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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 2018: 4.945, ranked #1 out of 26 journals in the medical informatics category) 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 a leading high-impact journal in its disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. 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 an open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as with all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

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

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


Recent Articles:

  • Source:; Copyright: Charles Deluvio; URL:; License: Licensed by JMIR.

    Electronic Patient-Generated Health Data to Facilitate Disease Prevention and Health Promotion: Scoping Review


    Background: Digital innovations continue to shape health and health care. As technology socially integrates into daily living, the lives of health care consumers are transformed into a key source of health information, commonly referred to as patient-generated health data (PGHD). With chronic disease prevalence signaling the need for a refocus on primary prevention, electronic PGHD might be essential in strengthening proactive and person-centered health care. Objective: This study aimed to review and synthesize the existing literature on the utilization and implications of electronic PGHD for primary disease prevention and health promotion purposes. Methods: Guided by a well-accepted methodological framework for scoping studies, we screened MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, EMBASE, and IEEE Digital Library. We hand-searched 5 electronic journals and 4 gray literature sources, additionally conducted Web searches, reviewed relevant Web pages, manually screened reference lists, and consulted authors. Screening was based on predefined eligibility criteria. Data extraction and synthesis were guided by an adapted PGHD-flow framework. Beyond initial quantitative synthesis, we reported narratively, following an iterative thematic approach. Raw data were coded, thematically clustered, and mapped, allowing for the identification of patterns. Results: Of 183 eligible studies, targeting knowledge and self-awareness, behavior change, healthy environments, and remote monitoring, most literature (125/183, 68.3%) addressed weight reduction, either through physical activity or nutrition, applying a range of electronic tools from socially integrated to full medical devices. Participants generated their data actively (100/183, 54.6%), in combination with passive sensor-based trackers (63/183, 34.4%) or entirely passively (20/183, 10.9%). The proportions of active and passive data generation varied strongly across prevention areas. Most studies (172/183, 93.9%) combined electronic PGHD with reflective, process guiding, motivational and educational elements, highlighting the role of PGHD in multicomponent digital prevention approaches. Most of these interventions (110/183, 60.1%) were fully automatized, underlining broader trends toward low-resource and efficiency-driven care. Only a fraction (47/183, 25.6%) of studies provided indications on the impact of PGHD on prevention-relevant outcomes, suggesting overall positive trends, especially on vitals (eg, blood pressure) and body composition measures (eg, body mass index). In contrast, the impact of PGHD on health equity remained largely unexplored. Finally, our analysis identified a list of barriers and facilitators clustered around data collection and use, technical and design considerations, ethics, user characteristics, and intervention context and content, aiming to guide future PGHD research. Conclusions: The large, heterogeneous volume of the PGHD literature underlines the topic’s emerging nature. Utilizing electronic PGHD to prevent diseases and promote health is a complex matter owing to mostly being integrated within automatized and multicomponent interventions. This underlines trends toward stronger digitalization and weaker provider involvement. A PGHD use that is sensitive to identified barriers, facilitators, consumer roles, and equity considerations is needed to ensure effectiveness.

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

    Process Evaluation of Nurse-Led Online Self-Management Support for Family Caregivers to Deal With Behavior Changes of a Relative With Dementia (Part 1):...


    Background: Coping with behavioral changes is a daily challenge for family caregivers in all phases of dementia, and assistance is needed for it. An online self-management support intervention was therefore developed and conducted involving the following elements: (1) email contact with a specialized dementia nurse, (2) online videos, and (3) e-bulletins containing information about behavior changes and how to manage them. Objective: The aim of this study was to understand (1) family caregivers’ actual use of various elements of the online self-management support, (2) family caregivers’ evaluation and satisfaction with the various elements, and (3) nurses’ usage and evaluations of the online support through the tailored email contacts. Methods: A mixed-methods design was used in this process evaluation, combining quantitative and qualitative methods including analyses of dementia nurses’ registration forms, the number of clicks on online videos and e-bulletins, evaluation questions answered by family caregivers in a survey questionnaire, semistructured interviews with family caregivers and nurses, and analysis of the content of the email contacts. Results: The actual use of various elements of the online self-management support by family caregivers varied: 78% (21/27) of family caregivers had an email contact with the specialist nurse, 80% (43/54) of family caregivers clicked on an online video, and 37% (30/81) clicked on an e-bulletin. Family caregivers showed positive evaluations and satisfaction. The tailor-made approach in the personal email contacts in particular was valued by the family caregivers. Nurses’ evaluations about providing self-management support online were mixed as it was a relatively new task for them. Conclusions: An important insight is that not all participants made optimum use of the various elements of the intervention. Nurses also said that the email contacts were more often used to express feelings about coping with behavioral changes. More research is needed to investigate the reasons why people accept, adopt, and adhere to online interventions to reduce cases where they are not used and to back them up appropriately with tailored (online) information and advice for their personal situations.

  • Source: iStock by Getty Images; Copyright: chabybucko; URL:; License: Licensed by the authors.

