Maintenance Notice

Due to necessary scheduled maintenance, the JMIR Publications website will be unavailable from Wednesday, July 01, 2020 at 8:00 PM to 10:00 PM EST. We apologize in advance for any inconvenience this may cause you.

Who will be affected?


Journal Description

The Journal of Medical Internet Research (JMIR), now in its 21st year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2019: 5.03), ranking Q1 in the medical informatics category, and is also the largest journal in the field. The journal focuses on emerging technologies, medical devices, apps, engineering, telehealth and informatics applications for patient education, prevention, population health and clinical care. As a leading high-impact journal in its disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope, and which together receive over 6.000 submissions a year. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journal but can simply transfer it between journals. 

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

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

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


Recent Articles:

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

    Effects of COVID-19 Emergency Alert Text Messages on Practicing Preventive Behaviors: Cross-sectional Web-Based Survey in South Korea


    Background: Sending emergency messages via mobile phone text messaging can be a promising communication tool to rapidly disseminate information and promote preventive behavior among the public during epidemic outbreaks. The battle to overcome COVID-19 is not yet over; thus, it is essential that the public practices preventive measures to prevent the spread of COVID-19. Objective: This study aimed to investigate the effectiveness of reading and obtaining information via emergency alert SMS text messages and their effects on the individual's practice of preventive behaviors during the early stages of the COVID-19 outbreak in South Korea. Methods: A cross-sectional web-based survey comprising 990 participants was conducted over 3 days (March 25-27, 2020). A multivariable logistic regression analysis revealed the sociodemographic factors that might influence the behavior of reading emergency alert text messages. A hierarchical linear regression model estimated the associations between reading emergency alert text messages for each precautionary behavior practiced against COVID-19. Additionally, the indirect effects of reading the text messages on each precautionary behavior via psychological factors (ie, perceived risk and response efficacy) were calculated. All data were weighted according to the 2019 Korea census data. Results: Overall, 49.2% (487/990) of the participants reported that they always read emergency alert text messages and visited the linked website to obtain more information. Factors such as female sex (odds ratio [OR] 1.68, 95% CI 1.28-2.21) and older age (30-39 years: OR 2.02, 95% CI 1.25-3.28; 40-49 years: OR 2.84, 95% CI 1.80-4.47; 50-59 years: OR 3.19, 95% CI 2.01-5.06; 60 years and above: OR 3.12, 95% CI 2.00-4.86 versus 18-29 years) were identified to be associated with a higher frequency of reading the text messages. Participants who always read the text messages practiced wearing facial masks (β=.074, P=.01) more frequently than those who did not. In terms of social distancing, participants who reported they always read the text messages avoided crowded places (β=.078, P=.01) and canceled or postponed social gatherings (β=.103, P<.001) more frequently than those who did not read the text messages. Furthermore, reading text messages directly and indirectly affected practicing precautionary behaviors, as the mediation effect of response efficacy between reading text messages and practicing preventive behaviors was significant. Conclusions: Our findings suggest that emergency alert text messages sent to individuals' mobile phones are timely and effective strategies for encouraging preventive behavior in public. Sending emergency alert text messages to provide the public with accurate and reliable information could be positively considered by the health authorities, which might reduce the negative impact of infodemics.

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

    Health Care Workers’ Reasons for Choosing Between Two Different COVID-19 Prophylaxis Trials in an Acute Pandemic Context: Single-Center Questionnaire Study


    Background: In April 2020, two independent clinical trials to assess SARS-CoV-2 prophylaxis strategies among health care workers were initiated at our hospital: MeCOVID (melatonin vs placebo) and EPICOS (tenofovir disoproxil/emtricitabine vs hydroxychloroquine vs combination therapy vs placebo). Objective: This study aimed to evaluate the reasons why health care workers chose to participate in the MeCOVID and EPICOS trials, as well as why they chose one over the other. Methods: Both trials were offered to health care workers through an internal news bulletin. After an initial screening visit, all subjects were asked to respond to a web-based survey. Results: In the first month, 206 health care workers were screened and 160 were randomized. The survey participation was high at 73.3%. Health care workers cited “to contribute to scientific knowledge” (n=80, 53.0%), followed by “to avoid SARS-CoV-2 infection” (n=33, 21.9%) and “the interest to be tested for SARS-CoV-2” (n=28, 18.5%), as their primary reasons to participate in the trials. We observed significant differences in the expected personal benefits across physicians and nurses (P=.01). The vast majority of volunteers (n=202, 98.0%) selected the MeCOVID trial, their primary reason being their concern regarding adverse reactions to treatments in the EPICOS trial (n=102, 69.4%). Conclusions: Health care workers’ reasons to participate in prophylaxis trials in an acute pandemic context appear to be driven largely by their desire to contribute to science and to gain health benefits. Safety outweighed efficacy when choosing between the two clinical trials.

