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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2018: 4.945, ranked #1 out of 26 journals in the medical informatics category) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As a leading high-impact journal in its disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

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

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

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


Recent Articles:

  • Source: abyssrealdoll / Instagram; Copyright: Unknown; URL:; License: Fair use/fair dealings.

    The Attitudes of Therapists and Physicians on the Use of Sex Robots in Sexual Therapy: Online Survey and Interview Study


    Background: Various types of robots have already been successfully used in medical care, and the use of new technologies is also playing an increasing role in the area of sexuality. Sex robots are marketed as advanced sex toys and sex dolls with artificial intelligence. Only a few considerations about the therapeutic use of sex robots in sexual therapy are debated in expert discussions. Methods: This study comprised a quantitative online survey and a qualitative interview study. A self-constructed questionnaire was used to survey the general attitudes of sex therapists and physicians regarding the benefits of sex robots in therapy. The qualitative study was designed to gain in-depth insight into the participants’ beliefs and attitudes. Therefore, semistructured interviews were conducted. The quantitative data were evaluated by statistical analysis, and the interviews were transcribed and analyzed by using a grounded theory approach. Results: A total of 72 sex therapists and physicians completed our self-constructed questionnaire (response rate 15%, 72/480). Only a few respondents (11%, 8/72) said that the use of sex robots was not conceivable for them, and almost half of all therapists and physicians could imagine recommending sex robots in therapy (45%, 33/72). The attitude toward sex robots as a therapeutic tool was very heterogeneous, with gender (P=.006), age (P=.03), and occupational differences (P=.05); female therapists, older therapists, and psychologists (in contrast to physicians) were more critical toward the therapeutic use of sex robots. The analysis of the 5 interviews identified 3 high-level core themes that were representative of the participants’ responses: (1) the importance of the personal definition of sex robots for the assessment of their therapeutic benefits, (2) therapeutic benefits and dangers of sex robots, and (3) considerations on the quality of human-robot sexuality. Initial insights into the possible therapeutic use of sex robots in different disorders (eg, sexual dysfunction or pedophilia) and situations were gained from the perspective of sex therapists. Conclusions: The results of this study provide a first overview of the potential therapeutic use of sex robots. Moral, ethical, and treatment-related issues in this context are still unresolved and need to be further researched. We suggest integrating the topic into the training of sex therapists to form opinions beyond media images and to show therapy possibilities. Scientists engaged in sexual research should be involved in the development of sex robots to design robots with positive effects on sexual education, sexual therapy, sexual counseling, and sexual well-being for interested groups.

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

    Patient and Health Care Provider Experiences With a Recently Introduced Patient Portal in an Academic Hospital in the Netherlands: Mixed Methods Study


    Background: In the Netherlands, the health care system and related information technology landscape are fragmented. Recently, hospitals have started to launch patient portals. It is not clear how these portals are used by patients and their health care providers (HCPs). Objective: The objective of this study was to explore the adoption, use, usability, and usefulness of a recently introduced patient portal in an academic hospital to learn lessons for the implementation of patient portals in a fragmented health care system. Methods: A mixed methods study design was used. In the quantitative study arm, characteristics of patients who used the portal were analyzed, in addition to the utilization of the different functionalities of the portal. In the qualitative study arms, think-aloud observations were made to explore usability. Focus group discussions were conducted among patients and HCPs of the dermatology and ophthalmology outpatient departments. Thematic content analysis of qualitative data was carried out and overarching themes were identified using a framework analysis. Results: One year after the introduction of the portal, 24,514 patients, 13.49% of all patients who visited the hospital, had logged in to the portal. Adoption of the portal was associated with the age group 45 to 75 years, a higher socioeconomic status, and having at least one medical diagnosis. Overarching themes from the qualitative analyses were (1) usability and user-friendliness of the portal, (2) HCP-patient communication through the portal, (3) usefulness of the information that can be accessed through the portal, (4) integration of the portal in care and work processes, and (5) HCP and patient roles and relationships. Conclusions: One year after the introduction of the patient portal, patients and HCPs who used the portal recognized the potential of the portal to engage patients in their care processes, facilitate patient-HCP communication, and increase patient convenience. Uncertainties among patients and HCPs about how to use the messaging functionality and limited integration of the portal in care and work processes are likely to have limited portal use and usefulness.

  • A researcher selecting among various wearable sensors for a human behavior study. Source: Robert Scoble / FlickR; Copyright: Robert Scoble; URL:; License: Creative Commons Attribution (CC-BY).

