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Journal Description

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

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

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

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


Recent Articles:

  • Source: Flickr; Copyright: St. Ambrose University; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    QuikLitE, a Framework for Quick Literacy Evaluation in Medicine: Development and Validation


    Background: A plethora of health literacy instruments was developed over the decades. They usually start with experts curating passages of text or word lists, followed by psychometric validation and revision based on test results obtained from a sample population. This process is costly and it is difficult to customize for new usage scenarios. Objective: This study aimed to develop and evaluate a framework for dynamically creating test instruments that can provide a focused assessment of patients’ health literacy. Methods: A health literacy framework and scoring method were extended from the vocabulary knowledge test to accommodate a wide range of item difficulties and various degrees of uncertainty in the participant’s answer. Web-based tests from Amazon Mechanical Turk users were used to assess reliability and validity. Results: Parallel forms of our tests showed high reliability (correlation=.78; 95% CI 0.69-0.85). Validity measured as correlation with an electronic health record comprehension instrument was higher (.47-.61 among 3 groups) than 2 existing tools (Short Assessment of Health Literacy-English, .38-.43; Short Test of Functional Health Literacy in Adults, .34-.46). Our framework is able to distinguish higher literacy levels that are often not measured by other instruments. It is also flexible, allowing customizations to the test the designer’s focus on a particular interest in a subject matter or domain. The framework is among the fastest health literacy instrument to administer. Conclusions: We proposed a valid and highly reliable framework to dynamically create health literacy instruments, alleviating the need to repeat a time-consuming process when a new use scenario arises. This framework can be customized to a specific need on demand and can measure skills beyond the basic level.

  • Visual of the 3D model bar chart design in the 3D printing software. Source: Image created by the Authors; Copyright: Sam Graeme Morgan Crossley; URL:; License: Creative Commons Attribution (CC-BY).

    Understanding Youths’ Ability to Interpret 3D-Printed Physical Activity Data and Identify Associated Intensity Levels: Mixed-Methods Study


    Background: A significant proportion of youth in the United Kingdom fail to meet the recommended 60 minutes of moderate-to-vigorous physical activity every day. One of the major barriers encountered in achieving these physical activity recommendations is the perceived difficulty for youths to interpret physical activity intensity levels and apply them to everyday activities. Personalized physical activity feedback is an important method to educate youths about behaviors and associated outcomes. Recent advances in 3D printing have enabled novel ways of representing physical activity levels through personalized tangible feedback to enhance youths’ understanding of concepts and make data more available in the everyday physical environment rather than on screen. Objective: The purpose of this research was to elicit youths’ (children and adolescents) interpretations of two age-specific 3D models displaying physical activity and to assess their ability to appropriately align activities to the respective intensity. Methods: Twelve primary school children (9 boys; mean age 7.8 years; SD 0.4 years) and 12 secondary school adolescents (6 boys; mean age 14.1 years; SD 0.3 years) participated in individual semistructured interviews. Interview questions, in combination with two interactive tasks, focused on youths’ ability to correctly identify physical activity intensities and interpret an age-specific 3D model. Interviews were transcribed verbatim, content was analyzed, and outcomes were represented via tables and diagrammatic pen profiles. Results: Youths, irrespective of age, demonstrated a poor ability to define moderate-intensity activities. Moreover, children and adolescents demonstrated difficulty in correctly identifying light- and vigorous-intensity activities, respectively. Although youths were able to correctly interpret different components of the age-specific 3D models, children struggled to differentiate physical activity intensities represented in the models. Conclusions: These findings support the potential use of age-specific 3D models of physical activity to enhance youths’ understanding of the recommended guidelines and associated intensities.

  • Source: pxhere; Copyright: pxhere; URL:; License: Public Domain (CC0).

