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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 21st 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 2019: 5.03), ranking Q1 in the medical informatics category, and is also the largest journal in the field. The journal focuses on emerging technologies, medical devices, apps, engineering, telehealth 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, and which together receive over 6.000 submissions a year. 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 journal but can simply transfer it between 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.

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Recent Articles:

  • Source: Unsplash; Copyright: Bruno Nascimento; URL:; License: Licensed by JMIR.

    An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care...


    Background: There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course. Objective: This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care. Methods: A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m2 or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician–led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF). Results: Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means −3.86, 95% CI −6.81 to −0.90, P=.01; week 18: difference in means −4.05, 95% CI −6.81 to −1.28, P<.001; week 36: difference in means −4.99, 95% CI −8.04 to −1.94, P<.001; and week 62: difference in means −4.62, 95% CI −7.62 to −1.62, P<.001). Conclusions: A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results. Trial Registration: Australian clinical trials registration number (ACTRN): 12616000868482;

  • Source: Flickr; Copyright: Garry Knight; URL:; License: Creative Commons Attribution (CC-BY).

    Comparability of Emotion Dynamics Derived From Ecological Momentary Assessments, Daily Diaries, and the Day Reconstruction Method: Observational Study


    Background: Interest in the measurement of the temporal dynamics of people’s emotional lives has risen substantially in psychological and medical research. Emotions fluctuate and change over time, and measuring the ebb and flow of people’s affective experiences promises enhanced insights into people’s health and functioning. Researchers have used a variety of intensive longitudinal assessment (ILA) methods to create measures of emotion dynamics, including ecological momentary assessments (EMAs), end-of-day (EOD) diaries, and the day reconstruction method (DRM). To date, it is unclear whether they can be used interchangeably or whether ostensibly similar emotion dynamics captured by the methods differ in meaningful ways. Objective: This study aims to examine the extent to which different ILA methods yield comparable measures of intraindividual emotion dynamics. Methods: Data from 90 participants aged 50 years or older were collected in a probability-based internet panel, the Understanding America Study, and analyzed. Participants provided positive and negative affect ratings using 3 ILA methods: (1) smartphone-based EMA, administered 6 times per day over 1 week, (2) web-based EOD diaries, administered daily over the same week, and (3) web-based DRM, administered once during that week. We calculated 11 measures of emotion dynamics (addressing mean levels, variability, instability, and inertia separately for positive and negative affect, as well as emotion network density, mixed emotions, and emotional dialecticism) from each ILA method. The analyses examined mean differences and correlations of scores addressing the same emotion dynamic across the ILA methods. We also compared the patterns of intercorrelations among the emotion dynamics and their relationships with health outcomes (general health, pain, and fatigue) across ILA methods. Results: Emotion dynamics derived from EMAs and EOD diaries demonstrated moderate-to-high correspondence for measures of mean emotion levels (ρ≥0.95), variability (ρ≥0.68), instability (ρ≥0.51), mixed emotions (ρ=0.92), and emotional dialecticism (ρ=0.57), and low correspondence for measures of inertia (ρ≥0.17) and emotion network density (ρ=0.36). DRM-derived measures showed correlations with EMAs and EOD diaries that were high for mean emotion levels and mixed emotions (ρ≥0.74), moderate for variability (ρ=0.38-.054), and low to moderate for other measures (ρ=0.03-0.41). Intercorrelations among the emotion dynamics showed high convergence across EMAs and EOD diaries, and moderate convergence between the DRM and EMAs as well as EOD diaries. Emotion dynamics from all 3 ILA methods produced very similar patterns of relationships with health outcomes. Conclusions: EMAs and EOD diaries provide corresponding information about individual differences in various emotion dynamics, whereas the DRM provides corresponding information about emotion levels and (to a lesser extent) variability, but not about more complex emotion dynamics. Our results caution researchers against viewing these ILA methods as universally interchangeable.

  • Interaction with the digital health coach. Source: Austrian Institute  of Technology/Placeit; Copyright: AIT Austrian Institute  of Technology/Placeit; URL:; License: Licensed by the authors.