    Multimodal Human and Environmental Sensing for Longitudinal Behavioral Studies in Naturalistic Settings: Framework for Sensor Selection, Deployment, and...


    Background: Recent advances in mobile technologies for sensing human biosignals are empowering researchers to collect real-world data outside of the laboratory, in natural settings where participants can perform their daily activities with minimal disruption. These new sensing opportunities usher a host of challenges and constraints for both researchers and participants. Methods: This paper presents a collection of challenges, consideration criteria, and potential solutions for enabling researchers to select and manage appropriate sensors for their research studies. It explains a general data collection framework suitable for use with modern consumer sensors, enabling researchers to address many of the described challenges. In addition, it provides a description of the criteria affecting sensor selection, management, and integration that researchers should consider before beginning human behavior studies involving sensors. On the basis of a survey conducted in mid-2018, this paper further illustrates an organized snapshot of consumer-grade human sensing technologies that can be used for human behavior research in natural settings. Results: The research team applied the collection of methods and criteria to a case study aimed at predicting the well-being of nurses and other staff in a hospital. Average daily compliance for sensor usage measured by the presence of data exceeding half the total possible hours each day was about 65%, yielding over 355,000 hours of usable sensor data across 212 participants. A total of 6 notable unexpected events occurred during the data collection period, all of which had minimal impact on the research project. Conclusions: The satisfactory compliance rates and minimal impact of unexpected events during the case study suggest that the challenges, criteria, methods, and mitigation strategies presented as a guide for researchers are helpful for sensor selection and management in longitudinal human behavior studies in the wild.

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

    Digital Health Apps in the Clinical Care of Inflammatory Bowel Disease: Scoping Review


    Background: Digital health is poised to transform health care and redefine personalized health. As Internet and mobile phone usage increases, as technology develops new ways to collect data, and as clinical guidelines change, all areas of medicine face new challenges and opportunities. Inflammatory bowel disease (IBD) is one of many chronic diseases that may benefit from these advances in digital health. This review intends to lay a foundation for clinicians and technologists to understand future directions and opportunities together. Objective: This review covers mobile health apps that have been used in IBD, how they have fit into a clinical care framework, and the challenges that clinicians and technologists face in approaching future opportunities. Methods: We searched PubMed, Scopus, and to identify mobile apps that have been studied and were published in the literature from January 1, 2010, to April 19, 2019. The search terms were (“mobile health” OR “eHealth” OR “digital health” OR “smart phone” OR “mobile app” OR “mobile applications” OR “mHealth” OR “smartphones”) AND (“IBD” OR “Inflammatory bowel disease” OR “Crohn's Disease” (CD) OR “Ulcerative Colitis” (UC) OR “UC” OR “CD”), followed by further analysis of citations from the results. We searched the Apple iTunes app store to identify a limited selection of commercial apps to include for discussion. Results: A total of 68 articles met the inclusion criteria. A total of 11 digital health apps were identified in the literature and 4 commercial apps were selected to be described in this review. While most apps have some educational component, the majority of apps focus on eliciting patient-reported outcomes related to disease activity, and a few are for treatment management. Significant benefits have been seen in trials relating to education, quality of life, quality of care, treatment adherence, and medication management. No studies have reported a negative impact on any of the above. There are mixed results in terms of effects on office visits and follow-up. Conclusions: While studies have shown that digital health can fit into, complement, and improve the standard clinical care of patients with IBD, there is a need for further validation and improvement, from both a clinical and patient perspective. Exploring new research methods, like microrandomized trials, may allow for more implementation of technology and rapid advancement of knowledge. New technologies that can objectively and seamlessly capture remote data, as well as complement the clinical shift from symptom-based to inflammation-based care, will help the clinical and health technology communities to understand the full potential of digital health in the care of IBD and other chronic illnesses.

  • Source: Unsplash; Copyright: ALIAKSEI LEPIK; URL:; License: Licensed by the authors.

    Potential for Integrating Mental Health Specialist Video Consultations in Office-Based Routine Primary Care: Cross-Sectional Qualitative Study Among Family...