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

    Impact of Remote and Virtual Care Models on the Sustainability of Small Health Care Businesses: Perceptual Analysis of Small Clinics, Physician Offices, and...


    Background: Lockdowns and shelter-in-place orders during COVID-19 have accelerated the adoption of remote and virtual care (RVC) models, potentially including telehealth, telemedicine, and internet-based electronic physician visits (e-visits) for remote consultation, diagnosis, and care, deterring small health care businesses including clinics, physician offices, and pharmacies from aligning resources and operations to new RVC realities. Current perceptions of small health care businesses toward remote care, particularly perceptions of whether RVC adoption will synergistically improve business sustainability, would highlight the pros and cons of rapidly adopting RVC technology among policy makers. Objective: This study aimed to assess the perceptions of small health care businesses regarding the impact of RVC on their business sustainability during COVID-19, gauge their perceptions of their current levels of adoption of and satisfaction with RVC models and analyze how well that aligns with their perceptions of the current business scenario (SCBS), and determine whether these perceptions influence their view of their midterm sustainability (SUST). Methods: We randomly sampled small clinics, physician offices, and pharmacies across Colorado and sought assistance from a consulting firm to collect survey data in July 2020. Focal estimated study effects were compared across the three groups of small businesses to draw several insights. Results: In total, 270 respondents, including 82 clinics, 99 small physician offices, and 89 pharmacies, across Colorado were included. SRVC and SCBS had direct, significant, and positive effects on SUST. However, we investigated the effect of the interaction between SRVC and SCBS to determine whether RVC adoption aligns with their perceptions of the current business scenario and whether this interaction impacts their perception of business sustainability. Effects differed among the three groups. The interaction term SRVC×SCBS was significant and positive for clinics (P=.02), significant and negative for physician offices (P=.05), and not significant for pharmacies (P=.76). These variations indicate that while clinics positively perceived RVC alignment with the current business scenario, the opposite held true for small physician offices. Conclusions: As COVID-19 continues to spread worldwide and RVC adoption progresses rapidly, it is critical to understand the impact of RVC on small health care businesses and their perceptions of long-term survival. Small physician practices cannot harness RVC developments and, in contrast with clinics, consider it incompatible with business survival during and after COVID-19. If small health care firms cannot compete with RVC (or synergistically integrate RVC platforms into their current business practices) and eventually become nonoperational, the resulting damage to traditional health care services may be severe, particularly for critical care delivery and other important services that RVC cannot effectively replace. Our results have implications for public policy decisions such as incentive-aligned models, policy-initiated incentives, and payer-based strategies for improved alignment between RVC and existing models.

  • COVID-19 in American Sign Language. Source: Image created by the Authors; Copyright: Center for Deaf Health Equity; URL:; License: Creative Commons Attribution (CC-BY).

    Perception of COVID-19 Physical Distancing Effectiveness and Contagiousness of Asymptomatic Individuals: Cross-sectional Survey of Deaf and Hard of Hearing...


    Background: During the COVID-19 pandemic, there has been a rapid increase in the amount of information about the disease and SARS-CoV-2 on the internet. If the language used in video messages is not clear or understandable to deaf and hard of hearing (DHH) people with a high school degree or less, this can cause confusion and result in information gaps among DHH people during a health emergency. Objective: The aim of this study is to investigate the relationship between DHH people's perception of the effectiveness of physical distancing and contagiousness of an asymptomatic person. Methods: This is a cross-sectional survey study on DHH people's perceptions about COVID-19 (N=475). Items pertaining to COVID-19 knowledge were administered to US deaf adults from April 17, 2020, to May 1, 2020, via a bilingual American Sign Language/English online survey platform. Results: The sample consisted of 475 DHH adults aged 18-88 years old, with 74% (n=352) identifying as White and 54% (n=256) as female. About 88% (n=418) of the sample felt they knew most things or a lot about physical distancing. This figure dropped to 72% (n=342) for the question about the effectiveness of physical distancing in reducing the spread of COVID-19 and 70% (n=333) for the question about the contagiousness of an infected person without symptoms. Education and a knowledge of the effectiveness of physical distancing significantly predicted knowledge about the contagiousness of an asymptomatic individual. Race, gender, and age did not emerge as significant predictors. Conclusions: This results of this study point to the strong connection between education and coronavirus-related knowledge. Education-related disparities can be remedied by making information fully accessible and easily understood during emergencies and pandemics.