    Internet-Based Cognitive Behavioral Therapy for Chronic Fatigue Syndrome Integrated in Routine Clinical Care: Implementation Study


    Background: In a clinical trial, internet-based cognitive behavioral therapy (I-CBT) embedded in stepped care was established as noninferior to face-to-face (f2f) cognitive behavioral therapy (CBT) for chronic fatigue syndrome (CFS). However, treatment effects observed in clinical trials may not necessarily be retained after implementation. Objective: This study aimed to investigate whether stepped care for CFS starting with I-CBT, followed by f2f CBT, if needed, was also effective in routine clinical care. Another objective was to explore the role of therapists’ attitudes toward electronic health (eHealth) and manualized treatment on treatment outcome. Methods: I-CBT was implemented in 5 mental health care centers (MHCs) with 9 treatment sites throughout the Netherlands. All patients with CFS were offered I-CBT, followed by f2f CBT if still severely fatigued or disabled after I-CBT. Outcomes were the Checklist Individual Strength, physical and social functioning (Short-Form 36), and limitations in daily functioning according to the Work and Social Adjustment Scale. The change scores (pre to post stepped care) were compared with a benchmark: stepped care from a randomized controlled trial (RCT) testing this treatment format. We calculated correlations of therapists’ attitudes toward manualized treatment and eHealth with reduction of fatigue severity. Results: Overall, 100 CFS patients were referred to the centers. Of them, 79 started with I-CBT, 20 commenced directly with f2f CBT, and 1 did not start at all. After I-CBT, 48 patients met step-up criteria; of them, 11 stepped up to f2f CBT. Increase in physical functioning (score of 13.4), social functioning (20.4), and reduction of limitations (10.3) after stepped care delivered in routine clinical care fell within the benchmarks of the RCT (95% CIs: 12.8-17.6; 25.2-7.8; and 7.4-9.8, respectively). Reduction of fatigue severity in the MHCs was smaller (12.6) than in the RCT (95% CI 13.2-16.5). After I-CBT only, reduction of fatigue severity (13.2) fell within the benchmark of I-CBT alone (95% CI 11.1-14.2). Twenty therapists treated between 1 and 18 patients. Therapists were divided into 2 groups: one with the largest median reduction of fatigue and one with the smallest. Patients treated by the first group had a significantly larger reduction of fatigue severity (15.7 vs 9.0; t=2.42; P=.02). There were no (statistically significant) correlations between therapists’ attitudes and reduction in fatigue. Conclusions: This study is one of the first to evaluate stepped care with I-CBT as a first step in routine clinical care. Although fatigue severity and disabilities were reduced, reduction of fatigue severity appeared smaller than in the clinical trial. Further development of the treatment should aim at avoiding dropout and encouraging stepping up after I-CBT with limited results. Median reduction of fatigue severity varied largely between therapists. Further research will help understand the role of therapists’ attitudes in treatment outcome.

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

    Estimating the Impact of Novel Digital Therapeutics in Type 2 Diabetes and Hypertension: Health Economic Analysis


    Background: Behavioral interventions can meaningfully improve cardiometabolic conditions. Digital therapeutics (DTxs) delivering these interventions may provide benefits comparable to pharmacologic therapies, displacing medications for some patients. Objective: Our objective was to estimate the economic impact of a digital behavioral intervention in type 2 diabetes mellitus (T2DM) and hypertension (HTN) and estimate the impact of clinical inertia to deprescribing medications. Methods: Decision analytic models estimated health resource savings and cost effectiveness from a US commercial payer perspective. A 3-year time horizon was most relevant to the intervention and payer. Effectiveness of the DTx in improving clinical outcomes was based on cohort studies and published literature. Health resource utilization (HRU), health state utilities, and costs were drawn from the literature with costs adjusted to 2018 dollars. Future costs and quality-adjusted life years (QALYs) were discounted at 3%. Sensitivity analyses assessed uncertainty. Results: Average HRU savings ranged from $97 to $145 per patient per month, with higher potential benefits in T2DM. Cost-effectiveness acceptability analyses using a willingness-to-pay of $50,000/QALY indicated that the intervention would be cost effective at total 3-year program costs of $6468 and $6620 for T2DM and HTN, respectively. Sensitivity analyses showed that reduced medication costs are a primary driver of potential HRU savings, and the results were robust within values tested. A resistance to deprescribe medications when a patient’s clinical outcomes improve can substantially reduce the estimated economic benefits. Our models rely on estimates of clinical effectiveness drawn from limited cohort studies with DTxs and cannot account for other disease management programs that may be implemented. Performance of DTxs in real-world settings is required to further validate their economic benefits. Conclusions: The DTxs studied may provide substantial cost savings, in part by reducing the use of conventional medications. Clinical inertia may limit the full cost savings of DTxs.

  • Medical licentiate students during their rotation in a health facility in Sambia. Source: Image created by the Authors; Copyright: Sandra Barteit; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Technology Acceptance and Information System Success of a Mobile Electronic Platform for Nonphysician Clinical Students in Zambia: Prospective, Nonrandomized...