    Background: Although real-time mental health specialist video consultations have been proposed as an effective care model for treating patients with mental health conditions in primary care, little is known about their integration into routine practice from the perspective of family physicians. Objective: This study aimed to determine the degree to which family physicians advocate that mental health specialist video consultations can be integrated into routine primary care, where most patients with mental health conditions receive treatment. Methods: In a cross-sectional qualitative study, we conducted 4 semistructured focus groups and 3 telephonic interviews in a sample of 19 family physicians from urban and rural districts. We conducted a qualitative content analysis applying the Tailored Implementation in Chronic Diseases framework in a combined bottom-up (data-driven) and top-down strategy for deriving key domains. Results: Family physicians indicated that mental health specialist video consultations are a promising and practical way to address the most pressing challenges in current practice, that is, to increase the accessibility and co-ordination of specialized care. Individual health professional factors were the most frequently discussed topics. Specifically, family physicians valued the anticipated clinical outcomes for patients and the anticipated resources set for the primary care practice as major facilitators (16/19, 84%). However, family physicians raised a concern regarding a lack of facial expressions and physical interaction (19/19, 100%), especially in emergency situations. Therefore, most family physicians considered a viable emergency plan for mental health specialist video consultations that clearly delineates the responsibilities and tasks of both family physicians and mental health specialists to be essential (11/19, 58%). Social, political, and legal factors, as well as guideline factors, were hardly discussed as prerequisites for individual family physicians to integrate mental health specialist video consultations into routine care. To facilitate the implementation of future mental health specialist video consultation models, we compiled a checklist of recommendations that covers (1) buy-in from practices (eg, emphasizing logistical and psychological relief for the practice), (2) the engagement of patients (eg, establishing a trusted patient-provider relationship), (3) the setup and conduct of consultations (eg, reliable emergency plans), and (4) the fostering of collaboration between family physicians and mental health specialists (eg, kick-off meetings to build trust). Conclusions: By leveraging the primary care practice as a familiar environment for patients, mental health specialist video consultations provide timely specialist support and potentially lead to benefits for patients and more efficient processes of care. Integration should account for the determinants of practice as described by the family physicians. Trial Registration: German Clinical Trials Register DRKS00012487; navigationId=trial.HTML&TRIAL_ID=DRKS00012487

  • Source: Flickr; Copyright: jannoon028; URL:; License: Licensed by JMIR.

    Using Facebook Advertising to Recruit Representative Samples: Feasibility Assessment of a Cross-Sectional Survey


    Background: Facebook has shown promise as an economical means of recruiting participants for health research. However, few studies have evaluated this recruitment method in Canada, fewer still targeting older adults, and, to our knowledge, none specifically in Newfoundland and Labrador (NL). Objective: This study aimed to assess Facebook advertising as an economical means of recruiting a representative sample of adults aged 35 to 74 years in NL for a cross-sectional health survey. Methods: Facebook advertising was used to recruit for a Web-based survey on cancer awareness and prevention during April and May 2018; during recruitment, additional advertisements were targeted to increase representation of demographics that we identified as being underrepresented in our sample. Sociodemographic and health characteristics of the study sample were compared with distributions of the underlying population to determine representativeness. Cramer V indicates the magnitude of the difference between the sample and population distributions, interpreted as small (Cramer V=0.10), medium (0.30), and large (0.50). Sample characteristics were considered representative if there was no statistically significant difference in distributions (chi-square P>.01) or if the difference was small (V≤0.10), and practically representative if 0.10

  • Several files that can be used to document and reflect on a development process. Source: Shutterstock; Copyright:; URL:; License: Licensed by the authors.

    The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for...


    Background: The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them. Objective: The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap). Methods: In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method. Results: Information on 10 methods used is presented in a structured manner. These 10 methods were stakeholder identification, project team composition, focus groups, literature study, semistructured interviews, idea generation with scenarios, Web-based questionnaire, value specification, idea generation with prototyping, and a second round of interviews. The lessons learned showed that although each method added new insights to the development process, not every method appeared to be the most appropriate for each research goal. Conclusions: Reflection on the methods used pointed out that brief methods with concrete examples or scenarios fit the forensic psychiatric patients the best, among other things, because of difficulties with abstract reasoning and low motivation to invest much time in participating in research. Formulating clear research questions based on a model’s underlying principles and composing a multidisciplinary project team with prospective end users appeared to be important in this study. The research questions supported the project team in keeping the complex development processes structured and prevented tunnel vision. With regard to the CeHRes Roadmap, continuous stakeholder involvement and formative evaluations were evaluated as strong points. A suggestion to further improve the Roadmap is to explicitly integrate the use of domain-specific theories and models. To create a tool kit with a broad range of methods for eHealth development and further improve development models, studies that report and reflect on development processes in a consistent and structured manner are needed.