    Digital Health Professions Education on Diabetes Management: Systematic Review by the Digital Health Education Collaboration


    Background: There is a shortage of health care professionals competent in diabetes management worldwide. Digital education is increasingly used in educating health professionals on diabetes. Digital diabetes self-management education for patients has been shown to improve patients’ knowledge and outcomes. However, the effectiveness of digital education on diabetes management for health care professionals is still unknown. Objective: The objective of this study was to assess the effectiveness and economic impact of digital education in improving health care professionals’ knowledge, skills, attitudes, satisfaction, and competencies. We also assessed its impact on patient outcomes and health care professionals’ behavior. Methods: We included randomized controlled trials evaluating the impact of digitalized diabetes management education for health care professionals pre- and postregistration. Publications from 1990 to 2017 were searched in MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL, ERIC, and Web of Science. Screening, data extraction and risk of bias assessment were conducted independently by 2 authors. Results: A total of 12 studies met the inclusion criteria. Studies were heterogeneous in terms of digital education modality, comparators, outcome measures, and intervention duration. Most studies comparing digital or blended education to traditional education reported significantly higher knowledge and skills scores in the intervention group. There was little or no between-group difference in patient outcomes or economic impact. Most studies were judged at a high or unclear risk of bias. Conclusions: Digital education seems to be more effective than traditional education in improving diabetes management–related knowledge and skills. The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes such as health care professionals’ behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries.

  • Source: Pixabay; Copyright: HansMartinPaul; URL:; License: Public Domain (CC0).

    A Smoking Prevention Program Delivered by Medical Students to Secondary Schools in Brazil Called “Education Against Tobacco”: Randomized Controlled Trial


    Background: Smoking is the largest preventable cause of mortality in Brazil. Education Against Tobacco (EAT) is a network of more than 3500 medical students and physicians across 14 countries who volunteer for school-based smoking prevention programs. EAT educates 50,000 adolescents per year in the classroom setting. A recent quasi-experimental study conducted in Germany showed that EAT had significant short-term smoking cessation effects among adolescents aged 11 to 15 years. Objective: The aim is to measure the long-term effectiveness of the most recent version of the EAT curriculum in Brazil. Methods: A randomized controlled trial was conducted among 2348 adolescents aged 12 to 21 years (grades 7-11) at public secondary schools in Brazil. The prospective experimental design included measurements at baseline and at 6 and 12 months postintervention. The study groups comprised randomized classes receiving the standardized EAT intervention (90 minutes of mentoring in a classroom setting) and control classes in the same schools (no intervention). Data were collected on smoking status, gender, social aspects, and predictors of smoking. The primary endpoint was the difference in the change in smoking prevalence between the intervention group and the control group at 12-month follow-up. Results: From baseline to 12 months, the smoking prevalence increased from 11.0% to 20.9% in the control group and from 14.1% to 15.6% in the intervention group. This difference was statistically significant (P<.01). The effects were smaller for females (control 12.4% to 18.8% vs intervention 13.1% to 14.6%) than for males (control 9.1% to 23.6% vs intervention 15.3% to 16.8%). Increased quitting rates and prevented onset were responsible for the intervention effects. The differences in change in smoking prevalence from baseline to 12 months between the intervention and control groups were increased in students with low school performance. Conclusions: To our knowledge, this is the first randomized trial on school-based tobacco prevention in Brazil that shows significant long-term favorable effects. The EAT program encourages quitting and prevents smoking onset, especially among males and students with low educational background. Trial Registration: NCT02725021;

  • Source: Pexels; Copyright: Soumil Kumar; URL:; License: Licensed by the authors.

    Digital Trespass: Ethical and Terms-of-Use Violations by Researchers Accessing Data From an Online Patient Community


    With the expansion and popularity of research on websites such as Facebook and Twitter, there has been increasing concern about investigator conduct and social media ethics. The availability of large data sets has attracted researchers who are not traditionally associated with health data and its associated ethical considerations, such as computer and data scientists. Reliance on oversight by ethics review boards is inadequate and, due to the public availability of social media data, there is often confusion between public and private spaces. In addition, social media participants and researchers may pay little attention to traditional terms of use. In this paper, we review four cases involving ethical and terms-of-use violations by researchers seeking to conduct social media studies in an online patient research network. These violations involved unauthorized scraping of social media data, entry of false information, misrepresentation of researcher identities of participants on forums, lack of ethical approval and informed consent, use of member quotations, and presentation of findings at conferences and in journals without verifying accurate potential biases and limitations of the data. The correction of these ethical lapses often involves much effort in detecting and responding to violators, addressing these lapses with members of an online community, and correcting inaccuracies in the literature (including retraction of publications and conference presentations). Despite these corrective actions, we do not regard these episodes solely as violations. Instead, they represent broader ethical issues that may arise from potential sources of confusion, misinformation, inadequacies in applying traditional informed consent procedures to social media research, and differences in ethics training and scientific methodology across research disciplines. Social media research stakeholders need to assure participants that their studies will not compromise anonymity or lead to harmful outcomes while preserving the societal value of their health-related studies. Based on our experience and published recommendations by social media researchers, we offer potential directions for future prevention-oriented measures that can be applied by data producers, computer/data scientists, institutional review boards, research ethics committees, and publishers.

