JMIR Publications

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  New Methods

  Nov 16, 2018

  Measuring Engagement in eHealth and mHealth Behavior Change Interventions: Viewpoint of Methodologies

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  Authors List:

  • Camille E Short  
  • Ann DeSmet  
  • Catherine Woods  
  • Susan L Williams  
  • Carol Maher  
  • Anouk Middelweerd  
  • Andre Matthias Müller  
  • Petra A Wark  
  • Corneel Vandelanotte  
  • Louise Poppe  
  • Melanie D Hingle  
  • Rik Crutzen  

  Abstract:

  Engagement in electronic health (eHealth) and mobile health (mHealth) behavior change interventions is thought to be important for intervention effectiveness, though what constitutes engagement and how it enhances efficacy has been somewhat unclear in the literature. Recently published detailed definitions and conceptual models of engagement have helped to build consensus around a definition of engagement and improve our understanding of how engagement may influence effectiveness. This work has helped to establish a clearer research agenda. However, to test the hypotheses generated by the conceptual modules, we need to know how to measure engagement in a valid and reliable way. The aim of this viewpoint is to provide an overview of engagement measurement options that can be employed in eHealth and mHealth behavior change intervention evaluations, discuss methodological considerations, and provide direction for future research. To identify measures, we used snowball sampling, starting from systematic reviews of engagement research as well as those utilized in studies known to the authors. A wide range of methods to measure engagement were identified, including qualitative measures, self-report questionnaires, ecological momentary assessments, system usage data, sensor data, social media data, and psychophysiological measures. Each measurement method is appraised and examples are provided to illustrate possible use in eHealth and mHealth behavior change research. Recommendations for future research are provided, based on the limitations of current methods and the heavy reliance on system usage data as the sole assessment of engagement. The validation and adoption of a wider range of engagement measurements and their thoughtful application to the study of engagement are encouraged.

  • J Med Internet Res 2018;20(11):e292

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  Mobile Health (mhealth)

  Nov 15, 2018

  Defining and Predicting Pain Volatility in Users of the Manage My Pain App: Analysis Using Data Mining and Machine Learning Methods

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  Authors List:

  • Quazi Abidur Rahman  
  • Tahir Janmohamed  
  • Meysam Pirbaglou  
  • Hance Clarke  
  • Paul Ritvo  
  • Jane M Heffernan  
  • Joel Katz  

  Abstract:

  Background: Measuring and predicting pain volatility (fluctuation or variability in pain scores over time) can help improve pain management. Perceptions of pain and its consequent disabling effects are often heightened under the conditions of greater uncertainty and unpredictability associated with pain volatility. Objective: This study aimed to use data mining and machine learning methods to (1) define a new measure of pain volatility and (2) predict future pain volatility levels from users of the pain management app, Manage My Pain, based on demographic, clinical, and app use features. Methods: Pain volatility was defined as the mean of absolute changes between 2 consecutive self-reported pain severity scores within the observation periods. The k-means clustering algorithm was applied to users’ pain volatility scores at the first and sixth month of app use to establish a threshold discriminating low from high volatility classes. Subsequently, we extracted 130 demographic, clinical, and app usage features from the first month of app use to predict these 2 volatility classes at the sixth month of app use. Prediction models were developed using 4 methods: (1) logistic regression with ridge estimators; (2) logistic regression with Least Absolute Shrinkage and Selection Operator; (3) Random Forests; and (4) Support Vector Machines. Overall prediction accuracy and accuracy for both classes were calculated to compare the performance of the prediction models. Training and testing were conducted using 5-fold cross validation. A class imbalance issue was addressed using a random subsampling of the training dataset. Users with at least five pain records in both the predictor and outcome periods (N=782 users) are included in the analysis. Results: k-means clustering algorithm was applied to pain volatility scores to establish a threshold of 1.6 to differentiate between low and high volatility classes. After validating the threshold using random subsamples, 2 classes were created: low volatility (n=611) and high volatility (n=171). In this class-imbalanced dataset, all 4 prediction models achieved 78.1% (611/782) to 79.0% (618/782) in overall accuracy. However, all models have a prediction accuracy of less than 18.7% (32/171) for the high volatility class. After addressing the class imbalance issue using random subsampling, results improved across all models for the high volatility class to greater than 59.6% (102/171). The prediction model based on Random Forests performs the best as it consistently achieves approximately 70% accuracy for both classes across 3 random subsamples. Conclusions: We propose a novel method for measuring pain volatility. Cluster analysis was applied to divide users into subsets of low and high volatility classes. These classes were then predicted at the sixth month of app use with an acceptable degree of accuracy using machine learning methods based on the features extracted from demographic, clinical, and app use information from the first month.