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

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


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

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

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


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

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

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


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

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

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


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

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

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


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

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  • One-way text messages versus no text messages on attendance to follow-up cervical cancer screening among HPV-positive Tanzanian Women (Connected2Care): a parallel-group randomized controlled trial

    Date Submitted: Aug 15, 2019

    Open Peer Review Period: Aug 15, 2019 - Oct 10, 2019

    Background: Rapid HPV DNA testing is an emerging cervical cancer screening strategy in resource-limited countries, yet it requires follow-up of women who test HPV-positive. Objective: We conducted a r...

    Background: Rapid HPV DNA testing is an emerging cervical cancer screening strategy in resource-limited countries, yet it requires follow-up of women who test HPV-positive. Objective: We conducted a randomized controlled trial to determine if one-way text messages improved attendance to a 14-months follow-up cervical cancer screening among HPV-positive women. Methods: This multi-centre, parallel-group randomized controlled trial was conducted at three hospitals in Tanzania. Eligible participants were between 25-60 years, had tested positive to a rapid HPV-test during a patient-initiated screening, been informed of their HPV-result, and had a private mobile phone with a valid number. Participants were randomly assigned 1:1 into the intervention or control group through an incorporated algorithm in the text message system. The intervention group received one-way text messages, and the control group received no text messages. The primary outcome was attendance to a 14-months health provider-initiated follow-up screening. Participants were not blinded but outcome assessors were. The analysis was intention-to-treat. Results: Between August 2015 and July 2017, 4080 women were screened for cervical cancer of which 705 were included into this trial; 358 were allocated to the intervention group and 347 to the control group. Sixteen women were excluded prior to analysis due to developing cervical cancer or dying (eight from each group). In the intervention group, 84 women (24%) attended their follow-up screening, and in the control group 80 women (24%) attended (RR: 1.02; 95% CI: 0.79-1.33). Conclusions: Attendance to a health provider-initiated follow-up cervical cancer screening among HPV-positive women was strikingly low, and one-way text messages did not improve the attendance rate. Implementation of rapid HPV-testing as a primary screening method at clinic level entails a challenge of ensuring a proper follow-up of women. Clinical Trial:; NCT02509702.

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

    Date Submitted: Aug 14, 2019

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

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

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

  • How do patients experience activity data? Dimensions of self-tracking in chronic self-care

    Date Submitted: Aug 15, 2019

    Open Peer Review Period: Aug 14, 2019 - Oct 9, 2019

    Background: Most commercial activity trackers are developed as consumer devices and not as clinical devices. The aim is to monitor and motivate sport activities, healthy living, and similar wellness p...

    Background: Most commercial activity trackers are developed as consumer devices and not as clinical devices. The aim is to monitor and motivate sport activities, healthy living, and similar wellness purposes and the devices are not designed to support care management in a clinical context. There are great expectations for using wearable sensor devices in healthcare settings and the separate realms of wellness tracking and disease self-monitoring is increasingly becoming blurred. However, patients’ experiences with activity-tracking technologies designed for use outside the clinical context have received little academic attention. Objective: This study contributes to understanding how patients with a chronic disease experience activity data from consumer self-tracking devices related to self-care and their chronic illness. Our research question was: “How do heart patients experience activity data in relation to self-care and chronic illness?”. Methods: We conducted an explorative intervention study with patients with a heart arrhythmia (N = 27) who had an implanted cardioverter defibrillator, living in Denmark. The average age was 57,2 (twenty-five male and two female). Patients were invited to wear a wristband activity tracker for a minimum of three months and provide their perspectives on what experiences the data accentuate. Semi-structured interviews (N = 66) were conducted with patients 1–5 times and were analyzed iteratively in workshops using thematic analysis. Results: Eighteen out of twenty-seven patients related the heart rate, sleep, and step-count data directly to their heart disease. Wearable activity trackers actualized patients’ experiences across three dimensions with a spectrum of contrasting experiences: (1) Knowing, which spanned gaining insight and evoking doubts; (2) Feeling, which spanned being reassured and becoming anxious; and (3) Evaluating, which spanned promoting improvements and exposing failure. Conclusions: Patients’ experiences could reside more on one end of the spectrum across all three dimensions, or they could combine contrasting positions and even move across the spectrum over time. Activity data from wearable devices may be a resource for self-care; however, it may simultaneously constrain and create uncertainty, fear, and anxiety. By showing how patients experience self-tracking data across dimensions of knowing, feeling, and evaluating, we point toward the richness and complexity of these data experiences in the context of chronic illness.

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

    Date Submitted: Aug 13, 2019

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

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

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

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

    Date Submitted: Aug 8, 2019

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

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

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

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

    Date Submitted: Aug 7, 2019

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

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

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