    Background: Zambia is still experiencing a severe shortage of health workers, which is impacting the national health care system. Very few people are trained, educational infrastructure is inadequate, and senior human resources for training are not yet sufficient to produce the number of health care workers needed, especially for currently underserved rural areas. Therefore, to strengthen the medical education program of medical licentiates, we implemented a tablet-based electronic learning platform (e-platform) with a medical decision-support component. Objective: As the primary objective, this study aimed to explore the acceptance and information system (IS) success of an e-platform focused on offline-based tablet usage for nonphysician clinical students in a low-resource context in Zambia, Africa. Furthermore, we aimed to evaluate student demographic factors and prior technological experience, as well as medical lecturers’ acceptance of technology of the e-platform. Methods: We collected data for the study before and after the intervention. Before the intervention, we collected student demographic data and prior technological experience using a questionnaire. After the intervention, we collected results of the questionnaire on technology acceptance of students and IS success of the e-platform, as well as technology acceptance of medical lecturers. We calculated statistical measures such as means, standard deviations, and correlations of investigated variables. The study report was compiled using the Consolidated Standards of Reporting Trials-Electronic Health checklist. Results: Overall, questionnaire results of students and medical lecturers indicated acceptance of the e-platform and showed higher ratings for overall net benefits and information quality (students) and perceived ease of use and perceived usefulness (medical lecturers) as compared with ratings of other categories. The lowest scores were conveyed for system use and service quality (students) and attitude and behavioral intention (medical lecturers). Conclusions: Acceptance of the e-platform as a learning technology for strengthening medical education in a low-resource context in Zambia was generally high for students and medical lecturers, but shortcomings were also identified. Results indicated low overall usage of the e-platform as a learning and teaching tool. One hindering factor was the tablets’ overall weak reliability with regard to its service life and battery life span, and another was the teachers’ low engagement with the e-platform. Next steps may include other hardware and more technology-based training for medical lecturers. The evaluation results indicated that the e-platform may open new promise for further strengthening and expanding medical education in this context, especially with more affordable and viable technologies that are available.

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

    Barriers to the Use of Mobile Health in Improving Health Outcomes in Developing Countries: Systematic Review


    Background: The use of mobile health (mHealth) technologies to improve population-level health outcomes around the world has surged in the last decade. Research supports the use of mHealth apps to improve health outcomes such as maternal and infant mortality, treatment adherence, immunization rates, and prevention of communicable diseases. However, developing countries face significant barriers to successfully implement, sustain, and expand mHealth initiatives to improve the health of vulnerable populations. Objective: We aimed to identify and synthesize barriers to the use of mHealth technologies such as text messaging (short message service [SMS]), calls, and apps to change and, where possible, improve the health behaviors and health outcomes of populations in developing countries. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Deriving search criteria from the review’s primary objective, we searched PubMed and CINAHL using an exhaustive terms search (eg, mHealth, text messaging, and developing countries, with their respective Medical Subject Headings) limited by publication date, English language, and full text. At least two authors thoroughly reviewed each article’s abstract to verify the articles were germane to our objective. We then applied filters and conducted consensus meetings to confirm that the articles met the study criteria. Results: Review of 2224 studies resulted in a final group of 30 articles for analysis. mHealth initiatives were used extensively worldwide for applications such as maternal health, prenatal care, infant care, HIV/AIDS prevention, treatment adherence, cardiovascular disease, diabetes, and health education. Studies were conducted in several developing countries in Africa, Asia, and Latin America. From each article, we recorded the specific health outcome that was improved, mHealth technology used, and barriers to the successful implementation of the intervention in a developing country. The most prominent health outcomes improved with mHealth were infectious diseases and maternal health, accounting for a combined 20/30 (67%) of the total studies in the analysis. The most frequent mHealth technology used was SMS, accounting for 18/30 (60%) of the studies. We identified 73 individual barriers and grouped them into 14 main categories. The top 3 barrier categories were infrastructure, lack of equipment, and technology gap, which together accounted for 28 individual barriers. Conclusions: This systematic review shed light on the most prominent health outcomes that can be improved using mHealth technology interventions in developing countries. The barriers identified will provide leaders of future intervention projects a solid foundation for their design, thus increasing the chances for long-term success. We suggest that, to overcome the top 3 barriers, project leaders who wish to implement mHealth interventions must establish partnerships with local governments and nongovernmental organizations to secure funding, leadership, and the required infrastructure.

  • Source: Unsplash; Copyright: Charles Deluvio; URL:; License: Licensed by JMIR.