    Digital Health Coaching Programs Among Older Employees in Transition to Retirement: Systematic Literature Review


    Background: The rapid increase of the aging population is pushing many national governments to reshape retirement legislation in order to extend older adults’ working life. Once retired, older adults can be invaluable resources for the community as family carers, as volunteers, or by returning to work. Healthy aging is one of the main conditions for being able to work longer and being active after retirement. The latter, indeed, represents a very sensitive life transition, which can entail psychological and social difficulties. Interventions for promoting older workers’ health and well-being and supporting the transition to retirement are on the top of the policy agenda of most European countries. Recently, computer-based and digital health interventions have been seen as promising means to reach this purpose. Objective: This systematic literature review aimed to explore studies on digital health coaching programs for older workers that followed a user-centered design approach and evaluated their effectiveness in providing older adults with guidance for adopting a healthy lifestyle and being active in the community. Methods: The search identified 1931 papers, and 2 relevant articles were selected by applying specific eligibility criteria. Results: To our knowledge, only few digital health coaching programs have targeted the population of older workers to date; there is an insufficient number of studies on the efficacy of such programs. The results show the difficulties of assessing the efficacy of digital coaching itself and with respect to older employees. The 2 studies suggest that digital health programs for workplaces can improve various aspects of older employees’ well-being; however, they considered health mainly from a physical perspective and neglected contextual, social, psychological, and cultural factors that can influence older workers’ health and general well-being. Future digital health coaching programs should adopt the healthy aging paradigm as a multidimensional lens for interpreting the impact of eHealth technology on aging and retirement. The literature around this issue remains at an embryonic state, and this gap needs to be filled by further investigations that apply a user-centered approach for designing the technology, test innovative research methodologies, and adopt new technical solutions for high-quality interaction design. Conclusions: Further digital health coaching programs aimed at supporting healthy and active living for older workers and retirees are necessary. The user-centered design approach is recommended in order to fully address the users’ health needs and the technological requirements throughout development. Moreover, the healthy aging perspective allows inclusion of physical, social, and psychological factors influencing the transition from work to retirement, as well as the experiences and interactions of individuals with the technology.

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

    Evaluating Two Common Strategies for Research Participant Recruitment Into Autism Studies: Observational Study


    Background: Ongoing research is necessary to better understand the causes of autism spectrum disorder (ASD), the developmental outcomes for individuals diagnosed with ASD, and the efficacy of the interventions. However, it is often difficult to recruit sufficient numbers of participants for studies, and despite the prevalence of ASD (currently estimated to affect 1 in 54 children), little research has focused on how to efficiently recruit participants with ASD. Objective: The aim of this study was to determine the efficacy of two different paid advertisements—social media and radio advertising—in recruiting participants for a study enrolling people with ASD and their family members by examining the number of participants enrolled, the cost per participant, and the geographic reach of each type of advertising. Methods: We examined participant enrollment in a study following nonoverlapping paid advertisements on a popular FM radio station (aired in three cities across two states) and Facebook (six advertisements that ran in five cities across two states). The total paid investment in the radio campaign was $12,030 and that in the Facebook campaign was $2950. Following the advertising campaigns, 1391 participants in the study who were affiliated with the Houston, Texas, site received email invitations to participate in a brief survey about the ways in which they learned about the study (eg, social media, medical provider, website) and which of these were most influential in their decisions to participate; 374 (26.8%) of the participants completed this survey. Results: Social media advertising outperformed radio in all three parameters examined by enrolling more participants (338 vs 149), with a lower average cost per participant ($8.73 vs $80.74) and a wider geographic reach, based on a comparison of the number of zip codes within and outside of Texas for questionnaire respondents who rated social media as the most influential method of contact (n=367, χ21=5.85, P=.02). Of the 374 survey participants, 139 (37.2%) reported that they had seen the study on social media prior to enrollment, while only 9 (2.4%) said they heard about it via radio. Conclusions: Our findings suggest that advertising on social media can efficiently reach a large pool of potential participants with ASD, increasing the likelihood of meeting study enrollment goals. Researchers should consider allocating at least some portion of recruitment dollars to social media platforms as a means of quickly and inexpensively reaching out to their target populations, including for studies with in-person procedures.