  • Source: Stokpic; Copyright: Ed Gregory; URL:; License: Public Domain (CC0).

    How Do Adolescents Use Electronic Diaries? A Mixed-Methods Study Among Adolescents With Depressive Symptoms


    Background: Depression in adolescence is common. Less than half of the adolescents with depression receive mental health care; furthermore, treatment tends to be suspended, and its success rates are low. There is a need for these adolescents to have a safe place to share their thoughts. Studies have shown that writing may be a useful treatment method for people with mental health problems. Objective: This study aims to describe the use of an electronic diary (e-diary) among adolescents with depressive symptoms. Methods: This paper describes a substudy of a randomized controlled trial. We used a mixed-methods approach to understand the way in which e-diaries were used by participants in the intervention under the randomized controlled trial. Data were collected during 2008-2010 at 2 university hospitals in Finland. Study participants (N=89) were 15-17-year-old adolescents who had been referred to an adolescent outpatient psychiatric clinic due to depressive symptoms. Participants were instructed to use the e-diary at least once a week to describe their thoughts, feelings, and moods. The content of the e-diary data was analyzed using descriptive statistics and inductive content analysis. Results: Overall, 53% (47/89) of the adolescents used the e-diary. Most of them (39/47, 83%) logged into the program during the first week, and about one-third (19/47, 40%) logged into the e-diary weekly as suggested. The number of words used in the e-diary per each log ranged between 8 and 1442 words. The 3 topics most often written about in the e-diary were related to mental health problems (mental disorder), social interaction (relationship), and one’s own development (identity). Conclusions: An e-diary may be a usable tool to reflect experiences and thoughts, especially among adolescents who have signs of depression. The results of this study can be used to develop user-centered electronic health applications that allow users to express their own thoughts and experiences in ways other than systematic mood monitoring.

  • Source: iStock; Copyright: scyther5; URL:; License: Licensed by the authors.

    Tweet Classification Toward Twitter-Based Disease Surveillance: New Data, Methods, and Evaluations


    Background: The amount of medical and clinical-related information on the Web is increasing. Among the different types of information available, social media–based data obtained directly from people are particularly valuable and are attracting significant attention. To encourage medical natural language processing (NLP) research exploiting social media data, the 13th NII Testbeds and Community for Information access Research (NTCIR-13) Medical natural language processing for Web document (MedWeb) provides pseudo-Twitter messages in a cross-language and multi-label corpus, covering 3 languages (Japanese, English, and Chinese) and annotated with 8 symptom labels (such as cold, fever, and flu). Then, participants classify each tweet into 1 of the 2 categories: those containing a patient’s symptom and those that do not. Objective: This study aimed to present the results of groups participating in a Japanese subtask, English subtask, and Chinese subtask along with discussions, to clarify the issues that need to be resolved in the field of medical NLP. Methods: In summary, 8 groups (19 systems) participated in the Japanese subtask, 4 groups (12 systems) participated in the English subtask, and 2 groups (6 systems) participated in the Chinese subtask. In total, 2 baseline systems were constructed for each subtask. The performance of the participant and baseline systems was assessed using the exact match accuracy, F-measure based on precision and recall, and Hamming loss. Results: The best system achieved exactly 0.880 match accuracy, 0.920 F-measure, and 0.019 Hamming loss. The averages of match accuracy, F-measure, and Hamming loss for the Japanese subtask were 0.720, 0.820, and 0.051; those for the English subtask were 0.770, 0.850, and 0.037; and those for the Chinese subtask were 0.810, 0.880, and 0.032, respectively. Conclusions: This paper presented and discussed the performance of systems participating in the NTCIR-13 MedWeb task. As the MedWeb task settings can be formalized as the factualization of text, the achievement of this task could be directly applied to practical clinical applications.