    Trustworthy Health-Related Tweets on Social Media in Saudi Arabia: Tweet Metadata Analysis


    Background: Social media (SM) platforms play a vital role in the dissemination of health information. However, evidence suggests that a high proportion of Twitter posts (ie, tweets) are not necessarily accurate, and many studies suggest that tweets do not need to be accurate, or at least evidence based, to receive traction. This is a dangerous combination in the sphere of health information. Objective: The first objective of this study is to examine health-related tweets originating from Saudi Arabia in terms of their accuracy. The second objective is to find factors that relate to the accuracy and dissemination of these tweets, thereby enabling the identification of ways to enhance the dissemination of accurate tweets. The initial findings from this study and methodological improvements will then be employed in a larger-scale study that will address these issues in more detail. Methods: A health lexicon was used to extract health-related tweets using the Twitter application programming interface and the results were further filtered manually. A total of 300 tweets were each labeled by two medical doctors; the doctors agreed that 109 tweets were either accurate or inaccurate. Other measures were taken from these tweets’ metadata to see if there was any relationship between the measures and either the accuracy or the dissemination of the tweets. The entire range of this metadata was analyzed using Python, version 3.6.5 (Python Software Foundation), to answer the research questions posed. Results: A total of 34 out of 109 tweets (31.2%) in the dataset used in this study were classified as untrustworthy health information. These came mainly from users with a non-health care background and SM accounts that had no corresponding physical (ie, organization) manifestation. Unsurprisingly, we found that traditionally trusted health sources were more likely to tweet accurate health information than other users. Likewise, these provisional results suggest that tweets posted in the morning are more trustworthy than tweets posted at night, possibly corresponding to official and casual posts, respectively. Our results also suggest that the crowd was quite good at identifying trustworthy information sources, as evidenced by the number of times a tweet’s author was tagged as favorited by the community. Conclusions: The results indicate some initially surprising factors that might correlate with the accuracy of tweets and their dissemination. For example, the time a tweet was posted correlated with its accuracy, which may reflect a difference between professional (ie, morning) and hobbyist (ie, evening) tweets. More surprisingly, tweets containing a kashida—a decorative element in Arabic writing used to justify the text within lines—were more likely to be disseminated through retweets. These findings will be further assessed using data analysis techniques on a much larger dataset in future work.

  • Paramedics treating a patient with the support of a tele-emergency medical service physician. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Utilization, Safety, and Technical Performance of a Telemedicine System for Prehospital Emergency Care: Observational Study


    Background: As a consequence of increasing emergency medical service (EMS) missions requiring an EMS physician on site, we had implemented a unique prehospital telemedical emergency service as a new structural component to the conventional physician-based EMS in Germany. Objective: We sought to assess the utilization, safety, and technical performance of this telemedical emergency service. Methods: We conducted a retrospective analysis of all primary emergency missions with telemedical consultation of an EMS physician in the City of Aachen (250,000 inhabitants) during the first 3 operational years of our tele-EMS system. Main outcome measures were the number of teleconsultations, number of complications, and number of transmission malfunctions during teleconsultations. Results: The data of 6265 patients were analyzed. The number of teleconsultations increased during the run-in period of 4 quarters toward full routine operation from 152 to 420 missions per quarter. When fully operational, around the clock, and providing teleconsultations to 11 mobile ambulances, the number of teleconsultations further increased by 25.9 per quarter (95% CI 9.1-42.6; P=.009). Only 6 of 6265 patients (0.10%; 95% CI 0.04%-0.21%) experienced adverse events, all of them not inherent in the system of teleconsultations. Technical malfunctions of single transmission components occurred from as low as 0.3% (95% CI 0.2%-0.5%) during two-way voice communications to as high as 1.9% (95% CI 1.6%-2.3%) during real-time vital data transmissions. Complete system failures occurred in only 0.3% (95% CI 0.2%-0.6%) of all teleconsultations. Conclusions: The Aachen prehospital EMS is a frequently used, safe, and technically reliable system to provide medical care for emergency patients without an EMS physician physically present. Noninferiority of the tele-EMS physician compared with an on-site EMS physician needs to be demonstrated in a randomized trial.

  • Source: Flickr; Copyright: Pan American Health Organization PAHO; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Using Patient and Family Engagement Strategies to Improve Outcomes of Health Information Technology Initiatives: Scoping Review