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

    Online Health Resource Use by Individuals With Inflammatory Bowel Disease: Analysis Using the National Health Interview Survey


    Background: The internet has enabled convenient and efficient health information searching which is valuable for individuals with chronic conditions requiring some level of self-management. However, there is little research evaluating what factors may impact the use of the internet for health-related tasks for specific clinical populations, such as individuals with inflammatory bowel diseases. Objective: Our goal was to investigate the factors that influence internet use in acquiring health information by individuals with inflammatory bowel diseases. Specifically, we identified factors associated with internet searching behavior and using the internet for completing health-related tasks. Methods: We used 2016 National Health Interview Survey weighted data to develop logistic regression models to predict the likelihood that individuals with inflammatory bowel diseases would use the internet for 2 types of tasks: seeking health information through online searches and using the internet to perform health-related tasks including scheduling appointments and emailing care providers. Results: 2016 National Health Interview Survey weighted data include more than 3 million weighted adult respondents with inflammatory bowel diseases (approximately 1.29% of adults in the weighted data set). Our results suggest that approximately 66.3% of those with inflammatory bowel diseases reported using the internet at least once a day, and approximately 14.7% reported being dissatisfied with their current health care. About 62.3% of those with inflammatory bowel diseases reported that they had looked up health information online, 16.3% of those with inflammatory bowel diseases reported that they had scheduled an appointment with a health care provider online, and 21.6% reported having used a computer to communicate with a health provider by email. We found that women who were self-regulating their care were more likely to look up health information online than others. Both middle-aged and older adults with inflammatory bowel diseases who were unsatisfied with their current health care were less likely to look up health information online. Frequent internet users who were worried about medical costs were more likely to look up health information online. Similarly, the results from our statistical models suggest that individuals with inflammatory bowel diseases who were frequent internet users were more likely to use the internet for specific health-related tasks. Additionally, women with inflammatory bowel diseases who reported being married were less likely to use the internet for specific health-related tasks. Conclusions: For those with inflammatory bowel diseases, there are additional socioeconomic and behavioral factors that impact the use of the internet for health information and health-related tasks. Future research should evaluate how these factors moderate the use of the internet and identify how online resources can support clinical populations in ways that improve access to information, support health self-management, and subsequently improve health outcomes.

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

    Leveraging Interdisciplinary Teams to Develop and Implement Secure Websites for Behavioral Research: Applied Tutorial


    Behavioral researchers are increasingly using interactive digital platforms, either as standalone or supplementary intervention tools, to facilitate positive changes in research participants’ health habits. Research-oriented interactive websites optimally offer a variety of participatory mediums, such as blogs, user-driven content, or health activities. Owing to the multidirectional features of interactive websites, and a corresponding need to protect research participants’ identity and data, it is paramount that researchers design ethical platforms that ensure privacy and minimize loss of anonymity and confidentiality. Authentication (ie, digital verification of one’s identity) of interactive sites is one viable solution to these concerns. Although previous publications have addressed ethical requirements related to authenticated platforms, few applied guidelines in the literature facilitate adherence to ethical principles and legally compliant study protocols during all phases of research website creation (feasibility, design, implementation, and maintenance). Notably, to remain compliant with ethical standards and study protocols, behavioral researchers must collaborate with interdisciplinary teams to ensure that the authenticated site remains secure and usable in all stages of the project. In this tutorial, we present a case study conducted at a large research university. Through iterative and practical recommendations, we detail lessons learned from collaborations with the Institutional Review Board, legal experts, and information technology teams. Although the intricacies of our applied tutorial may require adaptations based on each institution’s technological capacity, we are confident that the core takeaways are universal and thus useful to behavioral researchers creating ethically responsible and compliant interactive websites.

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

    A Rapid Electronic Cognitive Assessment Measure for Multiple Sclerosis: Validation of Cognitive Reaction, an Electronic Version of the Symbol Digit...