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

    Differences in the Gut Microbiome of Women With and Without Hypoactive Sexual Desire Disorder: Case Control Study


    Background: The gut microbiome is receiving considerable attention as a potentially modifiable risk factor and therapeutic target for numerous mental and neurological diseases. Objective: This study aimed to explore and assess the difference in the composition of gut microbes and fecal metabolites between women with hypoactive sexual desire disorder (HSDD) and healthy controls. Methods: We employed an online recruitment method to enroll “hard-to-reach” HSDD populations. After a stringent diagnostic and exclusion process based on DSM-IV criteria, fecal samples collected from 24 women with HSDD and 22 age-matched, healthy controls underwent microbiome analysis using 16S ribosomal RNA gene sequencing and metabolome analysis using untargeted liquid chromatography–mass spectrometry. Results: We found a decreased abundance of Ruminococcaceae and increased abundance of Bifidobacterium and Lactobacillus among women with HSDD. Fecal samples from women with HSDD showed significantly altered metabolic signatures compared with healthy controls. The abundance of Bifidobacterium, Lactobacillus, and several fecal metabolites correlated negatively with the sexual desire score, while the number of Ruminococcaceae correlated positively with the sexual desire score in all subjects. Conclusions: Our analysis of fecal samples from women with HSDD and healthy controls identified significantly different gut microbes and metabolic signatures. These preliminary findings could be useful for developing strategies to adjust the level of human sexual desire by modifying gut microbiota. Trial Registration: Chinese Clinical Trial Registry ChiCTR1800020321;

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

    Telemedicine Awareness, Knowledge, Attitude, and Skills of Health Care Workers in a Low-Resource Country During the COVID-19 Pandemic: Cross-sectional Study


    Background: Since the onset of the COVID-19 pandemic, several health care programs intended to provide telemedicine services have been introduced in Libya. Many physicians have used these services to provide care and advice to their patients remotely. Objective: This study aimed to provide an overview of physicians’ awareness, knowledge, attitude, and skill in using telehealth services in Libya. Methods: In this cross-sectional study, we administered a web-based survey to health care workers in Libya in May 2020. The questionnaire collected information on physicians’ general demographic characteristics, ability to use a computer, and telemedicine awareness, knowledge, attitude, and skills. Results: Among 673 health care workers who responded to the survey, 377 (56%) and 248 (36.8%) reported high awareness and high computer skill scores, respectively, for telemedicine. Furthermore, 582 (86.5%) and 566 (82.6%) health care workers reported high knowledge and high attitude scores, respectively. We observed no significant differences in awareness, knowledge, attitude, and skill scores among physicians employed at public, private, or both types of hospitals. We observed significant differences in the mean awareness (P<.001), attitude (P=.001), and computer skill scores (P<.001) , where the score distribution of the groups based on the ability to use computers was not similar. Knowledge scores did not significantly differ among the three groups (P=.37). Respondents with professional computer skills had significantly higher awareness (χ23=14.5; P<.001) and attitude (χ23=13.5; P=.001) scores than those without professional computer skills. We observed significant differences in the mean computer skill scores of the groups (χ23=199.6; P<.001). Conclusions: The consequences of the COVID-19 pandemic are expected to persist for a long time. Hence, policy programs such as telemedicine services, which aim to address the obstacles to medical treatment owing to physical distancing measures, will likely continue for a long time. Therefore, there is a need to train and support health care workers and initiate government programs that provide adequate and supportive health care services to patients in transitional countries.

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

    Husbands’ Knowledge of Breast Cancer and Their Wives’ Attitudes and Practices Related to Breast Cancer Screening in Saudi Arabia: Cross-sectional Online...


    Background: Despite Saudi Arabia’s free and well-established cancer care program, breast cancer incidence and mortality are rising. Husbands’ knowledge, and wives’ attitudes and practices related to breast cancer screening are not well understood in Saudi Arabia. Objective: The aim of this study was to investigate husbands’ knowledge, and wives’ attitudes and practices related to breast cancer screening in Saudi Arabia. Methods: This cross-sectional study collected data from 403 husbands in the holy city of Makkah through an online self-reported questionnaire over a period of 2 months, from May 6 to July 7, 2020. Tabulation, bivariate, and multiple regression analyses were the major tools used for data analysis. Multivariate logistic regressions were used to examine the association between husbands’ knowledge and wives’ behavior regarding breast cancer screening methods. Results: Husbands’ knowledge score (a 1-point increase) was significantly associated with the wives’ utilization of mammograms (adjusted odds ratio [AOR] 1.089, 95% CI 1.024-1.159) and breast self-examination (AOR 1.177, 95% CI 1.105-1.255). Husbands’ knowledge also influenced the wives’ attitudes toward learning about breast self-examination (AOR 1.138, 95% CI 1.084-1.195). There was no significant association between husbands’ knowledge and wives’ utilization of clinical breast examination. However, richer husbands showed a socioeconomic gradient concerning their wives’ utilization of clinical breast examinations (AOR 2.603, 95% CI 1.269-5.341). Conclusions: Overall, husbands’ knowledge of breast cancer influences wives’ attitudes and practices related to breast cancer screening methods in Saudi Arabia. Thus, interventions delivered to husbands might increase breast cancer awareness and survival.