    Background: Many health care organizations around the world have implemented health information technologies (ITs) to enhance health service efficiency, effectiveness, and safety. Studies have demonstrated that promising outcomes of health IT initiatives can be obtained when patients and family members participate and engage in the adoption, use, and evaluation of these technologies. Despite knowing this, there is a lack of health care organizations using patient and family engagement strategies to enhance the use and adoption of health ITs, specifically. Objective: This study aimed to answer the following 3 research questions (RQs): (1) what current frameworks or theories have been used to guide patient and family engagement in health IT adoption, use, implementation, selection, and evaluation?, (2) what studies have been done on patient and family engagement strategies in health IT adoption, use, implementation, selection, and evaluation?, and (3) what patient and family engagement frameworks, studies, or resources identified in the literature can be applied to health IT adoption, use, implementation, selection, and evaluation? Methods: This scoping review used a 5-step framework developed by Arksey and O’Malley and adapted by Levac et al. These steps include the following: (1) identifying the RQ, (2) identifying relevant studies, (3) selecting studies, (4) charting relevant data, and (5) summarizing and reporting the result. Retrieved academic and grey literature records were evaluated using a literature review software based on inclusion and exclusion criteria by two independent reviewers. If consensus was not achieved, two reviewers would resolve conflicts by discussion. Research findings and strategies were extracted from the studies and summarized in data tables. Results: A total of 35 academic articles and 23 gray literature documents met the inclusion criteria. In total, 20 of the 35 included studies have been published since 2017. Frameworks found include the patient engagement framework developed by Healthcare Information and Management Systems Society and the patient and family engagement framework proposed by Carman et al. Effective strategies include providing patients with clear expectations and responsibilities and providing reimbursement for time and travel. The gray literature sources outlined key considerations for planning and supporting engagement initiatives such as providing patients with professional development opportunities, and embedding patients in existing governance structures. Conclusions: Several studies have reported their findings regarding successful strategies to engage patients and family members in health IT initiatives and the positive impact that can emerge when patients and family members are engaged in such initiatives in an effective manner. Currently, no framework has consolidated all of the key strategies and considerations that were found in this review to guide health care organizations when engaging patients and family members in a health IT–specific project or initiative. Further research to evaluate and validate the existing strategies would be of value.

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

    Growing Disparities in Patient-Provider Messaging: Trend Analysis Before and After Supportive Policy


    Background: Public policy introduced since 2011 has supported provider adoption of electronic medical records (EMRs) and patient-provider messaging, primarily through financial incentives. It is unclear how disparities in patients’ use of incentivized electronic health (eHealth) tools, like patient-provider messaging, have changed over time relative to disparities in use of eHealth tools that were not directly incentivized. Objective: This study examines trends in eHealth disparities before and after the introduction of US federal financial incentives. We compare rates of patient-provider messaging, which was directly incentivized, with rates of looking for health information on the Web, which was not directly incentivized. Methods: We used nationally representative Health Information National Trends Survey data from 2003 to 2018 (N=37,300) to describe disparities in patient-provider messaging and looking for health information on the Web. We first reported the percentage of individuals across education and racial and ethnic groups who reported using these tools in each survey year and compared changes in unadjusted disparities during preincentive (2003-2011) and postincentive (2011-2018) periods. Using multivariable linear probability models, we then examined adjusted effects of education and race and ethnicity in 3 periods—preincentive (2003-2005), early incentive (2011-2013), and postincentive (2017-2018)—controlling for sociodemographic and health factors. In the postincentive period, an additional model tested whether internet adoption, provider access, or providers’ use of EMRs explained disparities. Results: From 2003 to 2018, overall rates of provider messaging increased from 4% to 36%. The gap in provider messaging between the highest and lowest education groups increased by 10 percentage points preincentive (P<.001) and 22 additional points postincentive (P<.001). The gap between Hispanics and non-Hispanic whites increased by 3.2 points preincentive (P=.42) and 11 additional points postincentive (P=.01). Trends for blacks resembled those for Hispanics, whereas trends for Asians resembled those for non-Hispanic whites. In contrast, education-based disparities in looking for health information on the Web (which was not directly incentivized) did not significantly change in preincentive or postincentive periods, whereas racial disparities narrowed by 15 percentage points preincentive (P=.008) and did not significantly change postincentive. After adjusting for other sociodemographic and health factors, observed associations were similar to unadjusted associations, though smaller in magnitude. Including internet adoption, provider access, and providers’ use of EMRs in the postincentive model attenuated, but did not eliminate, education-based disparities in provider messaging and looking for health information on the Web. Racial and ethnic disparities were no longer statistically significant in adjusted models. Conclusions: Disparities in provider messaging widened over time, particularly following federal financial incentives. Meanwhile, disparities in looking for health information on the Web remained stable or narrowed. Incentives may have disproportionately benefited socioeconomically advantaged groups. Future policy could address disparities by incentivizing providers treating these populations to adopt messaging capabilities and encouraging patients’ use of messaging.

  • Virtual care TOC. Source: Adobe Stock Images; Copyright: agenturfotografin; URL:; License: Licensed by the authors.