    Background: Incorporating cognitive testing into routine clinical practice is a challenge in multiple sclerosis (MS), given the wide spectrum of both cognitive and physical impairments people can have and the time that testing requires. Shortened paper and verbal assessments predominate but still are not used routinely. Computer-based tests are becoming more widespread; however, changes in how a paper test is implemented can impact what exactly is being assessed in an individual. The Symbol Digit Modalities Test (SDMT) is one validated test that forms part of the cognitive batteries used in MS and has some computer-based versions. We developed a tablet-based SDMT variant that has the potential to be ultimately deployed to patients’ own devices. Objective: This paper aims to develop, validate, and deploy a computer-based SDMT variant, the Cognition Reaction (CoRe) test, that can reliably replicate the characteristics of the paper-based SDMT. Methods: We carried out analysis using Pearson and intraclass correlations, as well as a Bland-Altman comparison, to examine consistency between the SDMT and CoRe tests and for test-retest reliability. The SDMT and CoRe tests were evaluated for sensitivity to disability levels and age. A novel metric in CoRe was found: question answering velocity could be calculated. This was evaluated in relation to disability levels and age for people with MS and compared with a group of healthy control volunteers. Results: SDMT and CoRe test scores were highly correlated and consistent with 1-month retest values. Lower scores were seen in patients with higher age and some effect was seen with increasing disability. There was no learning effect evident. Question answering velocity demonstrated a small increase in speed over the 90-second duration of the test in people with MS and healthy controls. Conclusions: This study validates a computer-based alternative to the SDMT that can be used in clinics and beyond. It enables accurate recording of elements of cognition relevant in MS but offers additional metrics that may offer further value to clinicians and people with MS.

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

    Self-Practice of Stabilizing and Guided Imagery Techniques for Traumatized Refugees via Digital Audio Files: Qualitative Study


    Background: Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees’ emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings. Objective: This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany. Methods: From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone. Results: At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique “The Inner Safe Place” was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations. Conclusions: The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, “The Inner Safe Place” technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees.

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

    Exploring Participants’ Experiences of a Web-Based Program for Bulimia and Binge Eating Disorder: Qualitative Study


    Background: Guided cognitive behavioral self-help is a recommended first-line treatment for eating disorders (EDs) such as bulimia nervosa (BN) or binge eating disorder (BED). Online versions of such self-help programs are increasingly being studied in randomized controlled trials (RCTs), with some evidence that they can reduce ED symptoms, although intervention dropout is variable across interventions. However, in-depth research into participants’ experiences and views on the acceptability of web-based interventions is limited. Objective: This is a qualitative process study of participants’ experiences of everyBody Plus, a web-based cognitive behavioral intervention, integrated into a large RCT to aid the interpretation of the main trial’s results. To our knowledge, this is the first such study in digital intervention for EDs research to include real-time feedback into the qualitative analysis. This study aims to build upon the emerging literature by qualitatively exploring participants’ experiences of a web-based intervention for BN and BED. Methods: Participants were those who took part in the UK arm of a larger RCT investigating the efficacy of the everyBody Plus intervention. Reflexive thematic analysis was completed on 2 sources of data from the online platform: real-time feedback quotes provided at the end of completing a module on the platform (N=104) and semistructured telephone interview transcripts (n=12). Results: Four main themes were identified. The first theme identified positive and negative user experiences, with a desire for a more customized and personalized intervention. Another theme positively reflected on how flexible and easy the intervention was to embed into daily life, compared with the silo of face-to-face therapy. The third theme identified how the intervention had a holistic impact cognitively, emotionally, interpersonally, and behaviorally. The final theme was related to how the intervention was not a one size fits all and how the perceived usefulness and relevance were often dependent on participants’ demographic and clinical characteristics. Conclusions: Overall, participants reported positive experiences with the use of the everyBody Plus web-based intervention, including flexibility of use and the potential to holistically impact people’s lives. The participants also provided valuable suggestions for how similar future web-based interventions could be improved and, in the context of EDs, how programs can be designed to be more inclusive of people by encompassing different demographic and clinical characteristics.

  • Developing data dashboard. Source: Adobe Stock; Copyright: golubovy; URL:; License: Licensed by the authors.