  • Source: Shutterstock; Copyright: Andrei_R; URL:; License: Licensed by JMIR.

    Revolutionizing Medical Data Sharing Using Advanced Privacy-Enhancing Technologies: Technical, Legal, and Ethical Synthesis


    Multisite medical data sharing is critical in modern clinical practice and medical research. The challenge is to conduct data sharing that preserves individual privacy and data utility. The shortcomings of traditional privacy-enhancing technologies mean that institutions rely upon bespoke data sharing contracts. The lengthy process and administration induced by these contracts increases the inefficiency of data sharing and may disincentivize important clinical treatment and medical research. This paper provides a synthesis between 2 novel advanced privacy-enhancing technologies—homomorphic encryption and secure multiparty computation (defined together as multiparty homomorphic encryption). These privacy-enhancing technologies provide a mathematical guarantee of privacy, with multiparty homomorphic encryption providing a performance advantage over separately using homomorphic encryption or secure multiparty computation. We argue multiparty homomorphic encryption fulfills legal requirements for medical data sharing under the European Union’s General Data Protection Regulation which has set a global benchmark for data protection. Specifically, the data processed and shared using multiparty homomorphic encryption can be considered anonymized data. We explain how multiparty homomorphic encryption can reduce the reliance upon customized contractual measures between institutions. The proposed approach can accelerate the pace of medical research while offering additional incentives for health care and research institutes to employ common data interoperability standards.

  • Source: Unsplash; Copyright: National Cancer Institute; URL:; License: Licensed by the authors.

    Quantifying Patient Portal Use: Systematic Review of Utilization Metrics


    Background: Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users’ interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization. Objective: The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use. Methods: Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term “Patient Portals” and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into “super user” or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor. Results: Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal’s impact factor. Conclusions: Portal utilization measures in the research literature can fall below established standards for “meaningful” or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.

  • Source: Image created by the authors/rawpixel; Copyright: The Authors/Ake; URL:; License: Public Domain (CC0).

    Development and Feasibility of a Web-Based Decision Aid for Patients With Ulcerative Colitis: Qualitative Pilot Study


    Background: Shared decision making (SDM) is becoming an important part of ulcerative colitis (UC) management because of the increasing complexity of available treatment choices and their trade-offs. The use of decision aids (DA) may be effective in increasing patients’ participation in UC management but their uptake has been limited due to high attrition rates and lack of a participatory approach to their design and implementation. Objective: The primary aim of this study is to explore the perspectives of Australian patients and their clinicians regarding the feasibility and acceptability of myAID, a web-based DA, in informing treatment decisions in UC. The secondary aim is to use the findings of this pilot study to inform the design of a cluster randomized clinical trial (CRCT) to assess the efficacy of the DA compared with usual care. Methods: myAID, a DA was designed and developed using a participatory approach by a multidisciplinary team of clinicians, patients, and nonmedical volunteers. A qualitative pilot study to evaluate the DA, involving patients with UC facing new treatment decisions and inflammatory bowel disease clinicians, was undertaken. Results: A total of 11 patients with UC and 15 clinicians provided feedback on myAID. Themes explored included the following: Acceptability and usability of myAID—myAID was found to be acceptable by the majority of clinicians as a tool to facilitate SDM, uptake was thought to vary depending on clinicians’ approaches to patient education and practice, potential to overcome time restrictions associated with outpatient clinics was identified, presentation of unbiased information enabling patients to digest information at their own pace was noted, and potential to provoke anxiety among patients with a new diagnosis or mild disease was raised; Perceived role and usefulness of myAID—discordance was observed between patients who prioritized voicing preferences and clinicians who prioritized treatment adherence, and myAID facilitated early discussion of medical versus surgical treatment options; Target population and timing of use—greatest benefit was perceived at the time of initiating or changing treatment and following commencement of immunosuppressive therapy; and Potential concerns and areas for improvement—some perceived that use of myAID may precipitate anxiety by increasing decisional conflict and impact the therapeutic relationship between patient and the clinician and may increase resource requirements. Conclusions: These preliminary findings suggest that patients and clinicians consider myAID as a feasible and acceptable tool to facilitate SDM for UC management. These pilot data have informed a participatory approach to the design of a CRCT, which will evaluate the clinical efficacy of myAID compared with usual care. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12617001246370;

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

    Associations of Health Literacy, Social Media Use, and Self-Efficacy With Health Information–Seeking Intentions Among Social Media Users in China:...