  • J Med Internet Res 2018;20(11):e12001

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• New Methods

  Nov 15, 2018

  Feasibility, Acceptability, and Adoption of Digital Fingerprinting During Contact Investigation for Tuberculosis in Kampala, Uganda: A Parallel-Convergent...

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  Authors List:

  • Elizabeth B White  
  • Amanda J Meyer  
  • Joseph M Ggita  
  • Diana Babirye  
  • David Mark  
  • Irene Ayakaka  
  • Jessica E Haberer  
  • Achilles Katamba  
  • Mari Armstrong-Hough  
  • John Lucian Davis  

  Abstract:

  Background: In resource-constrained settings, challenges with unique patient identification may limit continuity of care, monitoring and evaluation, and data integrity. Biometrics offers an appealing but understudied potential solution. Objective: The objective of this mixed-methods study was to understand the feasibility, acceptability, and adoption of digital fingerprinting for patient identification in a study of household tuberculosis contact investigation in Kampala, Uganda. Methods: Digital fingerprinting was performed using multispectral fingerprint scanners. We tested associations between demographic, clinical, and temporal characteristics and failure to capture a digital fingerprint. We used generalized estimating equations and a robust covariance estimator to account for clustering. In addition, we evaluated the clustering of outcomes by household and community health workers (CHWs) by calculating intraclass correlation coefficients (ICCs). To understand the determinants of intended and actual use of fingerprinting technology, we conducted 15 in-depth interviews with CHWs and applied a widely used conceptual framework, the Technology Acceptance Model 2 (TAM2). Results: Digital fingerprints were captured for 75.5% (694/919) of participants, with extensive clustering by household (ICC=.99) arising from software (108/179, 60.3%) and hardware (65/179, 36.3%) failures. Clinical and demographic characteristics were not markedly associated with fingerprint capture. CHWs successfully fingerprinted all contacts in 70.1% (213/304) of households, with modest clustering of outcomes by CHWs (ICC=.18). The proportion of households in which all members were successfully fingerprinted declined over time (ρ=.30, P<.001). In interviews, CHWs reported that fingerprinting failures lowered their perceptions of the quality of the technology, threatened their social image as competent health workers, and made the technology more difficult to use. Conclusions: We found that digital fingerprinting was feasible and acceptable for individual identification, but problems implementing the hardware and software lead to a high failure rate. Although CHWs found fingerprinting to be acceptable in principle, their intention to use the technology was tempered by perceptions that it was inconsistent and of questionable value. TAM2 provided a valuable framework for understanding the motivations behind CHWs’ intentions to use the technology. We emphasize the need for routine process evaluation of biometrics and other digital technologies in resource-constrained settings to assess implementation effectiveness and guide improvement of delivery.

  • J Med Internet Res 2018;20(11):e11541

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  Clinical Information and Decision Making

  Nov 14, 2018

  An Interpretable and Expandable Deep Learning Diagnostic System for Multiple Ocular Diseases: Qualitative Study

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  Authors List:

  • Kai Zhang  
  • Xiyang Liu  
  • Fan Liu  
  • Lin He  
  • Lei Zhang  
  • Yahan Yang  
  • Wangting Li  
  • Shuai Wang  
  • Lin Liu  
  • Zhenzhen Liu  
  • Xiaohang Wu  
  • Haotian Lin  

  Abstract:

  Background: Although artificial intelligence performs promisingly in medicine, few automatic disease diagnosis platforms can clearly explain why a specific medical decision is made. Objective: We aimed to devise and develop an interpretable and expandable diagnosis framework for automatically diagnosing multiple ocular diseases and providing treatment recommendations for the particular illness of a specific patient. Methods: As the diagnosis of ocular diseases highly depends on observing medical images, we chose ophthalmic images as research material. All medical images were labeled to 4 types of diseases or normal (total 5 classes); each image was decomposed into different parts according to the anatomical knowledge and then annotated. This process yields the positions and primary information on different anatomical parts and foci observed in medical images, thereby bridging the gap between medical image and diagnostic process. Next, we applied images and the information produced during the annotation process to implement an interpretable and expandable automatic diagnostic framework with deep learning. Results: This diagnosis framework comprises 4 stages. The first stage identifies the type of disease (identification accuracy, 93%). The second stage localizes the anatomical parts and foci of the eye (localization accuracy: images under natural light without fluorescein sodium eye drops, 82%; images under cobalt blue light or natural light with fluorescein sodium eye drops, 90%). The third stage carefully classifies the specific condition of each anatomical part or focus with the result from the second stage (average accuracy for multiple classification problems, 79%-98%). The last stage provides treatment advice according to medical experience and artificial intelligence, which is merely involved with pterygium (accuracy, >95%). Based on this, we developed a telemedical system that can show detailed reasons for a particular diagnosis to doctors and patients to help doctors with medical decision making. This system can carefully analyze medical images and provide treatment advices according to the analysis results and consultation between a doctor and a patient. Conclusions: The interpretable and expandable medical artificial intelligence platform was successfully built; this system can identify the disease, distinguish different anatomical parts and foci, discern the diagnostic information relevant to the diagnosis of diseases, and provide treatment suggestions. During this process, the whole diagnostic flow becomes clear and understandable to both doctors and their patients. Moreover, other diseases can be seamlessly integrated into this system without any influence on existing modules or diseases. Furthermore, this framework can assist in the clinical training of junior doctors. Owing to the rare high-grade medical resource, it is impossible that everyone receives high-quality professional diagnosis and treatment service. This framework can not only be applied in hospitals with insufficient medical resources to decrease the pressure on experienced doctors but also deployed in remote areas to help doctors diagnose common ocular diseases.

  • J Med Internet Res 2018;20(11):e11144

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  Web-based and Mobile Health...

  Nov 14, 2018

  Internet-Delivered Early Interventions for Individuals Exposed to Traumatic Events: Systematic Review

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  Authors List:

  • Naomi Ennis  
  • Iris Sijercic  
  • Candice M Monson  

  Abstract:

  Background: Over 75% of individuals are exposed to a traumatic event, and a substantial minority goes on to experience mental health problems that can be chronic and pernicious in their lifetime. Early interventions show promise for preventing trauma following psychopathology; however, a face-to-face intervention can be costly, and there are many barriers to accessing this format of care. Objective: The aim of this study was to systematically review studies of internet-delivered early interventions for trauma-exposed individuals. Methods: A literature search was conducted in PsycINFO and PubMed for papers published between 1991 and 2017. Papers were included if the following criteria were met: (1) an internet-based intervention was described and applied to individuals exposed to a traumatic event; (2) the authors stated that the intervention was intended to be applied early following trauma exposure or as a preventive intervention; and (3) data on mental health symptoms at pre-and postintervention were described (regardless of whether these were primary outcomes). Methodological quality of included studies was assessed using the Downs and Black checklist. Results: The interventions in the 7 studies identified were categorized as selected (ie, delivered to an entire sample after trauma regardless of psychopathology symptoms) or indicated (ie, delivered to those endorsing some level of posttraumatic distress). Selected interventions did not produce significant symptom improvement compared with treatment-as-usual or no intervention control groups. However, indicated interventions yielded significant improvements over other active control conditions on mental health outcomes. Conclusions: Consistent with the notion that many experience natural recovery following trauma, results imply that indicated early internet-delivered interventions hold the most promise in future prevention efforts. More studies that use rigorous methods and clearly defined outcomes are needed to evaluate the efficacy of early internet-delivered interventions. Moreover, basic research on risk and resilience factors following trauma exposure is necessary to inform indicated internet-delivered interventions.

  • J Med Internet Res 2018;20(11):e280

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  Physician and Health Services Rating...

  Nov 12, 2018

  Automatic Classification of Online Doctor Reviews: Evaluation of Text Classifier Algorithms

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  Authors List:

  • Ryan Rivas  
  • Niloofar Montazeri  
  • Nhat XT Le  
  • Vagelis Hristidis  

  Abstract:

  Background: An increasing number of doctor reviews are being generated by patients on the internet. These reviews address a diverse set of topics (features), including wait time, office staff, doctor’s skills, and bedside manners. Most previous work on automatic analysis of Web-based customer reviews assumes that (1) product features are described unambiguously by a small number of keywords, for example, battery for phones and (2) the opinion for each feature has a positive or negative sentiment. However, in the domain of doctor reviews, this setting is too restrictive: a feature such as visit duration for doctor reviews may be expressed in many ways and does not necessarily have a positive or negative sentiment. Objective: This study aimed to adapt existing and propose novel text classification methods on the domain of doctor reviews. These methods are evaluated on their accuracy to classify a diverse set of doctor review features. Methods: We first manually examined a large number of reviews to extract a set of features that are frequently mentioned in the reviews. Then we proposed a new algorithm that goes beyond bag-of-words or deep learning classification techniques by leveraging natural language processing (NLP) tools. Specifically, our algorithm automatically extracts dependency tree patterns and uses them to classify review sentences. Results: We evaluated several state-of-the-art text classification algorithms as well as our dependency tree–based classifier algorithm on a real-world doctor review dataset. We showed that methods using deep learning or NLP techniques tend to outperform traditional bag-of-words methods. In our experiments, the 2 best methods used NLP techniques; on average, our proposed classifier performed 2.19% better than an existing NLP-based method, but many of its predictions of specific opinions were incorrect. Conclusions: We conclude that it is feasible to classify doctor reviews. Automatically classifying these reviews would allow patients to easily search for doctors based on their personal preference criteria.

  • J Med Internet Res 2018;20(11):e11141

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  Review

  Nov 9, 2018

  The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review...

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  Authors List:

  • Lorenzo Lorenzo-Luaces  
  • Emily Johns  
  • John R Keefe  

  Abstract:

  Background: Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT. Objective: We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria’s effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes. Methods: We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review. Results: Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes. Conclusions: A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies.

  • J Med Internet Res 2018;20(11):e10113

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  Medicine 2.0: Social Media, Open,...

  Nov 8, 2018

  Correlations Between Hospitals’ Social Media Presence and Reputation Score and Ranking: Cross-Sectional Analysis

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  Authors List:

  • Justin D Triemstra  
  • Rachel Stork Poeppelman  
  • Vineet M Arora  

  Abstract:

  Background: The US News and World Report reputation score correlates strongly with overall rank in adult and pediatric hospital rankings. Social media affects how information is disseminated to physicians and is used by hospitals as a marketing tool to recruit patients. It is unclear whether the reputation score for adult and children’s hospitals relates to social media presence. Objective: The objective of our study was to analyze the association between a hospital’s social media metrics and the US News 2017-2018 Best Hospital Rankings for adult and children’s hospitals. Methods: We conducted a cross-sectional analysis of the reputation score, total score, and social media metrics (Twitter, Facebook, and Instagram) of hospitals who received at least one subspecialty ranking in the 2017-2018 US News publicly available annual rankings. Regression analysis was employed to analyze the partial correlation coefficients between social media metrics and a hospital’s total points (ie, rank) and reputation score for both adult and children’s hospitals while controlling for the bed size and time on Twitter. Results: We observed significant correlations for children’s hospitals’ reputation score and total points with the number of Twitter followers (total points: r=.465, P<.001; reputation: r=.524, P<.001) and Facebook followers (total points: r=.392, P=.002; reputation: r=.518, P<.001). Significant correlations for the adult hospitals reputation score were found with the number of Twitter followers (r=.848, P<.001), number of tweets (r=.535, P<.001), Klout score (r=.242, P=.02), and Facebook followers (r=.743, P<.001). In addition, significant correlations for adult hospitals total points were found with Twitter followers (r=.548, P<.001), number of tweets (r=.358, P<.001), Klout score (r=.203, P=.05), Facebook followers (r=.500, P<.001), and Instagram followers (r=.692, P<.001). Conclusions: A statistically significant correlation exists between multiple social media metrics and both a hospital’s reputation score and total points (ie, overall rank). This association may indicate that a hospital’s reputation may be influenced by its social media presence or that the reputation or rank of a hospital drives social media followers.

  • J Med Internet Res 2018;20(11):e289

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  Tutorial

  Nov 8, 2018

  Using Facebook for Large-Scale Online Randomized Clinical Trial Recruitment: Effective Advertising Strategies

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  Authors List:

  • Laura Akers  
  • Judith S Gordon  

  Abstract:

  Targeted Facebook advertising can be an effective strategy to recruit participants for a large-scale online study. Facebook advertising is useful for reaching people in a wide geographic area, matching a specific demographic profile. It can also target people who would be unlikely to search for the information and would thus not be accessible via Google AdWords. It is especially useful when it is desirable not to raise awareness of the study in a demographic group that would be ineligible for the study. This paper describes the use of Facebook advertising to recruit and enroll 1145 women over a 15-month period for a randomized clinical trial to teach support skills to female partners of male smokeless tobacco users. This tutorial shares our study team’s experiences, lessons learned, and recommendations to help researchers design Facebook advertising campaigns. Topics covered include designing the study infrastructure to optimize recruitment and enrollment tracking, creating a Facebook presence via a fan page, designing ads that attract potential participants while meeting Facebook’s strict requirements, and planning and managing an advertising campaign that accommodates the rapid rate of diminishing returns for each ad.