    Dynamic Panel Estimate–Based Health Surveillance of SARS-CoV-2 Infection Rates to Inform Public Health Policy: Model Development and Validation


    Background: SARS-CoV-2, the novel coronavirus that causes COVID-19, is a global pandemic with higher mortality and morbidity than any other virus in the last 100 years. Without public health surveillance, policy makers cannot know where and how the disease is accelerating, decelerating, and shifting. Unfortunately, existing models of COVID-19 contagion rely on parameters such as the basic reproduction number and use static statistical methods that do not capture all the relevant dynamics needed for surveillance. Existing surveillance methods use data that are subject to significant measurement error and other contaminants. Objective: The aim of this study is to provide a proof of concept of the creation of surveillance metrics that correct for measurement error and data contamination to determine when it is safe to ease pandemic restrictions. We applied state-of-the-art statistical modeling to existing internet data to derive the best available estimates of the state-level dynamics of COVID-19 infection in the United States. Methods: Dynamic panel data (DPD) models were estimated with the Arellano-Bond estimator using the generalized method of moments. This statistical technique enables control of various deficiencies in a data set. The validity of the model and statistical technique was tested. Results: A Wald chi-square test of the explanatory power of the statistical approach indicated that it is valid (χ210=1489.84, P<.001), and a Sargan chi-square test indicated that the model identification is valid (χ2946=935.52, P=.59). The 7-day persistence rate for the week of June 27 to July 3 was 0.5188 (P<.001), meaning that every 10,000 new cases in the prior week were associated with 5188 cases 7 days later. For the week of July 4 to 10, the 7-day persistence rate increased by 0.2691 (P=.003), indicating that every 10,000 new cases in the prior week were associated with 7879 new cases 7 days later. Applied to the reported number of cases, these results indicate an increase of almost 100 additional new cases per day per state for the week of July 4-10. This signifies an increase in the reproduction parameter in the contagion models and corroborates the hypothesis that economic reopening without applying best public health practices is associated with a resurgence of the pandemic. Conclusions: DPD models successfully correct for measurement error and data contamination and are useful to derive surveillance metrics. The opening of America involves two certainties: the country will be COVID-19–free only when there is an effective vaccine, and the “social” end of the pandemic will occur before the “medical” end. Therefore, improved surveillance metrics are needed to inform leaders of how to open sections of the United States more safely. DPD models can inform this reopening in combination with the extraction of COVID-19 data from existing websites.

  • Health worker in Vietnam using the National Immunization Information System (NIIS). Source: PATH; Copyright: PATH; URL:; License: Creative Commons Attribution (CC-BY).

    Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation


    Background: Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam’s National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries. Objective: The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam. Methods: This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the “axes of scale,” to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation. Results: The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up. Conclusions: The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations.

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

    Patient Portal Functionalities and Patient Outcomes Among Patients With Diabetes: Systematic Review


    Background: Patient portal use could help improve the care and health outcomes of patients with diabetes owing to functionalities, such as appointment booking, electronic messaging (e-messaging), and repeat prescription ordering, which enable patient-centered care and improve patient self-management of the disease. Objective: This review aimed to summarize the evidence regarding patient portal use (portals that are connected to electronic health care records) or patient portal functionality use (eg, appointment booking and e-messaging) and their reported associations with health and health care quality outcomes among adult patients with diabetes. Methods: We searched the MEDLINE, Embase, and Scopus databases and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed the full texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tool to assess the risk of bias of the included studies. Data were summarized through narrative synthesis. Results: Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and health care quality outcomes. Six studies reported e-messaging or email use–associated outcomes, and two studies reported prescription refill–associated outcomes. The reported health outcomes included the associations of patient portal use with blood pressure, low-density lipoprotein cholesterol, and BMI. Few studies reported health care utilization outcomes such as office visits, emergency department visits, and hospitalizations. A limited number of studies reported overall quality of care for patients with diabetes who used patient portals. Conclusions: The included studies mostly reported improved glycemic control outcomes for patients with diabetes who used patient portals. However, limitations of studying the effects of patient portals exist, which do not guarantee whether the outcomes reported are completely the result of patient portal use or if confounding factors exist. Randomized controlled trials and mixed-methods studies could help understand the mechanisms involved in health outcome improvements and patient portal use among patients with diabetes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019141131;

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  • Emergency response to the COVID-19 pandemic using digital health technologies: practical experience of a tertiary hospital in China

    Date Submitted: Sep 22, 2020

    Open Peer Review Period: Sep 22, 2020 - Nov 17, 2020

    Background: The outbreak of the novel corona virus disease (COVID-19) has caused a continuing global pandemic. Hospitals are integral in the control and prevention of COVID-19 but are met with numerou...