    Background: Empirical research has demonstrated that people frequently use social media for gathering and sharing online health information. Health literacy, social media use, and self-efficacy are important factors that may influence people’s health behaviors online. Objective: We aimed to examine the associations between health literacy, health-related social media use, self-efficacy, and health behavioral intentions online. Methods: We conducted a cross-sectional survey of adults 18 years and older (n=449) to examine predictors of health-related behavioral intentions online including health literacy, social media use, and self-efficacy in China using 2 moderated mediation models. Mediation and moderation analyses were conducted. Results: Self-efficacy mediated the effects of health literacy (Bindirect=0.213, 95% CI 0.101 to 0.339) and social media use (Bindirect=0.023, 95% CI 0.008 to 0.045) on health behavioral intentions on social media. Age moderated the effects of health literacy on self-efficacy (P=.03), while previous experience moderated the effects of social media use on self-efficacy (P<.001). Conclusions: Health literacy and health-related social media use influenced health behavioral intentions on social media via their prior effects on self-efficacy. The association between health literacy and self-efficacy was stronger among younger respondents, whereas the association between health-related social media use and self-efficacy was stronger among those who previously had positive experiences with health information on social media. Health practitioners should target self-efficacy among older populations and increase positive media experience related to health.

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

    Understanding Gaps Between Daily Living and Clinical Settings in Chronic Disease Management: Qualitative Study


    Background: Management of chronic conditions entails numerous activities in both clinical and daily living settings. Activities across these settings interact, creating a high potential for a gap to occur if there is an inconsistency or disconnect between controlled clinical settings and complex daily living environments. Objective: The aim of this study is to characterize gaps (from the patient’s perspective) between health-related activities across home-based and clinical settings using anticoagulation treatment as an example. The causes, consequences, and mitigation strategies (reported by patients) were identified to understand these gaps. We conceptualized gaps as latent phenomena (ie, a break in continuity). Methods: Patients (n=39) and providers (n=4) from the anticoagulation clinic of an urban, western mountain health care system were recruited. Data were collected through primary interviews with patients, patient journaling with tablet computers, exit interviews with patients, and provider interviews. Data were analyzed qualitatively using a theory-driven approach and framework method of analysis. Results: The causes of gaps included clinician recommendations not fitting into patients’ daily routines, recommendations not fitting into patients’ living contexts, and information not transferred across settings. The consequences of these gaps included increased cognitive and physical workload on the patient, poor patient satisfaction, and compromised adherence to the therapy plan. We identified resources and strategies used to overcome these consequences as patient-generated strategies, routines, collaborative management, social environment, and tools and technologies. Conclusions: Understanding gaps, their consequences, and mitigating strategies can lead to the development of interventions that help narrow these gaps. Such interventions could take the form of collaborative health information technologies, novel patient and clinician education initiatives, and programs that strongly integrate health systems and community resources. Current technologies are insufficient to narrow the gaps between clinical and daily living settings due to the limited number and types of routines that are tracked.

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Latest Submissions Open for Peer-Review:

View All Open Peer Review Articles
  • Teleconsultation in the management of elective orthopaedic and spinal conditions during the COVID-19 pandemic: A prospective cohort study of patient experiences

    Date Submitted: Feb 22, 2021

    Open Peer Review Period: Feb 22, 2021 - Apr 19, 2021

    Background: The global adoption of teleconsultation has been expedited as a result of the COVID-19 pandemic. By allowing remote communication, teleconsultation may help limit the spread of the virus w...

