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Journal Description

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

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

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

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


Recent Articles:

  • Digital recruitment invitation for participation in a stepwise model for prevention of chronic diseases (montage). Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Digital Recruitment and Acceptance of a Stepwise Model to Prevent Chronic Disease in the Danish Primary Care Sector: Cross-Sectional Study


    Background: During recent years, stepwise approaches to health checks have been advanced as an alternative to general health checks. In 2013, we set up the Early Detection and Prevention project (Tidlig Opsporing og Forebyggelse, TOF) to develop a stepwise approach aimed at patients at high or moderate risk of a chronic disease. A novel feature was the use of a personal digital mailbox for recruiting participants. A personal digital mailbox is a secure digital mailbox provided by the Danish public authorities. Apart from being both safe and secure, it is a low-cost, quick, and easy way to reach Danish residents. Objective: In this study we analyze the association between the rates of acceptance of 2 digital invitations sent to a personal digital mailbox and the sociodemographic determinants, medical treatment, and health care usage in a stepwise primary care model for the prevention of chronic diseases. Methods: We conducted a cross-sectional analysis of the rates of acceptance of 2 digital invitations sent to randomly selected residents born between 1957 and 1986 and residing in 2 Danish municipalities. The outcome was acceptance of the 2 digital invitations. Statistical associations were determined by Poisson regression. Data-driven chi-square automatic interaction detection method was used to generate a decision tree analysis, predicting acceptance of the digital invitations. Results: A total of 8814 patients received an invitation in their digital mailbox from 47 general practitioners. A total of 40.22% (3545/8814) accepted the first digital invitation, and 30.19 % (2661/8814) accepted both digital invitations. The rates of acceptance of both digital invitations were higher among women, older patients, patients of higher socioeconomic status, and patients not diagnosed with or being treated for diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular disease. Conclusions: To our knowledge, this is the first study to report on the rates of acceptance of digital invitations to participate in a stepwise model for prevention of chronic diseases. More studies of digital invitations are needed to determine if the acceptance rates seen in this study should be expected from future studies as well. Similarly, more research is needed to determine whether a multimodal recruitment approach, including digital invitations to personal digital mailboxes will reach hard-to-reach subpopulations more effectively than digital invitations only.

  • JustMakeSense Campaign. Source: JustMakeSense Campaign; Copyright: BC Centre for Disease Control; URL:; License: Licensed by the authors.

    Assessing the Impact of a Social Marketing Campaign on Program Outcomes for Users of an Internet-Based Testing Service for Sexually Transmitted and...


    Background: While social marketing (SM) campaigns can be effective in increasing testing for sexually transmitted and blood-borne infections (STBBIs), they are seldom rigorously evaluated and often rely on process measures (eg, Web-based ad click-throughs). With Web-based campaigns for internet-based health services, there is a potential to connect campaign process measures to program outcomes, permitting the assessment of venue-specific yield based on health outcomes (eg, click-throughs per test). Objective: This study aims to evaluate the impact of an SM campaign by the promotional venue on use and diagnostic test results of the internet-based STBBI testing service (GCO). Methods: Through GCO, clients create an account using an access code, complete a risk assessment, print a lab form, submit specimens at a lab, and get results online or by phone. From April to August 2015, a campaign promoted GCO to gay, bisexual, and other men who have sex with men in Vancouver, Canada. The campaign highlighted GCO’s convenience in 3 types of promotional venues—location advertisements in print or video displayed in gay venues or events, ads on a queer news website, and ads on geosocial websites and apps. Where feasible, individuals were tracked from campaign exposures to account creation and testing using venue-specific GCO access codes. In addition, Web-based ads were linked to alternate versions of the campaign website, which used URLs with embedded access codes to connect ad exposure to account creation. Furthermore, we examined the number of individuals creating GCO accounts, number tested, and cost per account created and test for each venue type. Results: Over 6 months, 177 people created a GCO account because of the campaign, where 22.0% (39/177) of these completed testing; the overall cost was Can $118 per account created and Can $533 per test. Ads on geosocial websites and apps accounted for 46.9% (83/177) of all accounts; ads on the news website had the lowest testing rate and highest cost per test. We observed variation between different geosocial websites and apps with some ads having high click-through rates yet low GCO account creation rates, and vice versa. Conclusions: Developing mechanisms to track individuals from Web-based exposure to SM campaigns to outcomes of internet-based health services permits greater evaluation of the yield and cost-effectiveness of different promotional efforts. Web-based ads with high click-through rates may not have a high conversion to service use, the ultimate outcome of SM campaigns.