    Background: The outbreak of the novel corona virus disease (COVID-19) has caused a continuing global pandemic. Hospitals are integral in the control and prevention of COVID-19 but are met with numerous challenges in the midst of the epidemic. Objective: The objective of our study was to introduce the practical experience of design and implementation, as well as the preliminary results, of an online COVID-19 service platform from a tertiary hospital in China. Methods: The online COVID-19 service platform was deployed within the healthcare system of the Guangdong Second Provincial General Hospital-Internet Hospital, a program function which provides online medical services for both public individuals and lay-healthcare workers. The focal functions of this system include COVID-19 automated screening, related symptoms monitoring, online consultation, psychological support, and it also serves as a COVID-19 knowledge hub. The design and process of each functionality were introduced. The platform services usage data were collected and represented by three periods: the pre-epidemic period (2019.12.22~2020.1.22), the outbreak period (2020.1.23~2020.3.31), and the post-epidemic period (2020.4.1~2020.6.30). Results: By the end of June 2020, the COVID-19 automated screening and symptoms monitoring system had been used by 96,642 people for 161,884 and 7,795,194 person-times. The general online consultation service volume scaled up from 930 visits per-month in pre-epidemic period to over 8406 visits during the outbreak period, and dropped to 2218 visits in the post-epidemic period. The psychological counseling program served 636 clients during epidemic period. For people who used the COVID-19 automated screening service, overall, 160,916 (99%) of the users were classified under the no risk category. Less than 464 (0.3%) of the people were categorized under the medium to high risk class, and 12 people (0.01%) were recommended for COVID-19 treatment. Among the 96,642 individuals who used the COVID-19 related symptoms monitoring service, 6,696(6.9%) were symptomatic at some points during monitoring period. Fever was the most frequently reported symptom, with 40% of the people having had this symptom. Cough (25%) and sore throat (24%) were also relatively frequently reported among the symptomatic clients. Conclusions: The online COVID-19 service platform exhibited as a role model for using digital health technologies to respond to the COVID-19 pandemic from a tertiary hospital in China. The digital solutions of COVID-19 automated screening, daily symptoms monitoring, online care service, and knowledge propagation have plausible acceptability and feasibility for complementing offline hospital services and facilitating disease control and prevention.

  • Experience and attitude of elementary school students and their parents towards online learning in China during the COVID-19 outbreak:Questionnaire Study

    Date Submitted: Sep 22, 2020

    Open Peer Review Period: Sep 22, 2020 - Nov 17, 2020

    Background: Due to the widespread of COVID-19, the emergency homeschooling plan has been rigorously implemented in China. Objective: This study aimed to investigate the experience and attitude of elem...

    Background: Due to the widespread of COVID-19, the emergency homeschooling plan has been rigorously implemented in China. Objective: This study aimed to investigate the experience and attitude of elementary school students and their parents towards online learning in China during the COVID-19 outbreak. Methods: A 16-item questionnaire was distributed to 867 elementary students and their parents at 10 days, and 141 elementary students and their parents 30 days after the first online learning course. The questionnaire comprised questions regarding the completeness of course and homework, effectiveness, reliability, and abundance of courses, the enthusiasm to take part in online learning, and the satisfaction of online learning. Sociodemographic data, like students’ grades and equipment for online learning, were recorded. Results: In terms of equipment, lower grade pupils were more likely to choose TV to execute their online learning. Most of the students had good enthusiasm for taking online learning courses. Most of the students couldn’t do well in the online learning class and homework after class. The majority of elementary school parents thought that the reliability, effectiveness, and abundance of online courses were perfect. In terms of satisfaction, most parents were satisfied with online learning courses, and the score was above 6 points. In consist of parents, most students were satisfied with online learning courses, and the score also was above 6 points. For future study, most parents or students hoped to return to face-to-face learning in our study. Compared with the first stage, the proportion of students completing courses and homework after class in the second stage decreased significantly. In terms of the validity and reliability of the course, compared with the first stage, the evaluation of parents on online courses in the second stage was lower. Parents and students’ satisfaction with online courses decreased in the second stage, but there was no statistically significant difference between the two stages. Conclusions: Online learning can prevent the spread of infectious diseases, meanwhile allowing elementary school students to gain knowledge during the COVID-19 outbreak. Most enrolled elementary school students had full enthusiastic about participating in online learning. Both elementary school students and their parents were highly satisfied with online learning. In the initial phase of online learning, students were able to complete all online lessons and homework assignments after school very well. However, as time went on, the percentage of students who completed the courses and homework on time was decreased. Compared with the first stage, the satisfaction of students and their parents towards online learning decreased in the second stage. As soon as this happened, online learning remained an excellent form of education during the epidemic outbreak. To achieve better teaching results, some corrections need to be made to the lessons, such as making them more interactive.