  • NOMAD questionnaire on-screen and CFA on paper. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Public Domain (CC0).

    Toward an Objective Assessment of Implementation Processes for Innovations in Health Care: Psychometric Evaluation of the Normalization Measure Development...


    Background: Successfully implementing eMental health (eMH) interventions in routine mental health care constitutes a major challenge. Reliable instruments to assess implementation progress are essential. The Normalization MeAsure Development (NoMAD) study developed a brief self-report questionnaire that could be helpful in measuring implementation progress. Based on the Normalization Process Theory, this instrument focuses on 4 generative mechanisms involved in implementation processes: coherence, cognitive participation, collective action, and reflexive monitoring. Objective: The aim of this study was to translate the NoMAD questionnaire to Dutch and to confirm the factor structure in Dutch mental health care settings. Methods: Dutch mental health care professionals involved in eMH implementation were invited to complete the translated NoMAD questionnaire. Confirmatory factor analysis (CFA) was conducted to verify interpretability of scale scores for 3 models: (1) the theoretical 4-factor structure, (2) a unidimensional model, and (3) a hierarchical model. Potential improvements were explored, and correlated scale scores with 3 control questions were used to assess convergent validity. Results: A total of 262 professionals from mental health care settings in the Netherlands completed the questionnaire (female: 81.7%; mean age: 45 [SD=11]). The internal consistency of the 20-item questionnaire was acceptable (.62≤alpha≤.85). The theorized 4-factor model fitted the data slightly better in the CFA than the hierarchical model (Comparative Fit Index=0.90, Tucker Lewis Index=0.88, Root Mean Square Error of Approximation=0.10, Standardized Root Mean Square Residual=0.12, χ22=22.5, P≤.05). However, the difference is small and possibly not outweighing the practical relevance of a total score and subscale scores combined in one hierarchical model. One item was identified as weak (λCA.2=0.10). A moderate-to-strong convergent validity with 3 control questions was found for the Collective Participation scale (.47≤r≤.54, P≤.05). Conclusions: NoMAD’s theoretical factor structure was confirmed in Dutch mental health settings to acceptable standards but with room for improvement. The hierarchical model might prove useful in increasing the practical utility of the NoMAD questionnaire by combining a total score with information on the 4 generative mechanisms. Future research should assess the predictive value and responsiveness over time and elucidate the conceptual interpretability of NoMAD in eMH implementation practices.

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

    Causal Relationships Among Pollen Counts, Tweet Numbers, and Patient Numbers for Seasonal Allergic Rhinitis Surveillance: Retrospective Analysis


    Background: Health-related social media data are increasingly used in disease-surveillance studies, which have demonstrated moderately high correlations between the number of social media posts and the number of patients. However, there is a need to understand the causal relationship between the behavior of social media users and the actual number of patients in order to increase the credibility of disease surveillance based on social media data. Objective: This study aimed to clarify the causal relationships among pollen count, the posting behavior of social media users, and the number of patients with seasonal allergic rhinitis in the real world. Methods: This analysis was conducted using datasets of pollen counts, tweet numbers, and numbers of patients with seasonal allergic rhinitis from Kanagawa Prefecture, Japan. We examined daily pollen counts for Japanese cedar (the major cause of seasonal allergic rhinitis in Japan) and hinoki cypress (which commonly complicates seasonal allergic rhinitis) from February 1 to May 31, 2017. The daily numbers of tweets that included the keyword “kafunshō” (or seasonal allergic rhinitis) were calculated between January 1 and May 31, 2017. Daily numbers of patients with seasonal allergic rhinitis from January 1 to May 31, 2017, were obtained from three healthcare institutes that participated in the study. The Granger causality test was used to examine the causal relationships among pollen count, tweet numbers, and the number of patients with seasonal allergic rhinitis from February to May 2017. To determine if time-variant factors affect these causal relationships, we analyzed the main seasonal allergic rhinitis phase (February to April) when Japanese cedar trees actively produce and release pollen. Results: Increases in pollen count were found to increase the number of tweets during the overall study period (P=.04), but not the main seasonal allergic rhinitis phase (P=.05). In contrast, increases in pollen count were found to increase patient numbers in both the study period (P=.04) and the main seasonal allergic rhinitis phase (P=.01). Increases in the number of tweets increased the patient numbers during the main seasonal allergic rhinitis phase (P=.02), but not the overall study period (P=.89). Patient numbers did not affect the number of tweets in both the overall study period (P=.24) and the main seasonal allergic rhinitis phase (P=.47). Conclusions: Understanding the causal relationships among pollen counts, tweet numbers, and numbers of patients with seasonal allergic rhinitis is an important step to increasing the credibility of surveillance systems that use social media data. Further in-depth studies are needed to identify the determinants of social media posts described in this exploratory analysis.