  • Source: Unsplash; Copyright: Yiran Ding; URL:; License: Licensed by JMIR.

    Leading by Example: Web-Based Sexual Health Influencers Among Men Who Have Sex With Men Have Higher HIV and Syphilis Testing Rates in China


    Background: The spread of healthy behaviors through social networks may be accelerated by influential individuals. Previous studies have used lay health influencers to prevent sexually transmitted infections (STIs) among internet-using men who have sex with men (MSM). However, there is a lack of understanding of the characteristics of this key subset of MSM. Objective: This study aimed to examine sociodemographic characteristics, HIV and syphilis testing, and sexual behaviors of Web-based MSM sexual health influencers (SHIs) in China, defined as individuals with relatively stronger influence on spreading HIV and STI information online. Methods: A Web-based survey of MSM was conducted in August 2017 as a final follow-up of a randomized controlled trial promoting HIV testing in 8 Chinese cities. Men were recruited through a gay social networking mobile phone app and were included if they were born biologically male, aged 16 years and above, ever had sex with another man, and HIV negative or with unknown HIV status. Information regarding sociodemographic characteristics, sexual behaviors, and HIV and syphilis testing was obtained. We assessed men’s Web-based sexual health influence using a standardized 6-item opinion leadership scale focused on HIV and STI information. Influencers were defined as those whose mean score ranked within the top 13% (a higher score means greater influence). We used multivariable linear and logistic regression models to measure Web-based sexual health influence’s association with HIV and syphilis testing, controlling for intervention trial effects, age, education, income, and marital status. Results: Overall, 1031 men completed the survey. Most men were younger than 30 years (819/1031, 79.43%) and had at least college education (667/1031, 64.69%). Influencers were more likely to get tested for HIV (73/132, 55.3% vs 337/899, 37.5%; P<.001) and syphilis (35/132, 26.5% vs 137/899, 15.2%; P=.001) in the last 3 months compared with noninfluencers. There were no significant differences in condomless sex with male partners (26/132, 19.7% vs 203/899, 22.6%; P=.46), mean number of male sex partners (1.32 vs 1.11; P=.16) in the last 3 months, and mainly meeting male sex partners online in the last 12 months (97/132, 73.5% vs 669/899, 74.4%; P=.82) between influencers and noninfluencers. Regression analyses showed that influencers had higher odds of HIV testing (adjusted odds ratio, AOR 2.16, 95% CI 1.48-3.17) and syphilis testing (AOR 1.99, 95% CI 1.28-3.10) in the last 3 months. Conclusions: We identified Web-based SHIs who might be more likely to help promote healthy HIV and syphilis testing behaviors through MSM populations. Leveraging existing influencers may help improve HIV and syphilis testing among their networks.

  • A  3-step fall prevention process (montage). Source: Brigham and Women's Hospital / Smartmockups; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Assessing the Effectiveness of Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall...


    Background: Patient falls are a major problem in hospitals. The development of a Patient-Centered Fall Prevention Toolkit, Fall TIPS (Tailoring Interventions for Patient Safety), reduced falls by 25% in acute care hospitals by leveraging health information technology to complete the 3-step fall prevention process—(1) conduct fall risk assessments; (2) develop tailored fall prevention plans with the evidence-based interventions; and (3) consistently implement the plan. We learned that Fall TIPS was most effective when patients and family were engaged in all 3 steps of the fall prevention process. Over the past decade, our team developed 3 Fall TIPS modalities—the original electronic health record (EHR) version, a laminated paper version that uses color to provide clinical decision support linking patient-specific risk factors to the interventions, and a bedside display version that automatically populates the bedside monitor with the patients’ fall prevention plan based on the clinical documentation in the EHR. However, the relative effectiveness of each Fall TIPS modality for engaging patients and family in the 3-step fall prevention process remains unknown. Objective: This study aims to examine if the Fall TIPS modality impacts patient engagement in the 3-step fall prevention process and thus Fall TIPS efficacy. Methods: To assess patient engagement in the 3-step fall prevention process, we conducted random audits with the question, “Does the patient/family member know their fall prevention plan?” In addition, audits were conducted to measure adherence, defined by the presence of the Fall TIPS poster at the bedside. Champions from 3 hospitals reported data from April to June 2017 on 6 neurology and 7 medical units. Peer-to-peer feedback to reiterate the best practice for patient engagement was central to data collection. Results: Overall, 1209 audits were submitted for the patient engagement measure and 1401 for the presence of the Fall TIPS poster at the bedside. All units reached 80% adherence for both measures. While some units maintained high levels of patient engagement and adherence with the poster protocol, others showed improvement over time, reaching clinically significant adherence (>80%) by the final month of data collection. Conclusions: Each Fall TIPS modality effectively facilitates patient engagement in the 3-step fall prevention process, suggesting all 3 can be used to integrate evidence-based fall prevention practices into the clinical workflow. The 3 Fall TIPS modalities may prove an effective strategy for the spread, allowing diverse institutions to choose the modality that fits with the organizational culture and health information technology infrastructure.