    Background: The global adoption of teleconsultation has been expedited as a result of the COVID-19 pandemic. By allowing remote communication, teleconsultation may help limit the spread of the virus while maintaining the crucial patient-provider relationship. Objective: To evaluate the value of teleconsultation compared to in-person visits in the management of elective orthopaedic and spinal procedures. Methods: This was a prospective observational cohort study of 853 patients receiving orthopaedic and spinal care at a private outpatient clinic in New Zealand. Patients were randomly divided into two groups: (1) patients receiving telephone consultation remotely; and (2) patients receiving in-person office consultations at the outpatient clinic. All patients received telephone consultations for four weeks during the mandated COVID-19 lockdown, followed by four weeks of telephone or in-person consultation. Patient preference, satisfaction, and duration of visit were recorded. Comparisons of patient preference between groups, visit type, sex, and location were performed using Chi-square tests; similarly, satisfaction scores and visit durations were compared using a general linear model. Results: We report that 91% of patients in the telephone group preferred teleconsultation over in-person office visits during the COVID-19 lockdown (p=0.000). A combined-group analysis shows that 55.3% of all patients preferred teleconsultation compared to 31.2% who preferred in-person office visits (p=0.000). Patients in the telephone group reported significantly higher satisfaction scores (9.95 +/- 0.04, 95% CI [9.87-10.03]) compared to patients in the in-person group (9.53 +/- 0.04, 95% CI [9.45-9.62]; p=0.000). Additionally, in-person consultations were significantly longer in duration compared to telephone consultations, with a mean visit time of 6.70 min +/-0.18, 95% CI [6.32-7.02] compared to 5.10 min +/-0.17, 95% CI [4.73-5.42], respectively (p=0.000). Conclusions: Patients who utilize telephone consultations are more likely to prefer it over traditional, in-person visits in the future. This increased preference, coupled with higher patient satisfaction scores and shorter duration of visits, suggests that teleconsultation has a role in orthopaedic surgery, which may even extend beyond the COVID-19 pandemic. Clinical Trial: N/A

  • Human-Technology Interaction Factors Associated with Electronic Personal Health Records (ePHRs) Use Among Younger and Older Adult Users: A Secondary Data Analysis

    Date Submitted: Feb 15, 2021

    Open Peer Review Period: Feb 15, 2021 - Apr 12, 2021

    Background: An electronic personal health record (ePHR), also known as a personal health record (PHR), was broadly defined as an electronic application through which individuals can access, manage, an...

    Background: An electronic personal health record (ePHR), also known as a personal health record (PHR), was broadly defined as an electronic application through which individuals can access, manage, and share their health information in a secure and confidential environment. Although ePHRs can benefit individuals as well as caregivers and healthcare providers, the use of ePHRs among individuals continues to remain low. The relationship between age and ePHRs use has been documented in previous studies, which indicated younger age was related to higher ePHRs use, and patients who are younger were more likely to use ePHRs. Objective: The current study aims to examine the relationship between human-technology interaction factors and ePHRs use among adults, and then compare the different effects of human-technology interaction factors on ePHRs use between younger adults (18-54 years old) and older adults (55 years of age and over). Methods: We analyzed the from the Health Information National Trends Survey (HINTS5, Cycle 3) collected from U.S. adults aged 18 years old and over in 2019. Descriptive analysis was conducted for all variables and each item of ePHRs use. Bivariate tests (Pearson test for categorical variable and F-test for continuous variables) were conducted over four age groups. Lastly, adjusting for socio-demographics and healthcare resources, a weighted multiple linear regression was conducted to examine the relationship between human-technology interaction factors and ePHRs use. Results: The final sample size was 1,363 and divided into two age groups: 18-54 years old and 55 years of age and older. The average level of ePHRs use was low (Mean=2.76, range=0-8). There is no significant difference on average ePHRs use between two age groups. Including clinical notes was positively related to ePHRs use in both groups: 18-54 years old (beta=0.28, P<0.01), 55 years old and above (beta=0.15, P<0.01). While accessing ePHRs using a smartphone app was only associated with ePHRs use among younger adults (beta=0.29, P<0.001), ease to understand health information in ePHRs was positively linked to ePHRs use only among older adults (beta=0.13, P<0.01). Conclusions: This study found that including clinical notes was positively related to ePHRs use in both age groups, which suggested that including clinical notes as a part of ePHRs might improve the effective use of ePHRs among patients. Moreover, accessing ePHRs using a smartphone app was associated with higher ePHRs use among younger adults while ease of understanding health information in ePHRs was linked to higher ePHRs use among older adults. The design of ePHRs should provide the option of being accessible through mobile devices to promote greater ePHRs use among young people. For older adults, providers could add additional notes to explain health information recorded in the ePHRs.

  • Anticipated benefits and concerns about sharing hospital outpatient visit notes with patients in the Netherlands: a mixed-methods study

    Date Submitted: Feb 5, 2021

    Open Peer Review Period: Feb 5, 2021 - Apr 2, 2021

    Background: The past few years have seen a rise in interest in sharing visit notes with patients, or "Open Notes". Objective: We sought to gather opinions about sharing outpatient clinic visit notes f...

