JMIR Publications

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  Physician and Health Services Rating...

  Mar 22, 2019

  Investigating the Effect of Paid and Free Feedback About Physicians' Telemedicine Services on Patients’ and Physicians’ Behaviors: Panel Data Analysis

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  Authors List:

  • Hualong Yang  
  • Xiaofei Zhang  

  Abstract:

  Background: In recent years, paid online patient-physician interaction has been incorporated into the telemedicine markets. With the development of telemedicine and telemedicine services, online feedback has been widely applied, helping other patients to identify quality services. Recently, in China, a new type of service feedback has been applied to the telemedicine markets, namely, paid feedback. Patients who are satisfied with a physician’s online service can buy a virtual gift or give a tip to the physicians. This paid feedback can improve the reliability of service feedback and reduce the proportion of false information because it increases the cost for feedback providers. Paid online feedback can benefit the physicians, such as by providing them with monetary incentives; however, research on the impacts and value of such paid feedback from the physician perspective in the telemedicine markets is scant. To fill this research gap, this study was designed to understand the role of paid feedback by developing a research model based on the theories of signaling and self-determination. Objective: This study aimed to explore the effects of free and paid feedback on patients’ choice and physicians’ behaviors as well as to investigate the substitute relationship between these 2 types of feedback in the telemedicine markets. Methods: A JAVA software program was used to collect online patient-doctor interaction data over a 6-month period from a popular telemedicine market in China (Good Physician Online). This study drew on a 2-equation panel model to test the hypotheses. Both fixed and random effect models were used to estimate the combined effects of paid feedback and free feedback on patients’ choice and physicians’ contribution. Finally, the Hausman test was adopted to investigate which model is better to explain our empirical results. Results: The results of this study show that paid feedback has a stronger effect on patients’ choice (a5=0.566; t2192 =9.160; P<.001) and physicians’ contribution (β4=1.332; t2193 =11.067; P<.001) in telemedicine markets than free feedback. Moreover, our research also proves that paid feedback and free feedback have a substitute relationship in determining patients’ and physicians’ behaviors (a6=−0.304; t2191 =−5.805; P<.001 and β5=−0.823; t2192 =−8.136; P<.001). Conclusions: Our findings contribute to the extant literature on service feedback in the telemedicine markets and provide insight for relevant stakeholders into how to design an effective feedback mechanism to improve patients’ service experience and physicians’ engagement.

  • J Med Internet Res 2019;21(3):e12156

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  Personal Health Records,...

  Mar 22, 2019

  The Role of Frontline Leaders in Building Health Professional Support for a New Patient Portal: Survey Study

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  Authors List:

  • Sari Kujala  
  • Iiris Hörhammer  
  • Tarja Heponiemi  
  • Kim Josefsson  

  Abstract:

  Background: Effective leadership and change management are thought to contribute to the successful implementation of health information technology innovations. However, limited attention has been paid to the role of frontline leaders in building health professional support for new technical innovations. Objective: First, we examined whether frontline leaders’ positive expectations of a patient portal and perceptions of its implementation were associated with their support for the portal. Second, we explored whether leaders’ positive perceptions influenced the same unit’s health professional support for the portal. Methods: Data were collected through an online survey of 2067 health professionals and 401 frontline leaders working in 44 units from 14 health organizations in Finland. The participating organizations run a joint self-care and digital value services project developing a new patient portal for self-management. The survey was conducted before the piloting and implementation of the patient portal. Results: The frontline leaders’ perception of vision clarity had the strongest association with their own support for the portal (ß=.40, P<.001). Results also showed an association between leaders’ view of organizational readiness and their support (ß=.15, P=.04). The leaders’ positive perceptions of the quality of informing about the patient portal was associated with both leaders’ own (ß=.16, P=.02) and subordinate health professionals’ support for the portal (ß=.08, P<.001). Furthermore, professional participation in the planning of the portal was positively associated with their support (ß=.57, P<.001). Conclusions: Findings suggest that assuring good informing, communicating a clear vision to frontline leaders, and acknowledging organizational readiness for change can increase health professional support for electronic health (eHealth) services in the pre-implementation phase. Results highlight the role of frontline leaders in engaging professionals in the planning and implementation of eHealth services and in building health professionals’ positive attitudes toward the implementation of eHealth services.