  • Source: Flickr; Copyright: Ministerio de Ciencia; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    The Most Influential Medical Journals According to Wikipedia: Quantitative Analysis


    Background: Wikipedia, the multilingual encyclopedia, was founded in 2001 and is the world’s largest and most visited online general reference website. It is widely used by health care professionals and students. The inclusion of journal articles in Wikipedia is of scholarly interest, but the time taken for a journal article to be included in Wikipedia, from the moment of its publication to its incorporation into Wikipedia, is unclear. Objective: We aimed to determine the ranking of the most cited journals by their representation in the English-language medical pages of Wikipedia. In addition, we evaluated the number of days between publication of journal articles and their citation in Wikipedia medical pages, treating this measure as a proxy for the information-diffusion rate. Methods: We retrieved the dates when articles were included in Wikipedia and the date of journal publication from Crossref by using an application programming interface. Results: From 11,325 Wikipedia medical articles, we identified citations to 137,889 journal articles from over 15,000 journals. There was a large spike in the number of journal articles published in or after 2002 that were cited by Wikipedia. The higher the importance of a Wikipedia article, the higher was the mean number of journal citations it contained (top article, 48.13 [SD 33.67]; lowest article, 6.44 [SD 9.33]). However, the importance of the Wikipedia article did not affect the speed of reference addition. The Cochrane Database of Systematic Reviews was the most cited journal by Wikipedia, followed by The New England Journal of Medicine and The Lancet. The multidisciplinary journals Nature, Science, and the Proceedings of the National Academy of Sciences were among the top 10 journals with the highest Wikipedia medical article citations. For the top biomedical journal papers cited in Wikipedia's medical pages in 2016-2017, it took about 90 days (3 months) for the citation to be used in Wikipedia. Conclusions: We found evidence of “recentism,” which refers to preferential citation of recently published journal articles in Wikipedia. Traditional high-impact medical and multidisciplinary journals were extensively cited by Wikipedia, suggesting that Wikipedia medical articles have robust underpinnings. In keeping with the Wikipedia policy of citing reviews/secondary sources in preference to primary sources, the Cochrane Database of Systematic Reviews was the most referenced journal.

  • Crisis Text Line (montage). Source: Crisis Text Line / Smartmockups; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line


    Data sharing between technology companies and academic health researchers has multiple health care, scientific, social, and business benefits. Many companies remain wary about such sharing because of unaddressed concerns about ethics, data security, logistics, and public relations. Without guidance on these issues, few companies are willing to take on the potential work and risks involved in noncommercial data sharing, and the scientific and societal potential of their data goes unrealized. In this paper, we describe the 18-month long pilot of a data-sharing program led by Crisis Text Line (CTL), a not-for-profit technology company that provides a free 24/7 text line for people in crisis. The primary goal of the data-sharing pilot was to design, develop, and implement a rigorous framework of principles and protocols for the safe and ethical sharing of user data. CTL used a stakeholder-based policy process to develop a feasible and ethical data-sharing program. The process comprised forming a data ethics committee; identifying policy challenges and solutions; announcing the program and generating interest; and revising the policy and launching the program. Once the pilot was complete, CTL examined how well the program ran and compared it with other potential program models before putting in place the program that was most suitable for its organizational needs. By drawing on CTL’s experiences, we have created a 3-step set of guidelines for other organizations that wish to develop their own data-sharing program with academic researchers. The guidelines explain how to (1) determine the value and suitability of the data and organization for creating a data-sharing program; (2) decide on an appropriate data sharing and collaboration model; and (3) develop protocols and technical solutions for safe and ethical data sharing and the best organizational structure for implementing the program. An internal evaluation determined that the pilot satisfied CTL’s goals of sharing scientific data and protecting client confidentiality. The policy development process also yielded key principles and protocols regarding the ethical challenges involved in data sharing that can be applied by other organizations. Finally, CTL’s internal review of the pilot program developed a number of alternative models for sharing data that will suit a range of organizations with different priorities and capabilities. In implementing and studying this pilot program, CTL aimed both to optimize its own future data-sharing programs and to inform similar decisions made by others. Open data programs are both important and feasible to establish. With careful planning and appropriate resources, data sharing between big data companies and academic researchers can advance their shared mission to benefit society and improve lives.

