JMIR Publications

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 26, 2021

  Influence of Health Beliefs on Adherence to COVID-19 Preventative Practices: International, Social Media–Based Survey Study

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  Authors List:

  • Julianna C Hsing  
  • Jasmin Ma  
  • Alejandra Barrero-Castillero  
  • Shilpa G Jani  
  • Uma Palam Pulendran  
  • Bea-Jane Lin  
  • Monika Thomas-Uribe  
  • C Jason Wang  

  Abstract:

  Background: Health behavior is influenced by culture and social context. However, there are limited data evaluating the scope of these influences on COVID-19 response. Objective: This study aimed to compare handwashing and social distancing practices in different countries and evaluate practice predictors using the health belief model (HBM). Methods: From April 11 to May 1, 2020, we conducted an online, cross-sectional survey disseminated internationally via social media. Participants were adults aged 18 years or older from four different countries: the United States, Mexico, Hong Kong (China), and Taiwan. Primary outcomes were self-reported handwashing and social distancing practices during COVID-19. Predictors included constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. Associations of these constructs with behavioral outcomes were assessed by multivariable logistic regression. Results: We analyzed a total of 71,851 participants, with 3070 from the United States, 3946 from Mexico, 1201 from Hong Kong (China), and 63,634 from Taiwan. Of these countries, respondents from the United States adhered to the most social distancing practices (χ²₃=2169.7, P<.001), while respondents from Taiwan performed the most handwashing (χ²₃=309.8, P<.001). Multivariable logistic regression analyses indicated that self-efficacy was a positive predictor for handwashing (odds ratio [OR]_{United States} 1.58, 95% CI 1.21-2.07; OR_Mexico 1.5, 95% CI 1.21-1.96; OR_{Hong Kong} 2.48, 95% CI 1.80-3.44; OR_Taiwan 2.30, 95% CI 2.21-2.39) and social distancing practices (OR_{United States} 1.77, 95% CI 1.24-2.49; OR_Mexico 1.77, 95% CI 1.40-2.25; OR_{Hong Kong} 3.25, 95% CI 2.32-4.62; OR_Taiwan 2.58, 95% CI 2.47-2.68) in all countries. Handwashing was positively associated with perceived susceptibility in Mexico, Hong Kong, and Taiwan, while social distancing was positively associated with perceived severity in the United States, Mexico, and Taiwan. Conclusions: Social media recruitment strategies can be used to reach a large audience during a pandemic. Self-efficacy was the strongest predictor for handwashing and social distancing. Policies that address relevant health beliefs can facilitate adoption of necessary actions for preventing COVID-19. Our findings may be explained by the timing of government policies, the number of cases reported in each country, individual beliefs, and cultural context.

  • J Med Internet Res 2021;23(2):e23720

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 26, 2021

  Using Automated Machine Learning to Predict the Mortality of Patients With COVID-19: Prediction Model Development Study

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  Authors List:

  • Kenji Ikemura  
  • Eran Bellin  
  • Yukako Yagi  
  • Henny Billett  
  • Mahmoud Saada  
  • Katelyn Simone  
  • Lindsay Stahl  
  • James Szymanski  
  • D Y Goldstein  
  • Morayma Reyes Gil  

  Abstract:

  Background: During a pandemic, it is important for clinicians to stratify patients and decide who receives limited medical resources. Machine learning models have been proposed to accurately predict COVID-19 disease severity. Previous studies have typically tested only one machine learning algorithm and limited performance evaluation to area under the curve analysis. To obtain the best results possible, it may be important to test different machine learning algorithms to find the best prediction model. Objective: In this study, we aimed to use automated machine learning (autoML) to train various machine learning algorithms. We selected the model that best predicted patients’ chances of surviving a SARS-CoV-2 infection. In addition, we identified which variables (ie, vital signs, biomarkers, comorbidities, etc) were the most influential in generating an accurate model. Methods: Data were retrospectively collected from all patients who tested positive for COVID-19 at our institution between March 1 and July 3, 2020. We collected 48 variables from each patient within 36 hours before or after the index time (ie, real-time polymerase chain reaction positivity). Patients were followed for 30 days or until death. Patients’ data were used to build 20 machine learning models with various algorithms via autoML. The performance of machine learning models was measured by analyzing the area under the precision-recall curve (AUPCR). Subsequently, we established model interpretability via Shapley additive explanation and partial dependence plots to identify and rank variables that drove model predictions. Afterward, we conducted dimensionality reduction to extract the 10 most influential variables. AutoML models were retrained by only using these 10 variables, and the output models were evaluated against the model that used 48 variables. Results: Data from 4313 patients were used to develop the models. The best model that was generated by using autoML and 48 variables was the stacked ensemble model (AUPRC=0.807). The two best independent models were the gradient boost machine and extreme gradient boost models, which had an AUPRC of 0.803 and 0.793, respectively. The deep learning model (AUPRC=0.73) was substantially inferior to the other models. The 10 most influential variables for generating high-performing models were systolic and diastolic blood pressure, age, pulse oximetry level, blood urea nitrogen level, lactate dehydrogenase level, D-dimer level, troponin level, respiratory rate, and Charlson comorbidity score. After the autoML models were retrained with these 10 variables, the stacked ensemble model still had the best performance (AUPRC=0.791). Conclusions: We used autoML to develop high-performing models that predicted the survival of patients with COVID-19. In addition, we identified important variables that correlated with mortality. This is proof of concept that autoML is an efficient, effective, and informative method for generating machine learning–based clinical decision support tools.