  • Homepage of RAW Mindfulness Program. Source: Sadhbh Joyce / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Resilience@Work Mindfulness Program: Results From a Cluster Randomized Controlled Trial With First Responders


    Background: A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time. Objective: This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers. Methods: We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills. Results: Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (P=.008), with the intervention group increasing in adaptive resilience over time. However, no significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience (P=.09). At 6-month follow-up, the group receiving the RAW intervention had an average increase in their resilience score of 1.3, equating to a moderate-to-large effect size compared with the control group of 0.73 (95% CI 0.38-1.06). Per-protocol analysis found that compared with the control group, the greatest improvements in adaptive resilience were observed among those who completed most of the RAW program, that is, 5 to 6 sessions (P=.002). Conclusions: The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000574549; (Archived by WebCite at

  • Patient falling. Source: iStock; Copyright: Toa55; URL:; License: Licensed by the authors.

    Novel Approach to Inpatient Fall Risk Prediction and Its Cross-Site Validation Using Time-Variant Data


    Background: Electronic medical records (EMRs) contain a considerable amount of information about patients. The rapid adoption of EMRs and the integration of nursing data into clinical repositories have made large quantities of clinical data available for both clinical practice and research. Objective: In this study, we aimed to investigate whether readily available longitudinal EMR data including nursing records could be utilized to compute the risk of inpatient falls and to assess their accuracy compared with existing fall risk assessment tools. Methods: We used 2 study cohorts from 2 tertiary hospitals, located near Seoul, South Korea, with different EMR systems. The modeling cohort included 14,307 admissions (122,179 hospital days), and the validation cohort comprised 21,172 admissions (175,592 hospital days) from each of 6 nursing units. A probabilistic Bayesian network model was used, and patient data were divided into windows with a length of 24 hours. In addition, data on existing fall risk assessment tools, nursing processes, Korean Patient Classification System groups, and medications and administration data were used as model parameters. Model evaluation metrics were averaged using 10-fold cross-validation. Results: The initial model showed an error rate of 11.7% and a spherical payoff of 0.91 with a c-statistic of 0.96, which represent far superior performance compared with that for the existing fall risk assessment tool (c-statistic=0.69). The cross-site validation revealed an error rate of 4.87% and a spherical payoff of 0.96 with a c-statistic of 0.99 compared with a c-statistic of 0.65 for the existing fall risk assessment tool. The calibration curves for the model displayed more reliable results than those for the fall risk assessment tools alone. In addition, nursing intervention data showed potential contributions to reducing the variance in the fall rate as did the risk factors of individual patients. Conclusions: A risk prediction model that considers longitudinal EMR data including nursing interventions can improve the ability to identify individual patients likely to fall.

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

    Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial


    Background: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. Objective: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. Methods: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. Results: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. Conclusions: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. Trial Registration: NCT00616837; (Archived by WebCite at

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  • Activation and Utilization of an Electronic Health Record Patient Portal by Emergency Department Patients at an Academic Medical Center: a Retrospective Study

    Date Submitted: Feb 22, 2019

    Open Peer Review Period: Feb 22, 2019 - Mar 1, 2019

    Background: Electronic health record (EHR) patient portals provide a means by which patients can access their health information, including diagnostic test results. Objective: We examined activation a...