  • The Power of Placebos website (montage). Source: University of Southampton / Smartmockups; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Informing Adults With Back Pain About Placebo Effects: Randomized Controlled Evaluation of a New Website With Potential to Improve Informed Consent in...


    Background: Placebo effects and their underpinning mechanisms are increasingly well understood. However, this is poorly communicated to participants in placebo-controlled trials. For valid informed consent, participants should be informed about the potential benefits and risks of participating in placebo-controlled trials. Existing information leaflets often fail to describe the potential benefits and adverse effects associated with placebo allocation. This study tested the effects of a new website designed to inform patients about placebo effects (The Power of Placebos, PoP). PoP was designed using qualitative methods in combination with theory- and evidence-based approaches to ensure it was engaging, informative, and addressed patients’ concerns. Objective: This study aimed to test the effects of PoP, compared with a control website, on people’s knowledge about placebo and the ability to make an informed choice about taking part in a placebo-controlled trial. Methods: A total of 350 adults with back pain recruited from 26 general practices in Southern England participated in this Web-based study. Participants were randomly assigned to PoP (which presented scientifically accurate information about placebo effects in an engaging way) or a control website (based on existing information leaflets from UK trials). Participants self-completed Web-based pre- and postintervention questionnaire measures of knowledge about placebo effects and preintervention questionnaire measures of attitudes toward and intentions to participate in a placebo-controlled trial. The 2 primary outcomes were (1) knowledge and (2) informed choice to take part in a placebo-controlled trial (computed from knowledge, attitudes, and intentions). Results: After viewing PoP, participants had significantly greater knowledge about placebos (mean 8.28 [SD 1.76]; n=158) than participants who viewed the control (mean 5.60 [SD 2.24]; n=174; F1,329=173.821; P<.001; η2=.346). Participants who viewed PoP were 3.16 times more likely than those who viewed the control to make an informed choice about placebos (χ21=36.5; P<.001). Conclusions: In a sample of adults with back pain, PoP increased knowledge and rates of informed choice about placebos compared with a control website. PoP could be used to improve knowledge about placebo effects in back pain. After essential further development and testing in clinical trial settings, it could support informed consent in placebo-controlled trials.

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

    The Absence of Evidence is Evidence of Non-Sense: Cross-Sectional Study on the Quality of Psoriasis-Related Videos on YouTube and Their Reception by Health...


    Background: Approximately 80% of internet users access health information online and patients with chronic illnesses especially rely on internet-based resources. YouTube ranks second among the most accessed websites worldwide and hosts an increasing number of videos with medical information. However, their quality is sometimes unscientific, misleading, or even harmful. Objective: As little is known about YouTube as a source of information on psoriasis, we aimed to investigate the quality of psoriasis-related videos and, if necessary, point out strategies for their improvement. Methods: The quality of the 100 most viewed psoriasis-related videos was assessed using the DISCERN instrument and the Global Quality Scale (GQS) by categorizing the videos into useful, misleading, and dangerous and by evaluating the reception of the videos by users. Results: Evaluation of the videos exhibited a total of 117,221,391 views and a total duration of 10:28 hour. The majority of clips contained anecdotal personal experiences with complementary and alternative psoriasis treatments, topical treatments, and nutrition and diets being the most frequently addressed topics. While advertisements accounted for 26.0% (26/100) of the videos, evidence-based health information amounted to only 20.0% (20/100); 32.0% (32/100) of the videos were classified as useful, 52.0% (52/100) as misleading, and 11.0% (11/100) as even dangerous. The quality of the videos evaluated by DISCERN and GQS was generally low (1.87 and 1.95, respectively, on a 1 to 5 scale with 5 being the maximum). Moreover, we found that viewers rated poor-quality videos better than higher quality videos. Conclusions: Our in-depth study demonstrates that nearly two-thirds of the psoriasis-related videos we analyzed disseminate misleading or even dangerous content. Subjective anecdotal and unscientific content is disproportionately overrepresented and poor-quality videos are predominantly rated positively by users, while higher quality video clips receive less positive ratings. Strategies by professional dermatological organizations are urgently needed to improve the quality of information on psoriasis on YouTube and other social media.