    Background: The past few years have seen a rise in interest in sharing visit notes with patients, or "Open Notes". Objective: We sought to gather opinions about sharing outpatient clinic visit notes from patients and hospital physicians in the Netherlands, where there is currently no policy or incentive plan for shared visit notes. Methods: We conducted a survey of patients and doctors, as well as "think aloud" interviews to elicit more insight into the reasons behind participants' answers. Results: We surveyed 350 physicians and 90 patients, and interviews were conducted with an additional 13 physicians and 6 patients. A majority of patients (77%) were interested in viewing their visit notes, while a majority of physicians (82%) were opposed. A majority of patients (60%) expected the notes to be written in layman's language, but most physicians (60%) did not want to change their writing style to make it more understandable for patients. Doctors raised concerns that reading the note would make patients feel confused and anxious, that the patient would not understand the note, and that shared notes would result in more documentation time or losing a way to communicate with colleagues. Interviews also revealed concerns about documenting sensitive topics such as suspected abuse, and unlikely but worrisome differential diagnoses. Physicians also raised concerns about fragmenting the patient record. Patients also were uncertain if they would understand the notes (51%), and in interviews raised questions about security and privacy. Physicians did anticipate some benefits, such as better patient recall of the visit, shared decision-making, and keeping patients informed, but 24% indicated that they saw no benefit. Patients anticipated that they would remember the visit better, feel more in control, and better understand their health. Conclusions: Dutch patients are interested in shared visit notes, but physicians have many concerns which should be addressed if shared notes are pursued. In hospitals where shared notes are implemented, the effects should be monitored (objectively, if possible) to determine if the concerns raised by our participants have actualized into problems and whether the anticipated benefits are being realized. Clinical Trial: n/a

  • Accuracy Assessment of Oura Ring Nocturnal Heart Rate and Heart Rate Variability in Comparison to Electrocardiography: A Comprehensive Analysis in Time and Frequency Domains

    Date Submitted: Jan 26, 2021

    Open Peer Review Period: Jan 26, 2021 - Mar 26, 2021

    Background: Photoplethysmography (PPG) is a non-invasive and low-cost method to remotely and continuously track vital signs. The Oura ring is a compact PPG-based smart ring, which has recently drawn a...

    Background: Photoplethysmography (PPG) is a non-invasive and low-cost method to remotely and continuously track vital signs. The Oura ring is a compact PPG-based smart ring, which has recently drawn attention to be used in remote health monitoring and wellness applications. The ring is employed to acquire nocturnal heart rate (HR) and heart rate variability (HRV) parameters ubiquitously. However, these parameters are highly susceptible to motion artifacts and environmental noises. Therefore, the validity of the parameters should be assessed separately in everyday settings. Objective: We evaluate the accuracy of HR and time-domain and frequency-domain HRV parameters collected by the Oura ring against a medical-grade chest electrocardiogram (ECG) monitor. Methods: We conducted overnight home-based monitoring using an Oura ring and an ECG Shimmer device. The nocturnal HR and HRV of 35 healthy individuals were collected and assessed. We evaluated the parameters within two tests: i.e., values collected from five-minute recordings (i.e., short-term HRV analysis) and the average values per night sleep. A linear regression method, the Pearson correlation coefficient, and the Bland–Altman plot were also exploited to compare the measurements of two devices. Results: Our findings showed low mean biases of the HR and HRV parameters collected by the Oura ring in both the five-minute and average-per-night tests. In the five-minute test, the error variances of the parameters were nevertheless different. The parameters provided by the Oura ring dashboard (i.e., HR and RMSSD) showed relatively low error variance compared to the HRV parameters extracted from the IBI signals. The Pearson correlation coefficient tests (P < 0.0001) indicated that HR, RMSSD, AVNN, and pNN50 had high positive correlations with the baseline values, SDNN and HF had moderate positive correlations, and LF and LF/HF ratio had low positive correlations. The HR, RMSSD, AVNN, and pNN50 had narrow 95% confidence intervals; however, SDNN, LF, HF, and LF/HF had relatively wider 95% confidence intervals. In contrast, the average-per-night test showed that the HR, RMSSD, SDNN, AVNN, pNN50, LF, and HF had high positive relationships (P < 0.0001), and the LF/HF ratio has a moderate positive relationship (P < 0.0001). The average-per-night test also indicated considerably lower error variances than the 5-minute test for the parameters. Conclusions: The Oura ring could accurately measure nocturnal HR and RMSSD in both the five-minute and average-per-night tests. It provided acceptable nocturnal AVNN, pNN50, HF, and SDNN accuracy in the average-per-night test but not in the five-minute test. On the other hand, the LF and LF/HF of the ring had high error rates in both the tests.