  • Public Engagement in Officials’ Stories about COVID-19 across Social Media, an Iraqi Case Study

    Date Submitted: Sep 18, 2020

    Open Peer Review Period: Sep 18, 2020 - Nov 13, 2020

    Background: Background: The world has not attended a major challenge like coronavirus disease (COVID-19) pandemic for several decades. Effective two-way communication across social media facilitates p...

    Background: Background: The world has not attended a major challenge like coronavirus disease (COVID-19) pandemic for several decades. Effective two-way communication across social media facilitates public engagement in health authorities and officials in a positive way which contributes to minimizing damage, impacts, and victims. Objective: Objective: This study examines public engagement in officials’ stories about COVID-19 on social media. This examination is to realize public responses and engagement particularly during the lockdown which allows us to understand the efforts and contributions of health authorities and officials on social media to give instructions and preventive measures to the public and how the public engage. Methods: Method: This study adopted a survey method through an online questionnaire using 'Google Forms' (N= 511) with responses from adults aged 18 and over. The data collection was carried out from the first week of March until the mid of April 2020. This period was in the quarantine days ordered by the Iraqi government (the first week of March to the end of May). The duration of data collection was very important because the officials were focusing on the measures to prevent the disease and giving instructions across social media to communicate and interact with the public. Results: Result: We revealed that the fear of the pandemic led people to change their perception of the government authorities and officials, and this argument was statistically approved (r=0.171**, p < 0.000). We revealed that the fear of the pandemic led people to change their perception of the government authorities and officials because before the outbreak of COVID-19 the public was not satisfied with the government authorities and officials performance, but during the outbreak, the public engaged with the officials positively, (r= 0.156**, p <0.000), (r=0.127**, p <0.000). Conclusions: Conclusion: The pandemic can be invested in restructuring the relationship between the government and the public positively, particularly to raise the public awareness of diseases, prevention, hygiene, and the practice of healthy behaviors. We found that only 191 (%38.2) of the participants did not try to consult the information from global sources about COVID-19. This indicates that through the internet and social media the public can potentially engage with global parties not only the local authorities.

  • Utilization of Electronic Medical Records Data for Medical Research in a Hospital in China: A Cross-Sectional Study

    Date Submitted: Sep 17, 2020

    Open Peer Review Period: Sep 17, 2020 - Nov 12, 2020

    Background: With the proliferation of electronic medical records systems (EMRs), there is an increasing interest in utilizing EMRs data for medical research, yet there is no quantitative research on E...

    Background: With the proliferation of electronic medical records systems (EMRs), there is an increasing interest in utilizing EMRs data for medical research, yet there is no quantitative research on EMRs data utilization for medical research purposes. Objective: Understand the current status of clinical data utilization in clinical research activities, including trends in recent years and differences between different populations, to find out the present problems in the use of EMR data for research, and provide a reference for promoting the utilization of EMR data in scientific research. Methods: For this descriptive, cross-sectional study, the utilization of EMRs data by staff at Xuanwu Hospital in Beijing, China between 2016 and 2019 was analyzed. The utilization of EMRs data was described as the number of requests, the proportion of requesters, and the frequency of requests per capita. The comparison by year, professional title, and age was conducted by double-sided chi square test. Results: From 2016 to 2019, EMRs data utilization was poor, as the proportion of requesters was 5.8% and the frequency was 0.1 times / person / year. The frequency per capita gradually slowed and more older, senior level staff used EMRs data compared to younger staff. Conclusions: The value of using EMRs data for research purposes does not get enough attention among researchers in Chinese hospitals. Ensuring equal availability of EMRs data and highlighting the benefits of such systems can help promote its use in research settings. Future research should focus on mechanisms that encourage data utilization, ensure fair data availability, and promote data sharing.