  • J Med Internet Res 2018;20(11):e290

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  Clinical Information and Decision Making

  Nov 7, 2018

  Automated Extraction of Diagnostic Criteria From Electronic Health Records for Autism Spectrum Disorders: Development, Evaluation, and Application

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  Authors List:

  • Gondy Leroy  
  • Yang Gu  
  • Sydney Pettygrove  
  • Maureen K Galindo  
  • Ananyaa Arora  
  • Margaret Kurzius-Spencer  

  Abstract:

  Background: Electronic health records (EHRs) bring many opportunities for information utilization. One such use is the surveillance conducted by the Centers for Disease Control and Prevention to track cases of autism spectrum disorder (ASD). This process currently comprises manual collection and review of EHRs of 4- and 8-year old children in 11 US states for the presence of ASD criteria. The work is time-consuming and expensive. Objective: Our objective was to automatically extract from EHRs the description of behaviors noted by the clinicians in evidence of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Previously, we reported on the classification of entire EHRs as ASD or not. In this work, we focus on the extraction of individual expressions of the different ASD criteria in the text. We intend to facilitate large-scale surveillance efforts for ASD and support analysis of changes over time as well as enable integration with other relevant data. Methods: We developed a natural language processing (NLP) parser to extract expressions of 12 DSM criteria using 104 patterns and 92 lexicons (1787 terms). The parser is rule-based to enable precise extraction of the entities from the text. The entities themselves are encompassed in the EHRs as very diverse expressions of the diagnostic criteria written by different people at different times (clinicians, speech pathologists, among others). Due to the sparsity of the data, a rule-based approach is best suited until larger datasets can be generated for machine learning algorithms. Results: We evaluated our rule-based parser and compared it with a machine learning baseline (decision tree). Using a test set of 6636 sentences (50 EHRs), we found that our parser achieved 76% precision, 43% recall (ie, sensitivity), and >99% specificity for criterion extraction. The performance was better for the rule-based approach than for the machine learning baseline (60% precision and 30% recall). For some individual criteria, precision was as high as 97% and recall 57%. Since precision was very high, we were assured that criteria were rarely assigned incorrectly, and our numbers presented a lower bound of their presence in EHRs. We then conducted a case study and parsed 4480 new EHRs covering 10 years of surveillance records from the Arizona Developmental Disabilities Surveillance Program. The social criteria (A1 criteria) showed the biggest change over the years. The communication criteria (A2 criteria) did not distinguish the ASD from the non-ASD records. Among behaviors and interests criteria (A3 criteria), 1 (A3b) was present with much greater frequency in the ASD than in the non-ASD EHRs. Conclusions: Our results demonstrate that NLP can support large-scale analysis useful for ASD surveillance and research. In the future, we intend to facilitate detailed analysis and integration of national datasets.

  • J Med Internet Res 2018;20(11):e10497

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  Medicine 2.0: Social Media, Open,...

  Nov 7, 2018

  Health Care Professionals’ Social Media Behavior and the Underlying Factors of Social Media Adoption and Use: Quantitative Study

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  Authors List:

  • Joe Hazzam  
  • Abdelmounaim Lahrech  

  Abstract:

  Background: In the last decade, social media has emerged as a newer platform for knowledge dissemination, information exchange, and interpersonal communication for health care professionals (HCPs). However, the underlying behaviors of HCPs and the ethical use of social media for productivity enhancement and a sustainable health care system remain ambiguous. Objective: This study seeks to understand the factors that relate to the frequency use of social media in the health care discipline. It also aims to explore the underlying online behaviors of HCPs, which include the exchange of medical information with peers, interpersonal communication, and productivity enhancement in their daily practice. Methods: This study adopted the quantitative method in collecting and analyzing data. A survey instrument based on the behavioral and technology acceptance theories was developed for this purpose. The survey was distributed via social media platforms to 973 participants that included physicians, pharmacists, and allied HCPs working in the United Arab Emirates. The responses from 203 completed questionnaires (response rate 20.3%) were analyzed. Results: Of 203 respondents, 133 HCPs used WhatsApp (65.5%); therefore, WhatsApp had the highest number of users compared to Facebook and YouTube, with 101 users out of 203 (49.7%). Overall, 109 of 203 (53.6%) HCPs used social media platforms for the exchange of peer medical information and 108 of 203 (53.2%) used social media several times during the day to improve their interpersonal communication with colleagues. However, only 71 of 203 (34.9%) utilized social media to enhance their productivity in general. The structural model equation showed that behavioral intention (beta=.47; P<.001), habit (beta=.26; P=.001), attitude (beta=.20; P=.002), and perceived usefulness (beta=.12; P=.09) were positively and significantly related to frequency of use. The model explained a rate of 45% variance in the frequency of use and a rate of 17% variance in the social media intention of use. Conclusions: The research highlights the significant factors that relate to the adoption of social media platforms in health care practice. Based on the findings of this study, the use of online platforms facilitates the exchange of medical information among peers and enhances the share of experiences that support HCP’s learning and development. Moreover, social media platforms foster a higher level of communication among practitioners and might improve daily productivity. Future researchers might explore other variables such as training and external factors. For instance, they may draw on areas related to guidelines and policies. From this standpoint, the health care discipline can benefit from highly interactive platforms and adopt them for development, collaboration, and better health outcomes.