  • J Med Internet Res 2019;21(3):e11413

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  Electronic/Mobile Data Capture,...

  Mar 22, 2019

  A Web-Based Form With Interactive Charts Used to Collect and Analyze Data on Home Births in Italy

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  Authors List:

  • Michele Zanetti  
  • Rita Campi  
  • Paola Olivieri  
  • Marta Campiotti  
  • Alice Faggianelli  
  • Maurizio Bonati  

  Abstract:

  Background: The use of Web-based forms and data analysis can improve the collection and visualization of data in clinical research. In Italy, no register exists that collects clinical data concerning home births. Objective: The purpose of this study was (1) to develop a Web portal to collect, through a Web-based form, data on home births in Italy and (2) to provide those interested with a graphic visualization of the analyses and data collected. Methods: Following the World Health Organization’s guidelines, and adding questions based on scientific evidence, the case report form (CRF) on the online form was drafted by midwives of the National Association of Out-of-Hospital Birth Midwives. During an initial phase, a group of midwives (n=10) tested the CRF, leading to improvements and adding the necessary questions to achieve a CRF that would allow a more complete collection of data. After the test phase, the entire group of midwives (n=166) registered themselves on the system and began filling out birth questionnaires. In a subsequent phase, the administrators of the portal were able to view the completed forms in a graphic format through the use of interactive maps and graphs. Results: From 2014 to 2016, 58 midwives included 599 birth questionnaires via the Web portal; of these, 443 were home-based, 76% (321/424) of which were performed at home and 24% (103/424) at a midwifery unit. Most of the births assisted (79%, 335/424) were in northern Italy, and the average ages of the mother and father were 33.6 (SD 4.7) years and 37.0 (SD 5.6) years, respectively. Conclusions: We developed an innovative Web-based form that allows, for the first time in Italy, the collection of data on home births and births in the midwifery unit. Furthermore, the data collected are viewable online by the midwives through interactive maps and graphs that allow them to have a general and continuously updated view of the situation of out-of-hospital births performed by the National Association of Out-of-Hospital Birth Midwives. The future goal is to be able to expand this data collection to all out-of-hospital births throughout the national territory. With an increase in the number of enrolled midwives, it would be possible to use the portal as a Web-based form and also as a portal for sharing resources that would help midwives in their clinical practice.

  • J Med Internet Res 2019;21(3):e10335

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  E-Health / Health Services Research...

  Mar 21, 2019

  Associations Between the Use of eHealth and Out-of-Hours Services in People With Type 1 Diabetes: Cross-Sectional Study

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  Authors List:

  • Anne Helen Hansen  
  • Tor Claudi  
  • Eirik Årsand  

  Abstract:

  Background: Despite the increasing prevalence of diabetes and the increasing use of eHealth, little is known about the association between provider-based health services and eHealth among people with diabetes. This is the second study in a project exploring the associations between the use of eHealth and the use of provider-based health services. Objective: The objective of this study was to investigate which eHealth services are used among out-of-hours (OOH) visitors with type 1 diabetes (T1D), and whether the use of eHealth (eg, apps, search engines, video services, and social media) was associated with the use of OOH services. We also wanted to investigate associations between anxiety, reassurance, and change in doctor-seeking behavior because of health information acquired from the Internet, and the use of OOH services. Methods: We used data from a 2018 email survey of members of the Norwegian Diabetes Association (18-89 years old). Respondents with T1D were eligible for analyses. Using descriptive statistics, we estimated the use of OOH services and eHealth. Using logistic regressions, we studied the associations between the use of OOH services and the use of eHealth, as well as associations between the use of OOH services and reported consequences of using Internet-based health information. Results: In the sample of 523 people with T1D (mean age 47 years), 26.7% (129/484) visited OOH services once or more during the previous year. Among the OOH visitors, search engines were used for health purposes by 86.7% (111/128), apps (health apps in general) by 63.6% (82/129), social media by 45.3% (58/128), and video services by 28.4% (36/127). The use of OOH services was positively associated with self-reported anxiety/depression (odds ratio [OR] 4.53, 95% CI 1.43-14.32) and with the use of apps (OR 1.73, 95% CI 1.05-2.85), but not with other types of eHealth. Those who had felt anxious based on information from the Internet were more likely to visit OOH services compared with those who had not felt anxious (OR 2.38, 95% CI 1.50-3.78). People who had decided to consult a doctor based on information from the Internet were more likely to visit OOH services (OR 2.76, 95% CI 1.64-4.66), compared to those who had not made such an Internet-based decision. Conclusions: People with T1D were frequent users of OOH services, and the OOH visitors were frequent users of eHealth. The use of OOH services was positively associated with the use of health apps, with self-reported anxiety/depression, and with feeling anxious based on information from the Internet. Likewise, deciding to consult a doctor based on information from the Internet was positively associated with OOH visits. The use of eHealth seems to have a significant impact on people with T1D.