  • Implementing remote collaboration in a virtual patient platform – enabling students and physicians to learn collaborative clinical reasoning

    Date Submitted: Sep 14, 2020

    Open Peer Review Period: Sep 14, 2020 - Nov 9, 2020

    Background: Learning with virtual patients is highly popular for fostering clinical reasoning in medical education. However, little learning with virtual patients is done collaboratively, despite the...

    Background: Learning with virtual patients is highly popular for fostering clinical reasoning in medical education. However, little learning with virtual patients is done collaboratively, despite the potential learning benefits of collaborative vs. individual learning. Objective: In this article, we describe the rationale behind the implementation of student collaboration in the CASUS virtual patient platform. Methods: The SimpleWebRTC library of andYet was used to implement the collaborative tool. It provided a basis for the conferencing platform and could be adapted to include features such as video communication and screensharing. An additional text chat was created based on the message protocol of the SimpleWebRTC library. We implemented a user interface for educators to set up and configure the collaboration. Educators can configure video, audio, and text-based chat communication, which are known to promote effective learning. Results: We tested the tool in a sample of 137 students working on virtual patients. The study results indicate that students successfully diagnosed 53% (SD = 26%) of the patients when working alone and 71% (SD= 20%) when collaborating using the tool (p < .05, eta2=.12). A usability questionnaire for the study sample shows a usability score of 82.16 (SD = 1.31), a B+ grade. Conclusions: The approach provides a technical framework for collaboration that can be used with the CASUS virtual patient system. Additionally, the application programming interface is generic, so that the setup can also be used with other learning management systems. The collaborative tool helps students diagnose virtual patients and results in a good overall usability of CASUS. Using learning analytics, we are able to track students’ progress in content knowledge and collaborative knowledge and guide them through a virtual patient curriculum designed to teach both. More broadly, the collaborative tool provides an array of new possibilities for researchers and educators alike to design courses, collaborative homework assignments, and research questions for collaborative learning.

  • Understanding barriers to linking novel consumer and lifestyle data for health research, results from the LifeInfo Survey: a topic modelling approach

    Date Submitted: Sep 18, 2020

    Open Peer Review Period: Sep 11, 2020 - Nov 6, 2020

    Background: Novel consumer and lifestyle data, for example those collected by supermarket loyalty cards or mobile phone exercise tracking apps, offer numerous benefits for researchers wishing to under...

    Background: Novel consumer and lifestyle data, for example those collected by supermarket loyalty cards or mobile phone exercise tracking apps, offer numerous benefits for researchers wishing to understand diet and exercise related risk factors for diseases. Yet, limited research has addressed public attitudes towards linking these data with individual health records for research purposes. Objective: The aim of this research was to identify key barriers for data linkage and recommend safeguards and procedures that would encourage individuals to share these data for potential future research. Methods: The LifeInfo Survey consulted the public on their attitudes towards sharing consumer and lifestyle data for research purposes. Where barriers to data sharing existed, participants provided unstructured survey responses detailing what would make them more likely to share data for linkage with their health record in the future. The topic modelling technique Latent Dirichlet Allocation (LDA) was used to analyse these textual responses to uncover common thematic topics within the texts. Results: Participants provided responses related to sharing their store loyalty card data (n = 2,338) and health/fitness app data (n = 1,531). Key barriers to data sharing identified through topic modelling included: data safety and security, personal privacy, requirements of further information, fear of data being accessed by others, problems with data accuracy, not understanding the reason for data linkage and not using data production services. We provide recommendations for addressing these issues to establish best practice for future researchers wishing to utilise these data. Conclusions: This study formulates large-scale consultation of public attitudes towards data linkage of this kind, as such, it is an important first step in understanding and addressing barriers to participation for research utilising novel consumer and lifestyle data.