    Home Virtual Visits for Outpatient Follow-Up Stroke Care: Cross-Sectional Study


    Background: Timely, in-person access to health care is a challenge for people living with conditions such as stroke that result in frailty, loss of independence, restrictions in driving and mobility, and physical and cognitive decline. In Southeastern Ontario, access is further complicated by rurality and the long travel distances to visit physician clinics. There is a need to make health care more accessible and convenient. Home virtual visits (electronic visits, eVisits) can conveniently connect physicians to patients. Physicians use a secure personal videoconferencing tool to connect to patients in their homes. Patients use their device of choice (smartphone, tablet, laptop, or desktop) for the visit. Objective: This study aimed to assess the feasibility and logistics of implementing eVisits in a stroke prevention clinic for seniors. Methods: A 6-month eVisit pilot study was initiated in the Kingston Health Sciences Centre stroke prevention clinic in August 2018. eVisits were used only for follow-up patient encounters. An integrated evaluation was used to test the impact of the program on clinic workflow and patient satisfaction. Patient satisfaction was evaluated by telephone interviews, using a brief questionnaire. Access and patient satisfaction metrics were compared with concurrent standard of care (patients’ prior personal experience with in-person visits). Values are presented as median (interquartile range). Results: There were 75 subjects in the pilot. The patients were aged 65 (56-73.5) years, and 39% (29/75) resided in rural areas. There was a shorter wait for an appointment by eVisit versus in-person (mean 59.98 [SD 48.36] days vs mean 78.36 [SD 50.54] days; P<.001). The eVisit was also shorter, taking on an average of only 10 min to deliver follow-up care with a high degree of patient satisfaction versus 90 (60-112) min for in-person care. The total time saved by patients per eVisit was 80 (50-102) min, 44 (21-69) min of which was travel time. Travel distance avoided by the patients was 30.1 km (11.2-82.2). The estimated total out-of-pocket cost savings for patients per eVisit was Can $52.83 (31.26-94.53). The estimated savings (opportunity cost for in-person outpatient care) for our eVisit pilot project was Can $23,832-$28,584. The patient satisfaction with eVisits was very good compared with their prior personal experience with in-person outpatient care. Conclusions: The eVisit program was well received by patients, deemed to be safe by physicians, and avoided unnecessary patient travel and expense. It also has the potential to reduce health care costs. We plan to scale the project within the department and the institution.

  • Source:; Copyright: John Schnobrich; URL:; License: Licensed by JMIR.

    Towards a Stakeholder-Oriented Blockchain-Based Architecture for Electronic Health Records: Design Science Research Study


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  • Do problematic internet use and perceived stress mediate health behaviors and work-life balance? - An online study with internet-users in Germany and China

    Date Submitted: Oct 2, 2019

    Open Peer Review Period: Oct 2, 2019 - Nov 27, 2019

    Background: Work-life balance is associated with health behaviors. In the face of digitalization, understanding this link requires investigating the roles of problematic internet use and perceived str...

    Background: Work-life balance is associated with health behaviors. In the face of digitalization, understanding this link requires investigating the roles of problematic internet use and perceived stress, which are so far unknown. Objective: The aim of this study was to explore whether problematic internet use and perceived stress mediate health behaviors and work-life balance in two groups of internet-users from different environments (residents in Germany or China), therefore, also to see if residence was a moderator. Methods: An online questionnaire (N=877) was launched with residents from Germany (n=374) and China (n=503) in three language versions (German, English and Chinese). Moderated mediation analyses were run with health behaviors as the independent variable, work-life balance as the dependent variable, problematic internet use and perceived stress as the mediator variables, and residence as potential moderator. Results: Results showed that health behaviors seem to be directly related to work-life balance in both groups. In residents of Germany, a partial mediation was revealed (β = .13, P = .01), while in residents of China, a full mediation was revealed (β = .02, P =.61). The mediation role of perceived stress was prominent compared to problematic internet use in all of the serial models, and the parallel model. Residence moderated the relationship between health behaviors and work-life balance. On a mean level, individuals in Germany performed more health behaviors than individuals in China, however, have higher perceived stress. The interrelation between health behaviors and work-life balance was stronger in Germany (β = .19, P < .001), compared in China (β = .11, P =.01). Conclusions: These findings are in line with the compensatory carry-over action model. To promote work-life balance, individuals should perform health behaviors to help overcome problematic internet use and perceived stress.

  • Patient-Centric Scheduling Practices: Implementation of Health Information Technology to Improve the Patient Experience and Access to Care

    Date Submitted: Sep 30, 2019

    Open Peer Review Period: Sep 30, 2019 - Nov 25, 2019

    Background: Cancellations and rescheduling of doctor’s appointments are common. An automated rescheduling system has the potential to facilitate rescheduling process so that newly opened slots are p...

    Background: Cancellations and rescheduling of doctor’s appointments are common. An automated rescheduling system has the potential to facilitate rescheduling process so that newly opened slots are promptly filled by patients who need and can take the slot. Building on an existing online patient portal, a large healthcare system adopted an automated rescheduling system, called Fast Pass, that sends out an earlier appointment offer via email or text alert to patients and allows patients to reschedule their appointment through the online portal. Objective: We examined the uptake of Fast Pass at its early stage of implementation. We assessed program features and patient and visit characteristics associated with higher levels of Fast Pass utilization and association between Fast Pass use and no-show and cancellation rates. Methods: This study was a retrospective analysis of Fast Pass offers sent between July and December 2018. Multivariable logistic regression was used to assess the independent contribution of program, patient, and visit characteristics on the likelihood of accepting the offer. We then assessed appointment outcome (completion, cancellation, or no-show) of Fast Pass offered appointments compared to appointments with the same patient and visit characteristics but without an offer. Results: Of 177,311 Fast Pass offers sent, 8.3% were accepted. Overall, there were 1.3 percentage points (or 38%) reduction in no-show rates among Fast Pass accepted appointments than other appointments with matching characteristics (P < .001). The offers were more likely to be accepted if they were sent in the evening (vs. early morning), the first (vs. repeated) offer for the same appointment, for a slot 1-31 days ahead (vs. same-day), for later in a day (vs. before 10am), for primary care (vs. specialty) visit, sent via text message (vs. email only), for an appointment made through patient online portal (vs. via phone call or in-person), or for younger adults aged 18-49 (vs. ≥65) (all at P < .001). Factors negatively associated with offer acceptance were increasing number of comorbidities (P = .02) and visits scheduled for chronic conditions (vs. acute conditions only) (P = .002). Conclusions: An automated rescheduling system can improve patient’s access by reducing wait time for an appointment, with an added benefit of preventing no-shows by serving as a reminder of an upcoming appointment. Future modifications, such as increasing adoption of text-based offers and targeting older adults or patients with complex conditions, may help promote wider utilization and patient-centeredness of the system. Clinical Trial: N/A