  • J Med Internet Res 2019;21(3):e13465

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  General Original Articles (Editor: G....

  Mar 21, 2019

  Experiences With Video Consultations in Specialized Palliative Home-Care: Qualitative Study of Patient and Relative Perspectives

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  Authors List:

  • Karen Frydenrejn Funderskov  
  • Mette Raunkiær  
  • Dorthe Boe Danbjørg  
  • Ann-Dorthe Zwisler  
  • Lene Munk  
  • Mia Jess  
  • Karin Brochstedt Dieperink  

  Abstract:

  Background: The work of specialized palliative care (SPC) teams is often challenged by substantial amounts of time spent driving to and from patients’ homes and long distances between the patients and the hospitals. Objective: Video consultations may be a solution for real-time SPC at home. The aim of this study was to explore the use of video consultations, experienced by patients and their relatives, as part of SPC at home. Methods: This explorative and qualitative study included palliative care patients in different stages and relatives to use video consultations as a part of their SPC between October 2016 and March 2017. Data collection took place in the patients’ homes and consisted of participant observations followed by semistructured interviews. Inclusion criteria consisted of patients with the need for SPC, aged more than 18 years, who agreed to participate, and relatives wanting to participate in the video consultations. Data were analyzed with Giorgi’s descriptive phenomenological methodology. Results: A number of patients (n=11) and relatives (n=3) were included and, in total, 86 video consultations were conducted. Patients participating varied in time from 1 month to 6 months, and the number of video consultations per patient varied from 3 to 18. The use of video consultations led to a situation where patients, despite life-threatening illnesses and technical difficulties, took an active role. In addition, relatives were able to join on equal terms, which increased active involvement. The patients had different opinions on when to initiate the use of video consultations in SPC; it was experienced as optional at the initiating stage as well as the final stage of illness. If the video consultations included multiple participants from the SPC team, the use of video consultations could be difficult to complete without interruptions. Conclusions: Video consultations in SPC for home-based patients are feasible and facilitate a strengthened involvement and communication between patients, relatives, and SPC team members.

  • J Med Internet Res 2019;21(3):e10208

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  Mobile Health (mhealth)

  Mar 20, 2019

  The Association Between Medication Adherence for Chronic Conditions and Digital Health Activity Tracking: Retrospective Analysis

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  Authors List:

  • Tom Quisel  
  • Luca Foschini  
  • Susan M Zbikowski  
  • Jessie L Juusola  

  Abstract:

  Background: Chronic diseases have a widespread impact on health outcomes and costs in the United States. Heart disease and diabetes are among the biggest cost burdens on the health care system. Adherence to medication is associated with better health outcomes and lower total health care costs for individuals with these conditions, but the relationship between medication adherence and health activity behavior has not been explored extensively. Objective: The aim of this study was to examine the relationship between medication adherence and health behaviors among a large population of insured individuals with hypertension, diabetes, and dyslipidemia. Methods: We conducted a retrospective analysis of health status, behaviors, and medication adherence from medical and pharmacy claims and health behavior data. Adherence was measured in terms of proportion of days covered (PDC), calculated from pharmacy claims using both a fixed and variable denominator methodology. Individuals were considered adherent if their PDC was at least 0.80. We used step counts, sleep, weight, and food log data that were transmitted through devices that individuals linked. We computed metrics on the frequency of tracking and the extent to which individuals engaged in each tracking activity. Finally, we used logistic regression to model the relationship between adherent status and the activity-tracking metrics, including age and sex as fixed effects. Results: We identified 117,765 cases with diabetes, 317,340 with dyslipidemia, and 673,428 with hypertension between January 1, 2015 and June 1, 2016 in available data sources. Average fixed and variable PDC for all individuals ranged from 0.673 to 0.917 for diabetes, 0.756 to 0.921 for dyslipidemia, and 0.756 to 0.929 for hypertension. A subgroup of 8553 cases also had health behavior data (eg, activity-tracker data). On the basis of these data, individuals who tracked steps, sleep, weight, or diet were significantly more likely to be adherent to medication than those who did not track any activities in both the fixed methodology (odds ratio, OR 1.33, 95% CI 1.29-1.36) and variable methodology (OR 1.37, 95% CI 1.32-1.43), with age and sex as fixed effects. Furthermore, there was a positive association between frequency of activity tracking and medication adherence. In the logistic regression model, increasing the adjusted tracking ratio by 0.5 increased the fixed adherent status OR by a factor of 1.11 (95% CI 1.06-1.16). Finally, we found a positive association between number of steps and adherent status when controlling for age and sex. Conclusions: Adopters of digital health activity trackers tend to be more adherent to hypertension, diabetes, and dyslipidemia medications, and adherence increases with tracking frequency. This suggests that there may be value in examining new ways to further promote medication adherence through programs that incentivize health tracking and leveraging insights derived from connected devices to improve health outcomes.