  • Price-per-unit feature on, which was one of the features tested in the study. Source: / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Measuring the Impact of an Open Web-Based Prescribing Data Analysis Service on Clinical Practice: Cohort Study on NHS England Data


    Background: OpenPrescribing is a freely accessible service that enables any user to view and analyze the National Health Service (NHS) primary care prescribing data at the level of individual practices. This tool is intended to improve the quality, safety, and cost-effectiveness of prescribing. Objective: We aimed to measure the impact of OpenPrescribing being viewed on subsequent prescribing. Methods: Having preregistered our protocol and code, we measured three different metrics of prescribing quality (mean percentile across 34 existing OpenPrescribing quality measures, available “price-per-unit” savings, and total “low-priority prescribing” spend) to see whether they changed after the viewing of Clinical Commissioning Group (CCG) and practice pages. We also measured whether practices whose data were viewed on OpenPrescribing differed in prescribing, prior to viewing, compared with those who were not. We used fixed-effects and between-effects linear panel regression to isolate change over time and differences between practices, respectively. We adjusted for the month of prescribing in the fixed-effects model to remove underlying trends in outcome measures. Results: We found a reduction in available price-per-unit savings for both practices and CCGs after their pages were viewed. The saving was greater at practice level (−£40.42 per thousand patients per month; 95% CI −54.04 to −26.81) than at CCG level (−£14.70 per thousand patients per month; 95% CI −25.56 to −3.84). We estimate a total saving since launch of £243 thosand at practice level and £1.47 million at CCG level between the feature launch and end of follow-up (August to November 2017) among practices viewed. If the observed savings from practices viewed were extrapolated to all practices, this would generate £26.8 million in annual savings for the NHS, approximately 20% of the total possible savings from this method. The other two measures were not different after CCGs or practices were viewed. Practices that were viewed had worse prescribing quality scores overall prior to viewing. Conclusions: We found a positive impact from the use of OpenPrescribing, specifically for the class of savings opportunities that can only be identified by using this tool. Furthermore, we show that it is possible to conduct a robust analysis of the impact of such a Web-based service on clinical practice.

  • NSFS researchers collect data. Source: Image created by the Authors; Copyright: Meagan Hanbury; URL:; License: Creative Commons Attribution (CC-BY).

    A Web-Based Application to Improve Data Collection in an Interventional Study Targeting Childhood Obesity: Pre-Post Analysis


    Background: Although participatory action research (PAR) studies have proliferated in recent years, the development of technological resources to manage these types of projects has not kept pace. Few studies show how Web-based applications can be used to efficiently manage the data collection process. Objective: This study described the development, use, and impact of a Web-based application to facilitate data management in Niños Sanos, Familia Sana (Healthy Children, Healthy Family), an interventional multifaceted PAR field study. Methods: We described the transformation of the data management process and evaluated the impact of the application in terms of time efficiency of data collection and engagement of community-based data collectors. We defined time efficiency as the total number of days it took to collect 3 main surveys, per year of data collection. The engagement of data collectors was assessed based on qualitative reports. Results: The amount of time it took to perform a round of data collection was reduced after implementation of the field team application (between 382 and 383 days and 198 and 233 days). Secondary data were also collected in a tighter time frame around collection of the primary outcome, and communication among data collectors, the field staff, and the research team was streamlined. In focus groups, community-based data collectors reported feeling more empowered and engaged in the data collection process after implementation of the application. Conclusions: A Web-based management application was successful in improving data collection time efficiency and engagement among data collectors.

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

    Improving Electronic Health Record Note Comprehension With NoteAid: Randomized Trial of Electronic Health Record Note Comprehension Interventions With...