  • eHealthMap: A review of eHealth teaching in health and medical degrees in Australia

    Date Submitted: Sep 29, 2019

    Open Peer Review Period: Sep 29, 2019 - Nov 24, 2019

    Background: As digital technology use in society increases, so does the need for health professionals to engage in eHealth-enabled clinical practice. To do so, higher education institutions need to su...

    Background: As digital technology use in society increases, so does the need for health professionals to engage in eHealth-enabled clinical practice. To do so, higher education institutions need to suitably prepare graduates of health professional degrees with the capabilities required to practice in eHealth contexts. Objective: This study aimed to understand how eHealth is taught at a major Australian University, and the challenges and suggestions for integrating eHealth into allied health, nursing and medical university curricula. Methods: Cross-disciplinary subject unit outlines (N=77) were reviewed for eHealth-related content, and interviews and focus groups conducted with the corresponding subject unit coordinators (N=26). Content analysis was used to identify themes around challenges and opportunities for embedding eHealth in teaching. Results: There was no evidence of a standardised approach to eHealth teaching across any of the health degrees at the university. Where eHealth content existed, it tended to focus on clinical applications rather than systems and policies, data analysis and knowledge creation, or system and technology implementation. Despite identifying numerous challenges to embedding eHealth in their subjects, unit coordinators expressed enthusiasm for eHealth teaching and were keen to adjust content and learning activities. Conclusions: Explicit strategies are required to address how eHealth capabilities can be embedded across clinical health degrees. Unit coordinators require support including access to relevant information, teaching resources, and curriculum mapping that clearly articulates eHealth capabilities for students across their degree. Degree-wide conversations and collaboration is required between professional bodes, clinical practice, and the universities for overcoming the practical and perceived challenges of integrating eHealth in health curricula.

  • Web-based interventions for dietary behavior in adults with type 2 diabetes: a systematic review of randomized controlled trials

    Date Submitted: Sep 29, 2019

    Open Peer Review Period: Sep 29, 2019 - Nov 24, 2019

    Background: Type 2 diabetes mellitus (T2DM) is among the most prevalent non-communicable health conditions worldwide, affecting over 500 million people globally. Diet is a key aspect of T2DM managemen...

    Background: Type 2 diabetes mellitus (T2DM) is among the most prevalent non-communicable health conditions worldwide, affecting over 500 million people globally. Diet is a key aspect of T2DM management with dietary modification shown to elicit clinically meaningful outcomes such as improved glycemic control, and reductions in weight and cardiovascular disease risk factors. Web-based interventions provide a potentially convenient and accessible method for delivering dietary education but its effects on dietary behavior in people with T2DM are unknown. Objective: The objective of this review was to determine the effectiveness of web-based interventions on dietary behavior change and glycemic control in people with T2DM. Methods: In accordance with PRISMA guidelines, systematic literature searches were performed using Medline, Embase, The Cochrane Library, and CINAHL to retrieve papers from January 2013 to May 2019. Randomized controlled trials of web-based interventions in adults with T2DM with reported dietary assessment were included. Population and intervention characteristics, dietary guidelines and assessments, and significant clinical outcomes were extracted. Differences between groups and within groups were assessed for dietary behavior and clinical outcomes. Results: There were 714 records screened and five studies comprising 1056 adults were included. Studies measured dietary changes by assessing overall diet quality, changes in specific dietary components, or dietary knowledge scores. Significant improvements in dietary behavior were reported in four out of the five studies, representing healthier food choices, improvements in eating habits, reductions in carbohydrates, added sugar, sodium, saturated fat and overall fat intake, and/or increases in dietary knowledge. Three studies found significant mean reductions for hemoglobin A1c ranging from –0.3% to –0.8%, and/or weight ranging from –2.3 kg to –12.7 kg, fasting blood glucose (–1 mmol/L), waist circumference (–1 cm), and triglycerides (–60.1 mg/dL). These studies provided varied dietary recommendations from standard dietary guidelines, national health program guidelines, and a very low carbohydrate ketogenic diet. Conclusions: Web-based interventions are effective for supporting dietary behavior change in adults with T2DM in most cases, though changes in glycemic control and other clinical outcomes are inconsistent. There was considerable heterogeneity in the diets recommended and the dietary assessment measures used across all studies, therefore, more research is needed to determine whether these effects are sufficiently greater than those achieved through usual care.