  • J Med Internet Res 2019;21(3):e11486

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  Artificial Intelligence (other than...

  Mar 20, 2019

  Artificial Intelligence and the Future of Primary Care: Exploratory Qualitative Study of UK General Practitioners’ Views

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  Authors List:

  • Charlotte Blease  
  • Ted J Kaptchuk  
  • Michael H Bernstein  
  • Kenneth D Mandl  
  • John D Halamka  
  • Catherine M DesRoches  

  Abstract:

  Background: The potential for machine learning to disrupt the medical profession is the subject of ongoing debate within biomedical informatics and related fields. Objective: This study aimed to explore general practitioners’ (GPs’) opinions about the potential impact of future technology on key tasks in primary care. Methods: In June 2018, we conducted a Web-based survey of 720 UK GPs’ opinions about the likelihood of future technology to fully replace GPs in performing 6 key primary care tasks, and, if respondents considered replacement for a particular task likely, to estimate how soon the technological capacity might emerge. This study involved qualitative descriptive analysis of written responses (“comments”) to an open-ended question in the survey. Results: Comments were classified into 3 major categories in relation to primary care: (1) limitations of future technology, (2) potential benefits of future technology, and (3) social and ethical concerns. Perceived limitations included the beliefs that communication and empathy are exclusively human competencies; many GPs also considered clinical reasoning and the ability to provide value-based care as necessitating physicians’ judgments. Perceived benefits of technology included expectations about improved efficiencies, in particular with respect to the reduction of administrative burdens on physicians. Social and ethical concerns encompassed multiple, divergent themes including the need to train more doctors to overcome workforce shortfalls and misgivings about the acceptability of future technology to patients. However, some GPs believed that the failure to adopt technological innovations could incur harms to both patients and physicians. Conclusions: This study presents timely information on physicians’ views about the scope of artificial intelligence (AI) in primary care. Overwhelmingly, GPs considered the potential of AI to be limited. These views differ from the predictions of biomedical informaticians. More extensive, stand-alone qualitative work would provide a more in-depth understanding of GPs’ views.

  • J Med Internet Res 2019;21(3):e12802

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  Innovations and Technology for...

  Mar 19, 2019

  Can Smartphone Apps Increase Physical Activity? Systematic Review and Meta-Analysis

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  Authors List:

  • Amelia Romeo  
  • Sarah Edney  
  • Ronald Plotnikoff  
  • Rachel Curtis  
  • Jillian Ryan  
  • Ilea Sanders  
  • Alyson Crozier  
  • Carol Maher  

  Abstract:

  Background: Smartphone apps are a promising tool for delivering accessible and appealing physical activity interventions. Given the large growth of research in this field, there are now enough studies using the “gold standard” of experimental design—the randomized controlled trial design—and employing objective measurements of physical activity, to support a meta-analysis of these scientifically rigorous studies. Objective: This systematic review and meta-analysis aimed to determine the effectiveness of smartphone apps for increasing objectively measured physical activity in adults. Methods: A total of 7 electronic databases (EMBASE, EmCare, MEDLINE, Scopus, Sport Discus, The Cochrane Library, and Web of Science) were searched from 2007 to January 2018. Following the Population, Intervention, Comparator, Outcome and Study Design format, studies were eligible if they were randomized controlled trials involving adults, used a smartphone app as the primary or sole component of the physical activity intervention, used a no- or minimal-intervention control condition, and measured objective physical activity either in the form of moderate-to-vigorous physical activity minutes or steps. Study quality was assessed using a 25-item tool based on the Consolidated Standards of Reporting Trials checklist. A meta-analysis of study effects was conducted using a random effects model approach. Sensitivity analyses were conducted to examine whether intervention effectiveness differed on the basis of intervention length, target behavior (physical activity alone vs physical activity in combination with other health behaviors), or target population (general adult population vs specific health populations). Results: Following removal of duplicates, a total of 6170 studies were identified from the original database searches. Of these, 9 studies, involving a total of 1740 participants, met eligibility criteria. Of these, 6 studies could be included in a meta-analysis of the effects of physical activity apps on steps per day. In comparison with the control conditions, smartphone apps produced a nonsignificant (P=.19) increase in participants’ average steps per day, with a mean difference of 476.75 steps per day (95% CI −229.57 to 1183.07) between groups. Sensitivity analyses suggested that physical activity programs with a duration of less than 3 months were more effective than apps evaluated across more than 3 months (P=.01), and that physical activity apps that targeted physical activity in isolation were more effective than apps that targeted physical activity in combination with diet (P=.04). Physical activity app effectiveness did not appear to differ on the basis of target population. Conclusions: This meta-analysis provides modest evidence supporting the effectiveness of smartphone apps to increase physical activity. To date, apps have been most effective in the short term (eg, up to 3 months). Future research is needed to understand the time course of intervention effects and to investigate strategies to sustain intervention effects over time.

  • J Med Internet Res 2019;21(3):e12053

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  Theme Issue (2018): Cybersecurity in...

  Mar 19, 2019

  The Case for a Hippocratic Oath for Connected Medical Devices: Viewpoint

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  Authors List:

  • Beau Woods  
  • Andrea Coravos  
  • Joshua David Corman  

  Abstract:

  Prior to graduating from medical school, soon-to-be physicians take the Hippocratic Oath, a symbolic declaration to provide care in the best interest of patients. As the medical community increasingly deploys connected devices to deliver patient care, a critical question emerges: should the manufacturers and adopters of these connected technologies be governed by the symbolic spirit of the Hippocratic Oath? In 2016, I Am The Cavalry, a grassroots initiative from the cybersecurity research community, published the first Hippocratic Oath for Connected Medical Devices (HOCMD), containing 5 principles. Over the past three years, the HOCMD has gained broad support and influenced regulatory policy. We introduce 5 case studies of the HOCMD in practice, illustrating how the 5 principles can lead to a safer and more effective adoption of connected medical technologies.

  • J Med Internet Res 2019;21(3):e12568

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  Viewpoint

  Mar 19, 2019

  A Human(e) Factor in Clinical Decision Support Systems

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  Authors List:

  • Tim Bezemer  
  • Mark C H de Groot  
  • Enja Blasse  
  • Maarten J ten Berg  
  • Teus H Kappen  
  • Annelien L Bredenoord  
  • Wouter W van Solinge  
  • Imo E Hoefer  
  • Saskia Haitjema  

  Abstract:

  The overwhelming amount, production speed, multidimensionality, and potential value of data currently available—often simplified and referred to as big data —exceed the limits of understanding of the human brain. At the same time, developments in data analytics and computational power provide the opportunity to obtain new insights and transfer data-provided added value to clinical practice in real time. What is the role of the health care professional in collaboration with the data scientist in the changing landscape of modern care? We discuss how health care professionals should provide expert knowledge in each of the stages of clinical decision support design: data level, algorithm level, and decision support level. Including various ethical considerations, we advocate for health care professionals to responsibly initiate and guide interprofessional teams, including patients, and embrace novel analytic technologies to translate big data into patient benefit driven by human(e) values.