    Background: Patient portals are becoming more common, and with them, the ability of patients to access their personal electronic health records (EHRs). EHRs, in particular the free-text EHR notes, often contain medical jargon and terms that are difficult for laypersons to understand. There are many Web-based resources for learning more about particular diseases or conditions, including systems that directly link to lay definitions or educational materials for medical concepts. Objective: Our goal is to determine whether use of one such tool, NoteAid, leads to higher EHR note comprehension ability. We use a new EHR note comprehension assessment tool instead of patient self-reported scores. Methods: In this work, we compare a passive, self-service educational resource (MedlinePlus) with an active resource (NoteAid) where definitions are provided to the user for medical concepts that the system identifies. We use Amazon Mechanical Turk (AMT) to recruit individuals to complete ComprehENotes, a new test of EHR note comprehension. Results: Mean scores for individuals with access to NoteAid are significantly higher than the mean baseline scores, both for raw scores (P=.008) and estimated ability (P=.02). Conclusions: In our experiments, we show that the active intervention leads to significantly higher scores on the comprehension test as compared with a baseline group with no resources provided. In contrast, there is no significant difference between the group that was provided with the passive intervention and the baseline group. Finally, we analyze the demographics of the individuals who participated in our AMT task and show differences between groups that align with the current understanding of health literacy between populations. This is the first work to show improvements in comprehension using tools such as NoteAid as measured by an EHR note comprehension assessment tool as opposed to patient self-reported scores.

  • Telemedicine for patients with sepsis. Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    Additional Telemedicine Rounds as a Successful Performance-Improvement Strategy for Sepsis Management: Observational Multicenter Study


    Background: Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians. Objective: Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. Methods: We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated. Results: In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046). Conclusions: Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.

Citing this Article

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  • Quality Assessment of Health Information about Scaphoid Fracture in Chinese Websites

    Date Submitted: Jan 16, 2019

    Open Peer Review Period: Jan 21, 2019 - Mar 18, 2019

    Background: With online health information becoming increasingly popular among patients and their family members, concerns have been raised about the accuracy from the websites. Objective: We aimed to...

    Background: With online health information becoming increasingly popular among patients and their family members, concerns have been raised about the accuracy from the websites. Objective: We aimed to evaluate the overall quality of the online information about scaphoid fracture obtained from Chinese websites using the local search engines. Methods: We conducted an online search using the keyword “scaphoid fracture” from the top 5 search engines in China, i.e. Baidu, Shenma, Haosou, Sougou and Bing, and gathered the top ranked websites, which included a total of 120 websites. Among them, 81 websites were kept for further analyses by removing duplicated and unrelated one as well as websites requiring payment. These websites were classified into four categories, including forum/social networks, commercials, academics and physician’s personals. Health information evaluation tool DISCERN and Scaphoid Fracture Specific Content Score (SFSCS) were used to assess the quality of the websites. Results: Among the 81 Chinese websites that we studied, commercial websites were the most common one accounting more than half of all websites. The mean DISCERN score of the 81 websites was 25.56 and no website had a score A (ranging from 64 to 80).The mean SFSCS score was 10.04 and no website had a score A (range between 24 and 30). In addition, DISCERN and SFSCS scores from academic and physician’s websites were significantly higher than those from the forum/social networks and commercials. Conclusions: The overall quality of health information obtained from Chinese websites about scaphoid fracture was very low, suggesting that patients and their family members should be aware such deficiency and pay special attentions for the medical information obtained by using the current search engines in China.

  • Is there really more flu in the south? Surveillance systems show differences in influenza activity across regions.

    Date Submitted: Jan 16, 2019

    Open Peer Review Period: Jan 21, 2019 - Mar 18, 2019

    Background: The Centers for Disease Control and Prevention (CDC) track influenza-like illness (ILI) using information on patient visits to health care providers through the Outpatient Influenza-like I...

    Background: The Centers for Disease Control and Prevention (CDC) track influenza-like illness (ILI) using information on patient visits to health care providers through the Outpatient Influenza-like Illness Surveillance Network (ILINet). Because participation in this system is voluntary, the composition, coverage, and consistency of healthcare reports varies from state to state, leading to different measures of ILI activity between regions. The degree to which these measures reflect actual differences in influenza activity or systematic differences in the methods used to collect and aggregate the data is unclear. Objective: We qualitatively and quantitatively compare national and region-specific ILI activity in the United States (US) across four data sources: CDC ILINet, Flu Near You (FNY), athenahealth, and to determine whether these data sources, commonly used as input in influenza modeling efforts, show geographical patterns that are similar to those observed in CDC ILINet’s data. We also compare the yearly percent of FNY participants who sought health-care for ILI symptoms across geographical areas. Methods: We compare the national and regional 2018 ILI activity baselines, calculated using non-influenza weeks from previous years, for each surveillance data source. We also compare measures of ILI activity across geographical areas during three influenza seasons, 2015-2016, 2016-2017, and 2017-2018. Geographical differences in weekly ILI activity within each data source are assessed using relative mean differences and time series heatmaps. National and regional age-adjusted health-care seeking percents are calculated for each influenza season by dividing the number of FNY participants who sought medical care for ILI symptoms by the total number of ILI reports within an influenza season. Results: We observe consistent differences in ILI activity across geographical areas for CDC ILINet and athenahealth data. ILI activity for FNY displayed little variation across geographical areas, while differences in ILI activity for appear to be associated with the total number of Tweets within a geographical area. The percent of FNY participants seeking health-care for ILI symptoms differs slightly across geographical areas. Specifically, regions with higher health-care seeking percentages correspond to regions with higher CDC ILINet and athenahealth ILI activity. Conclusions: Our findings suggest that differences in ILI activity across geographical areas as reported by a given surveillance system may not accurately reflect true differences in the prevalence of ILI. Instead, these differences may reflect systematic collection and/or aggregation biases that are particular to each system and consistent across influenza seasons. These findings are potentially relevant in the real-time analysis of the influenza season and in the definition of unbiased forecast models.