    Background: Electronic health record (EHR) patient portals provide a means by which patients can access their health information, including diagnostic test results. Objective: We examined activation and utilization rates of a patient portal for emergency department (ED) patients, a population for which little published data exists for patient portal usage. Patient portal utilization was assessed by account activation rates along with rates of access of diagnostic test results (laboratory results and radiology reports), analyzing the impact of age, gender, and self-reported patient race. Methods: This institutional review board-approved retrospective study was performed at a 60,000 visit university-based ED. We utilized EHR data reporting tools to examine EHR portal activation and utilization for all patients who had one or more ED encounters between October 1, 2016 and October 1, 2017. The total dataset for laboratory testing included 208,635 laboratory tests on 25,361 unique patients, of which 9,482 (37.4%) had active portal accounts. The total dataset for radiologic imaging included 23,504 radiology studies on 14,455 unique patients, of which 5,439 (37.6%) had an active portal account. Results: Overall, 8.9% (18,573/208,635) of laboratory tests and 9.0% (2,019/22,504) of radiology reports ordered in the ED were viewed in the patient portal. Highest rates of viewing of laboratory and radiology results were seen for females, 0-11 years (parent/guardian viewing by proxy), 18-60 years, and patients who self-reported they are race as Caucasian and Asian. Lowest rates were for teenagers, 81+ years, African-American/Black, and Hispanic/Latino. Infectious disease, urinalysis, and pregnancy testing comprised the highest viewed laboratory tests. Magnetic resonance imaging reports were viewed at higher rates than computed tomography or x-ray studies (P < 0.001). Approximately half of all diagnostic test results accessed by patients were reviewed within 72 hours of availability in the patient portal (laboratory results: 9,904/18,573, 53.3%; radiology reports: 971/2,099, 46.3%). On the other extreme, 19.9% (3,701/18,573) of laboratory results and 30.4% (639/2,099) of radiology reports were viewed more than 2 weeks after availability in the portal. Conclusions: The data highlight relatively low use of a patient portal by ED patients and existing disparities between patient groups. There can be wide lag time (months) between result/report availability and access by patients. Opportunities for improvement exist for both activation and more robust utilization of patient portals by ED patients.

  • Analysis of self-injury tweets among Korean Twitter users

    Date Submitted: Feb 19, 2019

    Open Peer Review Period: Feb 22, 2019 - Apr 19, 2019

    Background: In some countries, like South Korea, sharing self-injury experiences via social network sites such as Twitter and Instagram in the form of a photo and text, is becoming a trend among adole...

    Background: In some countries, like South Korea, sharing self-injury experiences via social network sites such as Twitter and Instagram in the form of a photo and text, is becoming a trend among adolescents, and is a serious social problem. Objective: The aims of this study were to examine social networks among Korean Twitter users who posted or retweeted self-injury tweets, and then analyze the content of these self-injury tweets. Methods: We collected Korean tweets containing the terms “self-injury” or “#self-injury” between June 17 and September 23, 2018, which resulted in 53,648 tweets. These tweets were analyzed using text analysis and network analysis techniques. Results: The most frequently appearing words in self-injury tweets were “photo,” “depression,” “suicide,” “person,” and “depressive disorder.” Most users who disclosed their ages were adolescents. Frequently mentioned mental illnesses were depressive, bipolar, panic, and anxiety disorder. A network analysis revealed minimal retweet interactions among users; few tweets were retweeted by many other users, and most users retweeted only one or no tweets. Conclusions: The findings imply that many users who intended to self-injure were adolescents or had mental health issues, or were those who belong to a social minority (e.g., LGBT), suggesting that they might wish to self-injure due to mental or physical problems. Thus, it is critical for society to help these individuals.

  • Cloud health resource sharing based on consensus-oriented blockchain technology: A case study on breast tumor diagnosis service

    Date Submitted: Feb 21, 2019

    Open Peer Review Period: Feb 22, 2019 - Apr 19, 2019

    Background: In recent years, an increasing number of researchers have made significant effort in advancing the blockchain technology. This technology, with distinct features of decentralization and se...