  • J Med Internet Res 2018;20(11):e12035

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  Personal Health Records,...

  Nov 7, 2018

  Dual Use of a Patient Portal and Clinical Video Telehealth by Veterans with Mental Health Diagnoses: Retrospective, Cross-Sectional Analysis

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  Authors List:

  • Erica A Abel  
  • Stephanie L Shimada  
  • Karen Wang  
  • Christine Ramsey  
  • Melissa Skanderson  
  • Joseph Erdos  
  • Linda Godleski  
  • Thomas K Houston  
  • Cynthia A Brandt  

  Abstract:

  Background: Access to mental health care is challenging. The Veterans Health Administration (VHA) has been addressing these challenges through technological innovations including the implementation of Clinical Video Telehealth, two-way interactive and synchronous videoconferencing between a provider and a patient, and an electronic patient portal and personal health record, My HealtheVet. Objective: This study aimed to describe early adoption and use of My HealtheVet and Clinical Video Telehealth among VHA users with mental health diagnoses. Methods: We conducted a retrospective, cross-sectional analysis of early My HealtheVet adoption and Clinical Video Telehealth engagement among veterans with one or more mental health diagnoses who were VHA users from 2007 to 2012. We categorized veterans into four electronic health (eHealth) technology use groups: My HealtheVet only, Clinical Video Telehealth only, dual users who used both, and nonusers of either. We examined demographic characteristics and mental health diagnoses by group. We explored My HealtheVet feature use among My HealtheVet adopters. We then explored predictors of My HealtheVet adoption, Clinical Video Telehealth engagement, and dual use using multivariate logistic regression. Results: Among 2.17 million veterans with one or more mental health diagnoses, 1.51% (32,723/2,171,325) were dual users, and 71.72% (1,557,218/2,171,325) were nonusers of both My HealtheVet and Clinical Video Telehealth. African American and Latino patients were significantly less likely to engage in Clinical Video Telehealth or use My HealtheVet compared with white patients. Low-income patients who met the criteria for free care were significantly less likely to be My HealtheVet or dual users than those who did not. The odds of Clinical Video Telehealth engagement and dual use decreased with increasing age. Women were more likely than men to be My HealtheVet or dual users but less likely than men to be Clinical Video Telehealth users. Patients with schizophrenia or schizoaffective disorder were significantly less likely to be My HealtheVet or dual users than those with other mental health diagnoses (odds ratio, OR 0.50, CI 0.47-0.53 and OR 0.75, CI 0.69-0.80, respectively). Dual users were younger (53.08 years, SD 13.7, vs 60.11 years, SD 15.83), more likely to be white, and less likely to be low-income than the overall cohort. Although rural patients had 17% lower odds of My HealtheVet adoption compared with urban patients (OR 0.83, 95% CI 0.80-0.87), they were substantially more likely than their urban counterparts to engage in Clinical Video Telehealth and dual use (OR 2.45, 95% CI 1.95-3.09 for Clinical Video Telehealth and OR 2.11, 95% CI 1.81-2.47 for dual use). Conclusions: During this study (2007-2012), use of these technologies was low, leaving much potential for growth. There were sociodemographic disparities in access to My HealtheVet and Clinical Video Telehealth and in dual use of these technologies. There was also variation based on types of mental health diagnosis. More research is needed to ensure that these and other patient-facing eHealth technologies are accessible and effectively used by all vulnerable patients.

  • J Med Internet Res 2018;20(11):e11350

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