  • Progressive 24-hour recall. Exploring the benefits of short retention intervals for human memory in online dietary assessment surveys

    Date Submitted: Jan 16, 2019

    Open Peer Review Period: Jan 21, 2019 - Mar 18, 2019

    Background: Omissions and under-reporting due to limits of human memory are still among the key challenges in dietary assessment. A number of studies indicate that shortening the retention interval (i...

    Background: Omissions and under-reporting due to limits of human memory are still among the key challenges in dietary assessment. A number of studies indicate that shortening the retention interval (i.e. time between an intake and recall) reduces the burden on memory and increases the accuracy of assessment. This paper investigates the application of short retention intervals in online dietary surveys with a view to applying this method in large scale population dietary assessment. Objective: We aimed to test whether reducing the retention interval increased the accuracy of a 24-hour dietary assessment system (Intake24) that typically implements the recall method, while without significant increasing subject burden. Methods: Automated 24-hour recall systems, such as Intake24, require respondents to remember all foods and drinks consumed the previous day. We modified the system to allow respondents to record their meals progressively throughout the day. Respondents thereby are required to retain less information for a shorter period of time. We conducted a dietary survey with 49 participants, in which we compared the results produced by these two methods and interviewed 24 participants to examine usability and acceptability of the new method. Results: We found that the mean number of foods reported for evening meals for progressive recalls (5.2 foods) was significantly higher (P = .001) than that for 24-hour recalls (4.3 foods). The mean energy for evening meals reported using progressive recalls (745.7 kcal) was also significantly higher (P = .02) than that for 24-hour recalls (726.4 kcal). The number of foods and the amount of energy reported for other meals remained similar across the two methods. In interviews, 63% of respondents indicated that they remembered meal contents and portion sizes better with the progressive 24-hour recall. However, 67% participants said that the original method is more convenient in terms of fitting in with their daily lifestyles. Conclusions: The results of our research indicate that progressive 24-hour recall may increase the accuracy of dietary assessment in online surveys.

  • Feasibility and ACceptability of a mobile Technology intervention to Support [FACTS] post-abortion care in British Columbia: Phase I

    Date Submitted: Jan 21, 2019

    Open Peer Review Period: Jan 21, 2019 - Jan 28, 2019

    Background: Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. Vast maj...

    Background: Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. Vast majority of the care is concentrated in urban settings. There is evidence to support utilization of innovative mobile technology solutions also known as mobile health (mHealth) to empower women to safely and effectively self-manage aspects of the abortion process. This study is part one of a three phase study that utilizes a human-centered design methodology to develop a mHealth solution to specifically support follow-up after an induced surgical abortion. Objective: Objectives for this study were: 1) To understand how women at three surgical abortion clinics in an urban center of British Columbia utilize their mobile phones to access healthcare information and 2) To understand women’s preferences of content and design of a mobile intervention that will support follow-up care after an induced abortion including contraceptive use. Methods: Study design was based on “Development-evaluation-implementation” process from Medical Research Council Framework for Complex Medical Interventions. This was a mixed methods formative study. Women (ages 14 – 45) were recruited from three urban abortion facilities in British Columbia who underwent a therapeutic abortion. Using the Technology Acceptance Model (TAM) and Theory of Reasoned Action (TRA), a cross-sectional survey was conducted. Interview topics included: demographic information, type of wireless device used, cell phone usage, acceptable information to include in a mobile intervention to support women’s abortion care, willingness to use a mobile phone to obtain reproductive health information, optimal strategies to use the mobile intervention to support women, understand preferences for health information resources, design qualities in a mobile intervention important for ease of use, privacy and security. Data analysis included descriptive statistics, t-tests and Chi square tests where appropriate. Qualitative analysis was conducted with NVivo using grounded theory. This study was approved by the local Ethics board. Results: Quantitative waiting-room survey was completed by 50 participants and 8 semi-structured interviews were completed and analyzed. Average age of participants was 26 years. 94% owned a smart phone, 85% used their personal phones to go online and 85% would use their cell phone to assist in clinical care. Qualitative analysis demonstrated that women prefer a comprehensive website that included secure email or text notifications to provide tools and resources for emotional well-being, contraceptive decision making, general sexual health and post-procedure care. Conclusions: A community based mixed methods approach allowed us to understand the key components of a mobile innovations that will assist in the development and testing of a mobile intervention to support post-abortion care.