  • J Med Internet Res 2019;21(3):e11732

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  e-Learning and Medical Education

  Mar 19, 2019

  WeChat as a Platform for Problem-Based Learning in a Dental Practical Clerkship: Feasibility Study

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  Authors List:

  • Wei Zhang  
  • Zheng-Rong Li  
  • Zhi Li  

  Abstract:

  Background: Problem-Based-Learning (PBL) has been widely accepted in student-centered medical education. Since WeChat is the most popular communication app in China, we have chosen to use WeChat as new platform for online PBL in order to reduce the limitations of traditional PBL in dental practical clerkships. Objective: This study aims to demonstrate the feasibility and acceptability of online PBL using WeChat (WeChat-PBL) in a dental practical clerkship. Methods: A total of 72 students in a dental practical clerkship and 10 tutors participated in this study from June to August 2017. We created 10 WeChat groups to provide a communication platform for the PBL teaching, in which the students selected the PBL cases themselves from their practical clerkship. After each individual PBL case, group members were required to complete an evaluation on the PBL process itself. A final questionnaire survey was completed by the participants to summarize the long-term evaluation of the whole WeChat-PBL experience after the 3-month clerkship. Data from the PBL cases, WeChat messages, periodic evaluations, and long-term evaluations were collected for analysis. Results: There were 45 cases presented in the WeChat-PBL within the 3-month clerkship. All students had positive reactions to the communication within the PBL groups. The results of the periodic evaluation showed that the students and tutors were quite satisfied with the process of WeChat-PBL and appreciated the group members’ contributions and performance. The final questionnaire results indicated that the WeChat-PBL had achieved positive effects. Conclusions: The results of this study indicate the feasibility and acceptability of the app, WeChat, for problem-based learning in a dental practical clerkship.

  • J Med Internet Res 2019;21(3):e12127

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  e-Learning and Medical Education

  Mar 18, 2019

  Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial

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  Authors List:

  • José Miguel Padilha  
  • Paulo Puga Machado  
  • Ana Ribeiro  
  • José Ramos  
  • Patrício Costa  

  Abstract:

  Background: In the field of health care, knowledge and clinical reasoning are key with regard to quality and confidence in decision making. The development of knowledge and clinical reasoning is influenced not only by students’ intrinsic factors but also by extrinsic factors such as satisfaction with taught content, pedagogic resources and pedagogic methods, and the nature of the objectives and challenges proposed. Nowadays, professors play the role of learning facilitators rather than simple “lecturers” and face students as active learners who are capable of attributing individual meanings to their personal goals, challenges, and experiences to build their own knowledge over time. Innovations in health simulation technologies have led to clinical virtual simulation. Clinical virtual simulation is the recreation of reality depicted on a computer screen and involves real people operating simulated systems. It is a type of simulation that places people in a central role through their exercising of motor control skills, decision skills, and communication skills using virtual patients in a variety of clinical settings. Clinical virtual simulation can provide a pedagogical strategy and can act as a facilitator of knowledge retention, clinical reasoning, improved satisfaction with learning, and finally, improved self-efficacy. However, little is known about its effectiveness with regard to satisfaction, self-efficacy, knowledge retention, and clinical reasoning. Objective: This study aimed to evaluate the effect of clinical virtual simulation with regard to knowledge retention, clinical reasoning, self-efficacy, and satisfaction with the learning experience among nursing students. Methods: A randomized controlled trial with a pretest and 2 posttests was carried out with Portuguese nursing students (N=42). The participants, split into 2 groups, had a lesson with the same objectives and timing. The experimental group (n=21) used a case-based learning approach, with clinical virtual simulator as a resource, whereas the control group (n=21) used the same case-based learning approach, with recourse to a low-fidelity simulator and a realistic environment. The classes were conducted by the usual course lecturers. We assessed knowledge and clinical reasoning before the intervention, after the intervention, and 2 months later, with a true or false and multiple-choice knowledge test. The students’ levels of learning satisfaction and self-efficacy were assessed with a Likert scale after the intervention. Results: The experimental group made more significant improvements in knowledge after the intervention (P=.001; d=1.13) and 2 months later (P=.02; d=0.75), and it also showed higher levels of learning satisfaction (P<.001; d=1.33). We did not find statistical differences in self-efficacy perceptions (P=.9; d=0.054). Conclusions: The introduction of clinical virtual simulation in nursing education has the potential to improve knowledge retention and clinical reasoning in an initial stage and over time, and it increases the satisfaction with the learning experience among nursing students.

  • J Med Internet Res 2019;21(3):e11529

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