    Background: In recent years, an increasing number of researchers have made significant effort in advancing the blockchain technology. This technology, with distinct features of decentralization and security, can be applied to many fields. On the aspects of health data and resource sharing, the application blockchain technology is emerging. Objective: In this study, we propose a cloud health resource sharing model based on consensus-oriented blockchain technology and develop a simulation study on the service of breast tumor diagnosis. Methods: The proposed platform is built on a consortium or federated blockchain which possesses the features of both centralization and decentralization. The consensus mechanisms generate the operating standards for the proposed model. The open source Ethereum code is employed to provide the blockchain environment. Proof-of-Authority (PoA) is selected as the consensus algorithm of block generation. Results: Based on the proposed model, a simulation case study for breast tumor classification is constructed. The simulation includes 9893 service requests from 100 users. 22 service providers are equipped with 22 different classification methods, respectively. Each request is fulfilled by a service provider which is recommended by the weighted k-nearest neighbors (KNN) algorithm. It is shown that the majority of service requests tend to be taken by 9 providers and the provider’s score of service evaluation tends to be stabilize. Also, the user priority on KNN weights significantly affects the system operation outcome. Conclusions: The proposed model is feasible based on the simulation case study for the cloud service of breast tumor diagnosis and has potential to be applied to many other purposes.

  • Awareness and factors associated with willingness to use Pre-exposure prophylaxis (PrEP) in Brazil, Mexico and Peru: an online survey among men who have sex with men (MSM)

    Date Submitted: Feb 21, 2019

    Open Peer Review Period: Feb 22, 2019 - Feb 28, 2019

    Background: Pre-exposure prophylaxis (PrEP) with daily oral emtricitabine/tenofovir is being implemented in the context of combined HIV prevention in different settings. Reports on PrEP awareness, wi...

    Background: Pre-exposure prophylaxis (PrEP) with daily oral emtricitabine/tenofovir is being implemented in the context of combined HIV prevention in different settings. Reports on PrEP awareness, willingness to use, and acceptability among MSM have started to emerge over the last few years. Previously reported factors associated with willingness include: awareness, costs, low perception of HIV acquisition risk, higher sexual risk, prior sexually transmitted infection (STI), and unwillingness to use condoms. Objective: This study aims to evaluate awareness of PrEP and the factors associated with willingness to use daily oral PrEP (PrEP willingness) among men who have sex with men (MSM) in three Latin American, middle-income countries (Brazil, Mexico and Peru). Methods: This online cross-sectional survey was advertised in two gay social networks apps (Grindr and Hornet) used by MSM to find sexual partners and on Facebook during two months in 2018. Inclusion criteria were ≥18 years of age, cisgender men and HIV-negative by self-report. Eligible individuals answered questions on: demographics, behavior, and PrEP (awareness, willingness, barriers and facilitators). Multivariable logistic regression modeling was performed to assess the factors associated with PrEP willingness in each country. Results: A total of 19,457 MSM completed the online survey (Brazil: 58%, Mexico: 31%, Peru: 11%); median age was 28 years (IQR: 24-34), almost half lived in large urban cities and 89% were sexually attracted only to men. The majority of the participants were recruited on Grindr (69%). Almost 20% had never tested for HIV and condomless receptive anal sex was reported by 46%. A total of 13,110 (67%) met the ImPrEP demonstration study’s risk-related inclusion criteria (based on WHO criteria for PrEP). PrEP awareness was reported by 65%, this was lower in Peru (46%). Overall, PrEP willingness was reported by 64%, highest in Mexico (70%) and lowest in Peru (58%). In multivariate regression models conducted by country and adjusted for age, schooling, and income: PrEP awareness and an increase of PrEP facilitators were associated with a greater PrEP willingness, while increased behavioral and belief-related barriers were associated with decreased PrEP willingness in all countries. Conclusions: In this first cross-country online survey in Latin America willingness to use PrEP was found to be high and directly related to levels of PrEP awareness. Interventions to increase awareness and PrEP knowledge about safety and efficacy are crucial to increase PrEP demand. This study provides important information to support the implementation of PrEP in Brazil, Mexico and Peru.

  • Languages, Length of Residence, and Diagnosis as Promising Predictors of Diverse eHealth Activities Among Immigrants: Case of First-Generation Immigrants from Pakistan in the Oslo Area, Norway

    Date Submitted: Aug 21, 2018

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: Immigrant populations are often disproportionally affected by chronic diseases, such as Type-2 diabetes [T2D]. Use of information and communication technology is one promising approach to...