  • J Med Internet Res 2021;23(2):e23458

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 25, 2021

  Infection Control Behavior at Home During the COVID-19 Pandemic: Observational Study of a Web-Based Behavioral Intervention (Germ Defence)

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  Authors List:

  • Ben Ainsworth  
  • Sascha Miller  
  • James Denison-Day  
  • Beth Stuart  
  • Julia Groot  
  • Cathy Rice  
  • Jennifer Bostock  
  • Xiao-Yang Hu  
  • Katherine Morton  
  • Lauren Towler  
  • Michael Moore  
  • Merlin Willcox  
  • Tim Chadborn  
  • Natalie Gold  
  • Richard Amlôt  
  • Paul Little  
  • Lucy Yardley  

  Abstract:

  Background: To control the COVID-19 pandemic, people should adopt protective behaviors at home (self-isolation, social distancing, putting shopping and packages aside, wearing face coverings, cleaning and disinfecting, and handwashing). There is currently limited support to help individuals conduct these behaviors. Objective: This study aims to report current household infection control behaviors in the United Kingdom and examine how they might be improved. Methods: This was a pragmatic cross-sectional observational study of anonymous participant data from Germ Defence between May 6-24, 2020. Germ Defence is an open-access fully automated website providing behavioral advice for infection control within households. A total of 28,285 users sought advice from four website pathways based on household status (advice to protect themselves generally, to protect others if the user was showing symptoms, to protect themselves if household members were showing symptoms, and to protect a household member who is at high risk). Users reported current infection control behaviors within the home and intentions to change these behaviors. Results: Current behaviors varied across all infection control measures but were between sometimes (face covering: mean 1.61, SD 1.19; social distancing: mean 2.40, SD 1.22; isolating: mean 2.78, SD 1.29; putting packages and shopping aside: mean 2.75, SD 1.55) and quite often (cleaning and disinfecting: mean 3.17, SD 1.18), except for handwashing (very often: mean 4.00, SD 1.03). Behaviors were similar regardless of the website pathway used. After using Germ Defence, users recorded intentions to improve infection control behavior across all website pathways and for all behaviors (overall average infection control score mean difference 0.30, 95% CI 0.29-0.31). Conclusions: Self-reported infection control behaviors other than handwashing are lower than is optimal for infection prevention, although handwashing is much higher. Advice using behavior change techniques in Germ Defence led to intentions to improve these behaviors. Promoting Germ Defence within national and local public health and primary care guidance could reduce COVID-19 transmission.

  • J Med Internet Res 2021;23(2):e22197

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 25, 2021

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

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  Authors List:

  • Myoungsoon You  
  • Minjung Lee  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e24165

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 25, 2021

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

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  Authors List:

  • Alberto M Borobia  
  • Irene García-García  
  • Lucía Díaz-García  
  • Amelia Rodríguez-Mariblanca  
  • Lucía Martínez de Soto  
  • Jaime Monserrat Villatoro  
  • Enrique Seco Meseguer  
  • Juan J González  
  • Jesús Frías Iniesta  
  • Elena Ramírez García  
  • Jose Ramón Arribas  
  • Antonio J Carcas-Sansuán  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e23441

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 25, 2021

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

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  Authors List:

  • Madhavan Parthasarathy  
  • Jiban Khuntia  
  • Rulon Stacey  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e23658

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 25, 2021

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

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  Authors List:

  • Raylene Paludneviciene  
  • Tracy Knight  
  • Gideon Firl  
  • Kaela Luttrell  
  • Kota Takayama  
  • Poorna Kushalnagar  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e21103

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  New Methods

  Feb 25, 2021

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

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  Authors List:

  • Guanjian Li  
  • Weiran Li  
  • Bing Song  
  • Chao Wang  
  • Qunshan Shen  
  • Bo Li  
  • Dongdong Tang  
  • Chuan Xu  
  • Hao Geng  
  • Yang Gao  
  • Guanxiong Wang  
  • Huan Wu  
  • Zhiguo Zhang  
  • Xiaofeng Xu  
  • Ping Zhou  
  • Zhaolian Wei  
  • Xiaojin He  
  • Yunxia Cao  

  Abstract:

  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; http://www.chictr.org.cn/showproj.aspx?proj=34267

  • J Med Internet Res 2021;23(2):e25342

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  JMIR Theme Issue 2020/21: COVID-19...

  Feb 25, 2021

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

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  Authors List:

  • Muhammed Elhadi  
  • Ahmed Elhadi  
  • Ahmad Bouhuwaish  
  • Fatimah Bin Alshiteewi  
  • Amna Elmabrouk  
  • Ali Alsuyihili  
  • Ayiman Alhashimi  
  • Samer Khel  
  • Alsafa Elgherwi  
  • Ahmed Alsoufi  
  • Ahmed Albakoush  
  • Abdulmuez Abdulmalik  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e20812

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  Consumer & Patient Education and...

  Feb 25, 2021

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

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  Authors List:

  • Afnan Abdulnasir Sabgul  
  • Ameerah M N Qattan  
  • Rubayyat Hashmi  
  • Mohammed Khaled Al-Hanawi  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e25404

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  Ethics, Privacy, and Legal Issues

  Feb 25, 2021

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

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  Authors List:

  • James Scheibner  
  • Jean Louis Raisaro  
  • Juan Ramón Troncoso-Pastoriza  
  • Marcello Ienca  
  • Jacques Fellay  
  • Effy Vayena  
  • Jean-Pierre Hubaux  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e25120

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  Personal Health Records,...

  Feb 25, 2021

  Quantifying Patient Portal Use: Systematic Review of Utilization Metrics

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  Authors List:

  • Lauren L Beal  
  • Jacob M Kolman  
  • Stephen L Jones  
  • Aroub Khleif  
  • Terri Menser  

  Abstract:

  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.

  • J Med Internet Res 2021;23(2):e23493

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