  • Machine Learning Algorithms to Detect Subclinical Keratoconus: Systematic Review

    Date Submitted: Jan 25, 2021

    Open Peer Review Period: Jan 24, 2021 - Mar 21, 2021

    Background: Keratoconus is a disorder characterized by progressive thinning and distortion of the cornea. If detected at an early stage corneal collagen cross linking can prevent disease progression a...

    Background: Keratoconus is a disorder characterized by progressive thinning and distortion of the cornea. If detected at an early stage corneal collagen cross linking can prevent disease progression and further visual loss. Whilst advanced forms are easily detected, reliably identifying subclinical disease can be problematic. A number of different machine learning algorithms have been used to improve the detection of subclinical keratoconus based on the analysis of single or multiple clinical measures such as corneal imaging, aberrometry, or biomechanical measurements. Objective: To survey and critically evaluate the literature on algorithmic detection of subclinical keratoconus and equivalent definitions. Methods: We performed a structured search of the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Web of Science and Cochrane from Jan 1, 2010 to Oct 31, 2020. We included all full text studies that have used algorithms for the detection of subclinical keratoconus. We excluded studies that did not perform validation. Results: We compared the parameters measured and the design of the machine learning algorithms reported in 26 papers that met the inclusion criteria. All salient information required for detailed comparison including diagnostic criteria, demographic data, sample size, acquisition system, validation details, parameter inputs, machine learning algorithm and key results are reported in this study. Conclusions: Machine learning has the potential to improve the detection of subclinical keratoconus or early keratoconus in routine ophthalmic practice. Presently there is no consensus regarding the corneal parameters that should be included for assessment and the optimal design for the machine learning algorithm. We have identified avenues for further research to improve early detection and stratification of patients for early intervention to prevent disease progression. Clinical Trial: N/A

  • Systematic Review on glaucoma detection using generative adversarial networks: Coherent Taxonomy, Motivations, Open Challenges, Recommendations and New Research Direction in the emerging Covid19 pandemic

    Date Submitted: Jan 26, 2021

    Open Peer Review Period: Jan 24, 2021 - Mar 21, 2021

    Background: Glaucoma means irreversible blindness. Globally, it is the second retinal disease leading to blindness, just preceded by the cataract. Therefore, there is a great need to avoid the silent...

    Background: Glaucoma means irreversible blindness. Globally, it is the second retinal disease leading to blindness, just preceded by the cataract. Therefore, there is a great need to avoid the silent growth of such disease using the recently developed Generative Adversarial Networks(GANs). Objective: This paper aims to introduce GAN technology for the diagnosis of eye disorders, particularly glaucoma. This paper illustrates deep adversarial learning as a potential diagnostic tool and the challenges involved in its implementation. This study describes and analyzes many of the pitfalls and problems that researchers will need to overcome in order to implement this kind of technology. Methods: To organize this review comprehensively, we used the keywords: ("Glaucoma", "optic disc", "blood vessels") and ("receptive field", "loss function", "GAN", "Generative Adversarial Network", "Deep learning", "CNN", "convolutional neural network" OR encoder), in different variations to gather all the relevant articles from five highly reputed databases: IEEE Xplore, Web of Science, Scopus, Science Direct, and Pubmed. These libraries broadly cover technical and medical literature. For the latest five years of publications, we only included those within that period. Researchers who used OCT or visual fields in their work were excluded. However, papers that used 2D images were included. A large-scale systematic analysis was performed, then a summary was generated. The study was conducted between March 2020 and November 2020. Results: We found 59 articles after a comprehensive survey of the literature. Among 59 articles, 29 present actual attempts to synthesize images and provide accurate segmentation/classification using single/multiple landmarks or share certain experiences. Twenty-nine journal articles discuss recent advances in generative adversarial networks, practical experiments, and analytical studies of retinal disease. Conclusions: Recent deep learning technique, namely generative adversarial network, has shown encouraging retinal disease detection performance. Although this methodology involves an extensive computing budget and optimization process, it saturates the greedy nature of deep learning techniques by synthesizing images and solves major medical issues. There is no existing systematic review paper on retinal disease utilizing generative adversarial networks to the extent of our knowledge. Two paper sets were reported; the first involves surveys on the recent development of GANs or overviews of papers reported in the literature applying machine learning techniques on retinal diseases. While in the second group, researchers have sought to establish and enhance the detection process through generating as real as possible synthetic images with the assistance of GANs. This paper contributes to this research field by offering a thorough analysis of existing works, highlighting current limitations, and suggesting alternatives to support other researchers and participants to improve further and strengthen future work. Finally, the new directions of this research have been identified.