  • A comparison of adverse events associated with insomnia drugs in patient online reviews and the FAERS database

    Date Submitted: Jan 15, 2019

    Open Peer Review Period: Jan 18, 2019 - Mar 15, 2019

    Background: Patient online drug reviews are a resource for other patients seeking information about the practical benefits of drug therapies. Patient reviews may also serve as a source of post marketi...

    Background: Patient online drug reviews are a resource for other patients seeking information about the practical benefits of drug therapies. Patient reviews may also serve as a source of post marketing safety data that is more user-friendly than regulatory databases. Hypnotic medications are particularly well-suited to direct evaluation by patients, because they are commonly used, and their acceptability of treatment provides insight into the balance of efficacy and adverse effects. Objective: Our primary objective was to compare adverse event data in the FDA Adverse Event Reporting System (FAERS) with analogous information in customer reviews of hypnotic medications on the consumer health website Secondary objectives were to describe patient reports of efficacy and adverse effects, and to determine whether cost, effectiveness, or adverse effects impacted the user’s rating of hypnotic medications. Methods: Patient ratings and narratives were retrieved from 1407 reviews on between February 2007 and March 2018 for the hypnotics eszopiclone, ramelteon, suvorexant, zaleplon, and zolpidem. Reviews were coded to preferred terms in the Medical Dictionary for Regulatory Activities. Data were compared to 5916 cases in the FAERS database from January 2015 to September 2017. Results: and FAERS identified many of the same adverse events as the most frequent. In both resources, lack of efficacy was a common complaint for all five drugs. Amnesia was common with eszopiclone, zaleplon, and zolpidem. Zolpidem users experienced a high rate of partial sleep activities, while suvorexant users complained of parasomnias. Based on patient rankings, zolpidem was the highest rated hypnotic. Statistical analyses showed that patient ranking is influenced by considerations of efficacy and adverse effects, while drug cost is unimportant. Conclusions: For hypnotic medications, online patient reviews and FAERS emphasized similar adverse events. Online reviewers rated drugs based on perception of efficacy and adverse events. We conclude that online patient reviews of hypnotics are a valid source that can supplement traditional adverse event reporting systems.

  • Google Trends in Infodemiology and Infoveillance: Methodology Framework

    Date Submitted: Jan 18, 2019

    Open Peer Review Period: Jan 18, 2019 - Jan 25, 2019

    Background: The use of Internet data is increasingly integrated in Health Informatics research and is becoming a useful tool in exploring human behavior. The most popular tool for examining online beh...

    Background: The use of Internet data is increasingly integrated in Health Informatics research and is becoming a useful tool in exploring human behavior. The most popular tool for examining online behavior is Google Trends, an open tool that provides information on what is trending and on the variations of the online interest in selected keywords and topics over time. Online search traffic data from Google have been shown to be useful in analyzing human behavior towards health topics and in predicting diseases’ occurrence and outbreaks. Objective: Despite the large number of Google Trends studies during the last decade, the literature on the subject lacks a specific methodology framework. This article aims at providing an overview of the tool and data, and at presenting the first methodology framework in using Google Trends in Infodemiology and Infoveillance, consisting of the main factors that need to be taken into account for a solid methodology base. Methods: We provide a step-by-step guide for the methodology that needs to be followed when researching with Google Trends; essential for robust results in this line of research. Results: At first, an overview of the tool and the data are presented, followed by the analysis of the key methodological points for ensuring the robustness of the results, i.e., selecting the appropriate keyword(s), region(s), period, and category. Conclusions: In the era of Big Data, the analysis of online queries is all the more integrated in health research. This article presents and analyzes the key points that need to be considered for a solid methodology basis when using Google Trends data, which is crucial for ensuring the value and validity of the results.