    Background: Immigrant populations are often disproportionally affected by chronic diseases, such as Type-2 diabetes [T2D]. Use of information and communication technology is one promising approach to provide health-related information, knowledge, and support in managing the chronic condition to a wider population. However, knowledge is scarce regarding eHealth activities for self-care among immigrants, especially in European countries. Objective: By setting the first-generation immigrants from Pakistan in the Oslo area, Norway, as a target group, we aimed to understand their diverse eHealth activities for T2D self-care in relation to target-group specific user factors such as proficiency in relevant languages (Urdu, Norwegian, English), length of residence in Norway, and diagnosis of T2D, compared to general factors like age, gender, education, digital skills, and self-rated health status. Methods: We used data from a survey among the target population (N=176) conducted in 2015-2016. Dichotomous data about whether or not an informant had experienced each type of eHealth activity for T2D self-care in the last 12 months were used as dependent variables for logistic regression analysis [LRA], and the total number of positive answers (variety) was used in Poisson regression analysis. Independent variables consisted of data regarding user factors named above. Best-fit method based on Akaike information criterion was employed as the selection criterion between models. Results: LRA yielded 7 models regarding the followings: (A) information seeking by (a) search engines (b) web portals or email subscriptions; (B) communication and consultation (d) by closed conversation with a few acquaintances using ICT (e) on social network services (f) on peer-portals; (C) active decision making by using applications for (h) tracking health information and (i) self-assessment of health status. Variables positively associated (p<.05) with eHealth experience were Urdu literacy (for (a), (b), (e) and variety), length of residence in Norway (for (d), (e), and variety), Norwegian language proficiency (for (f) and (i)), and diagnosis of T2D (for (a)), while having English proficiency was negatively associated with using social network services. Among general user factors, younger age (for (h), (i) and variety), a composite variable of education and digital skills (for (h) and (i)) and being female (for (d)) showed a positive association with each experience of eHealth. Self-assessment of health status did not remain in any model. Conclusions: In our sample, target-group specific user factors were dominant factors characterizing diverse eHealth activities compared to general user factors. The yielded knowledge will serve as a basis of further research on designing, developing, and disseminating eHealth services, and for studies exploring the influence of relevant user factors for eHealth activities in other user groups and contexts.

  • Influence of climate on geographic pruritus internet searches: A retrospective analysis of Google searches in 16 German cities

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: The burden of pruritus is high, especially among patients with dermatologic diseases. Estimating the prevalence rates of pruritus and the people’s medical needs is challeng-ing since not...

    Background: The burden of pruritus is high, especially among patients with dermatologic diseases. Estimating the prevalence rates of pruritus and the people’s medical needs is challeng-ing since not all affected people consult a physician. Objective: To investigate pruritus search behavior trends in Germany and identify associations with external factors. Methods: Google AdWords Keyword Planner was used to quantify pruritus-related search que-ries in 16 German cities from August 2014 to July 2018. All identified keywords were qualitatively categorized and pruritus-related terms were descriptively analyzed. The number of search queries per 100,000 inhabitants of each city was compared to envi-ronmental factors such as temperature, humidity, particulate matter (PM10), and sun-shine duration to investigate potential correlations. Results: We included 1,150 pruritus-related keywords, which resulted in 2,851,290 queries. “Pruritus” (n=115,680) and “anal pruritus” (n=102,390) were the most searched for keywords. The most populated cities had the lowest number of queries/100,000 inhab-itants (Berlin, n=13,641; Hamburg, n=18,303; and Munich, n=21,363), while smaller cities (Kiel, n=35,027; and Freiburg, n=39,501) had the highest. Temperature had a greater effect on search query number (β coefficient: -7.94, 95% confidence interval [CI] [-10.74; -5.15]) than PM10 (-5.13, [-7.04, -3.22]), humidity (4.73, [2.70, 6.75]), or sunshine duration (0.66, [0.36, 0.97]). The highest relative number of search queries occurred during the winter (December to February). Conclusions: Google data analysis provided good insight into general search behaviors. Examining different cities across Germany and comparing search volumes with weather data were valuable for identifying trends and respective inhabitants’ needs.