancer care in recent years have resulted in increased numbers of people living with and beyond cancer, and increased attention being placed on improving quality of life for...

    Sustained improvements in cancer care in recent years have resulted in increased numbers of people living with and beyond cancer, and increased attention being placed on improving quality of life for those living with and beyond cancer. Connected Health provides the foundations for the transformation of cancer care into a patient-centric model focused to provide personalised support to the unique needs of each patient. It creates an opportunity to overcome barriers of health care support among patients diagnosed with chronic conditions. This paper provides an overview of important areas for the creation of a new connected health paradigm in cancer care. It discusses the capabilities of mobile and wearable technologies and device systems to advance a multidisciplinary and inclusive approach for cancer patients for mental wellbeing, physical activity, and rehabilitation. Several examples already show that there is an enthusiasm to strengthen the possibilities offered by Connected Health in persuasive & pervasive technology in cancer care. Developments harnessing the internet of things, personalization, and artificial intelligence help to monitor and assess the health status of cancer patients. Furthermore, this paper analyses the Data Infrastructure Ecosystem the Connected Health economy ecosystem, and its associated barriers. Interoperability is essential when developing Connected Health solutions which integrate with health systems and electronic health records. Business growth in mHealth exponential, making it both an attractive and challenging market. As a conclusion, there is a need for user-centered and multi-disciplinary standards of practice to the design, development, evaluation, and implementation of Connected Health interventions in cancer care to ensure their acceptability, practicality, effectiveness, affordability, safety, and equity.

  • Using Social Media to Uncover Treatment Experiences and Decisions in Patients with Acute Myeloid Leukemia or Myelodysplastic Syndrome who are Ineligible for Intensive Chemotherapy: A Patient-Centric Approach

    Date Submitted: Apr 9, 2019

    Open Peer Review Period: Apr 10, 2019 - Jun 5, 2019

    Background: Until recently, treatment options were limited for patients with acute myeloid leukemia and myelodysplastic syndrome (AML/MDS) who are ineligible for intensive chemotherapy. Due to rapid p...

    Background: Until recently, treatment options were limited for patients with acute myeloid leukemia and myelodysplastic syndrome (AML/MDS) who are ineligible for intensive chemotherapy. Due to rapid progression of the condition, it is difficult to capture what is most important to patients when making treatment decisions. Patients’ needs can be better addressed by gaining a deeper understanding of their perspectives, which is valuable in the decision-making process. The Food and Drug Administration (FDA) recently encouraged the use of social media as a tool to gain insight on patients’ perspectives regarding symptoms experienced and the impacts of their disease. Objective: To use disease-specific social media posts by patients with AML/MDS who are ineligible for intensive chemotherapy and their caregivers to capture factors that are most important to this population, and to provide current evidence to inform and characterize these perspectives. Methods: Posts by patients with AML/MDS and their caregivers were extracted from publicly available discussions on three large AML/MDS-specific sites. These posts were manually reviewed to only include patients who are ineligible for intensive chemotherapy. A total of 1,443 posts from 220 AML patients/caregivers and 2,733 posts from 127 MDS patients/caregivers met the study inclusion criteria. A qualitative data analysis (QDA) of a sample of 85 patients/caregivers’ posts was conducted to identify themes, and a targeted QDA of posts from 79 users focused on treatment decision discussions. Posts were manually reviewed, and relevant text segments were coded and grouped into categories and overall themes. Results: A total of 86% (73 of 85) of users included in the overall QDA had relevant information about the key objectives. The most commonly discussed treatment experience theme was the humanistic burden of AML/MDS in terms of emotional/physical impact and impact on family (86% of users), followed by treatment decisions (56%) and unmet needs (50%). In the QDA of treatment decisions, 60 posts from 45 users contained relevant information. Patients commonly reported the desire to reach specific milestones including birthdays and weddings. They wished for a better quality of life over quantity of life, did not want the risk of suffering from side effects, and expressed a clear preference to be at home rather than in a hospital or care home. Conclusions: This study was a novel application of disease-specific social media. It highlighted experiences in the current treatment of AML/MDS including information gaps, patient/caregiver uncertainty, and the importance of understanding patient/caregiver goals and opinions. A clear finding from this research was the importance of reaching certain personal life goals and being at home with family and friends. The analysis showed that patients/caregivers face additional challenges that include humanistic impacts and a lack of information regarding treatment options.

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