  • Development and assessment of Mozzify app: an integrated mHealth for Dengue reporting and mapping, health communication and behavior modification

    Date Submitted: Sep 27, 2019

    Open Peer Review Period: Sep 27, 2019 - Nov 27, 2019

    Background: Dengue fever (DF), the world’s most rapidly spreading mosquito-borne disease, causes approximately 50 million cases a year, putting an estimated 2.5 billion people at risk in 128 countri...

    Background: Dengue fever (DF), the world’s most rapidly spreading mosquito-borne disease, causes approximately 50 million cases a year, putting an estimated 2.5 billion people at risk in 128 countries. For the last 10 years, mobile phones have provided the global health community with innovative and cost-effective strategies to address the challenges in the prevention and management of DF. Objective: In this paper, we have introduced and described the design and development process of Mozzify, an integrated mobile health (mHealth) application that features real-time DF cases reporting and mapping system, health communication (real-time reporting and mapping of DF cases, real-time worldwide news and chat forum (timeline), within-app educational videos, local and international health agencies websites and interactive signs and symptoms checker and hospital directions system), and behavior modification (reminders alert program on the preventive practices against DF). We also sought to assess Mozzify in terms of engagement and information-sharing abilities, functionality, aesthetic, subjective quality and perceived impact. Methods: We have developed and designed a mobile application, Mozzify, which main goals were to increase awareness, knowledge and attitude on DF, increase healthcare-seeking behavior and increase intention to change behavior on preventive practices against DF among users. It was initially assessed using the Mobile Application Rating Scale (MARS), among 50 purposively sampled individuals which were consisted of public health experts (PHE) (n = 5), environment and health-related researchers (EHR) (n = 23) and non-clinical (end-users) (n = 22) participants. Results: High acceptability and excellent satisfaction ratings (≥4.0 mean scores out of 5) based from the MARS subscales indicate that the app has excellent user design, functionality, usability, engagement, and contains relevant information system, app subjective and specific quality among PHE, HER and end-users. Some issues and suggestions were raised during the focus group and individual discussions on the availability of the app in Android; language options limitations, provision on predictive surveillance, and inclusion of other mosquito-borne diseases. Conclusions: We have learned that, Mozzify can be a promising integrated strategic health intervention system in DF cases reporting and mapping system, raising knowledge, awareness and attitude and disseminating and sharing information on DF among general population and health experts and can be an effective aid in the successful translation of knowledge on preventive measures against DF to practice.

  • Diagnosis Performance of Computer-Aided Detection on Breast Lesions Less and More Than 2cm

    Date Submitted: Sep 20, 2019

    Open Peer Review Period: Sep 21, 2019 - Nov 21, 2019

    Background: Computer-aided Detection (CAD) is increasingly being used as an aid tool by radiologists on breast lesion diagnosis. Previous studies demonstrated that CAD can improve the diagnosis perfor...

    Background: Computer-aided Detection (CAD) is increasingly being used as an aid tool by radiologists on breast lesion diagnosis. Previous studies demonstrated that CAD can improve the diagnosis performance of radiologist. However, the optimal use of CAD in breast lesions less and more than 2cm has not been mentioned. Objective: To compare the performance of different radiologists by using CAD to detect breast cancer in size less and more than 2cm. Methods: We prospectively enrolled 261 consecutive patients (mean age, 43years; age range, 17–70 years), 398 lesions (148 more than 2cm, 79 with malignant, 69 with benign; 250 less or equal to 2cm, 71 with malignant, 179 with benign), with breast mass as prominent symptom. One novice radiologist with 1 year of US experience and one experienced radiologist with 5 years of US experience were assigned to read US images without CAD, and at a second reading combined with CAD. Diagnostic performances were compared by using analysis of variance. Results: For novice reader, the area under the receiver operating characteristic curve improved from 0.743 (95% confidence interval [CI]: 0.669, 0.817) at without-CAD mode to 0.884 (95% CI: 0.834, 0.933; P<.001) at the combined-CAD mode in lesions less or equal to 2cm, for experienced reader those were from 0.838(95% CI :0.773,0.903) to 0.902(95% CI :0.862,0.942; P=.002). Those were from 0.806 to 0.797(novice reader) and 0.895 to 0.822 (experienced reader) in lesions more than 2cm. The sensitivity of novice and experienced reader in lesions less than 2cm improved from 61.97% and 73.23% at without-CAD mode to 90.14% and 97.18% at combined-CAD mode, respectively. Conclusions: Computer-aided detection (CAD) was helpful for novice and experienced reader to improve cancer detection at breast US in lesions less than 2cm. CAD was more sensitive for both novice and experienced reader. Clinical Trial: ChiCTR1800019649