@Article{info:doi/10.2196/65718, author="Wilke, Felix", title="The Impact of Trust and the Role of the Opt-Out Mechanism in Willingness to Share Health Data via Electronic Health Records in Germany: Telephone Survey Study", journal="JMIR Hum Factors", year="2025", month="Apr", day="15", volume="12", pages="e65718", keywords="data sharing", keywords="health", keywords="citizens", keywords="electronic health record", keywords="trust", keywords="digitalization", keywords="opt-out", abstract="Background: Electronic health records (EHRs) offer a valuable resource for research and health care improvement. However, public acceptance of sharing personal health data is critical to the success of such initiatives. In Germany, automatic data sharing via EHRs will be implemented unless people opt out. Objective: This study aims to assess the willingness of the German population to share health data via EHRs and to explore the role of trust in influencing these attitudes. Methods: A computer-assisted telephone interview study was conducted in December 2023, with 1004 respondents aged 18 years and older, representative of the German population. Descriptive statistics and multivariate linear regression models were used to analyze the data. Results: The survey shows that 43.4\% (n=432) of respondents would be willing to share their health data via EHR, and a significant 34\% (n=338) remain undecided. While the population is open to adoption of the EHR for personal health issues (n=483, 53\% show interest in using it), the opt-out model for data sharing is viewed critically, with 44.7\% (n=438) of respondents rejecting it. Socioeconomic status significantly influences the willingness to share data, with higher income, education, and digital literacy being associated with greater openness to data sharing. However, trust emerged as the most significant factor. Additionally, experiences with digital technologies increase the willingness to share personal health data. Conclusions: The German population shows general openness toward EHRs and data sharing. Trust plays a critical role in promoting willingness to share health data. The findings highlight challenges in Germany's transition to an opt-out system. ", doi="10.2196/65718", url="https://humanfactors.jmir.org/2025/1/e65718" } @Article{info:doi/10.2196/67318, author=" and Caviglia, Marta", title="Bridging Data Gaps in Emergency Care: The NIGHTINGALE Project and the Future of AI in Mass Casualty Management", journal="J Med Internet Res", year="2025", month="Apr", day="10", volume="27", pages="e67318", keywords="AI", keywords="technology", keywords="mass casualty incident", keywords="incident management", keywords="artificial intelligence", keywords="emergency care", keywords="MCI", keywords="data gaps", keywords="tool", doi="10.2196/67318", url="https://www.jmir.org/2025/1/e67318" } @Article{info:doi/10.2196/57421, author="Perakslis, Eric and Nolen, Kimberly and Fricklas, Ethan and Tubb, Tracy", title="Striking a Balance: Innovation, Equity, and Consistency in AI Health Technologies", journal="JMIR AI", year="2025", month="Apr", day="7", volume="4", pages="e57421", keywords="artificial intelligence", keywords="algorithm", keywords="regulatory landscape", keywords="predictive model", keywords="predictive analytics", keywords="predictive system", keywords="practical model", keywords="machine learning", keywords="large language model", keywords="natural language processing", keywords="deep learning", keywords="digital health", keywords="regulatory", keywords="health technology", doi="10.2196/57421", url="https://ai.jmir.org/2025/1/e57421" } @Article{info:doi/10.2196/60917, author="Cox, Samuel and Masood, Erum and Panagi, Vasiliki and Macdonald, Calum and Milligan, Gordon and Horban, Scott and Santos, Roberto and Hall, Chris and Lea, Daniel and Tarr, Simon and Mumtaz, Shahzad and Akashili, Emeka and Rae, Andy and Urwin, Esmond and Cole, Christian and Sheikh, Aziz and Jefferson, Emily and Quinlan, Roy Philip", title="Conversion of Sensitive Data to the Observational Medical Outcomes Partnership Common Data Model: Protocol for the Development and Use of Carrot", journal="JMIR Res Protoc", year="2025", month="Apr", day="2", volume="14", pages="e60917", keywords="data standardization", keywords="OMOP", keywords="Observational Medical Outcomes Partnership", keywords="ETL", keywords="extract, transform, and load", keywords="data discovery", keywords="transparency", keywords="Carrot tool", keywords="common data model", keywords="data standard", keywords="health care", keywords="data model", keywords="data protection", keywords="data privacy", keywords="open-source", abstract="Background: The use of data standards is low across the health care system, and converting data to a common data model (CDM) is usually required to undertake international research. One such model is the Observational Medical Outcomes Partnership (OMOP) CDM. It has gained substantial traction across researchers and those who have developed data platforms. The Observational Health Care Data Sciences and Informatics (OHDSI) partnership manages OMOP and provides many open-source tools to assist in converting data to the OMOP CDM. The challenge, however, is in the skills, knowledge, know-how, and capacity within teams to convert their data to OMOP. The European Health Care Data Evidence Network provided funds to allow data owners to bring in external resources to do the required conversions. The Carrot software (University of Nottingham) is a new set of open-source tools designed to help address these challenges while not requiring data access by external resources. Objective: The use of data protection rules is increasing, and privacy by design is a core principle under the European and UK legislations related to data protection. Our aims for the Carrot software were to have a standardized mechanism for managing the data curation process, capturing the rules used to convert the data, and creating a platform that can reuse rules across projects to drive standardization of process and improve the speed without compromising on quality. Most importantly, we aimed to deliver this design-by-privacy approach without requiring data access to those creating the rules. Methods: The software was developed using Agile approaches by both software engineers and data engineers, who would ultimately use the system. Experts in OMOP were used to ensure the approaches were correct. An incremental release program was initiated to ensure we delivered continuous progress. Results: Carrot has been delivered and used on a project called COVID-Curated and Open Analysis and Research Platform (CO-CONNECT) to assist in the process of allowing datasets to be discovered via a federated platform. It has been used to create over 45,000 rules, and over 5 million patient records have been converted. This has been achieved while maintaining our principle of not allowing access to the underlying data by the team creating the rules. It has also facilitated the reuse of existing rules, with most rules being reused rather than manually curated. Conclusions: Carrot has demonstrated how it can be used alongside existing OHDSI tools with a focus on the mapping stage. The COVID-Curated and Open Analysis and Research Platform project successfully managed to reuse rules across datasets. The approach is valid and brings the benefits expected, with future work continuing to optimize the generation of rules. International Registered Report Identifier (IRRID): RR1-10.2196/60917 ", doi="10.2196/60917", url="https://www.researchprotocols.org/2025/1/e60917" } @Article{info:doi/10.2196/63681, author="Senathirajah, Yalini and Kaufman, R. David and Cato, Kenrick and Daniel, Pia and Roblin, Patricia and Kushniruk, Andre and Borycki, M. Elizabeth and Feld, Emanuel and Debi, Poli", title="The Impact of the Burden of COVID-19 Regulatory Reporting in a Small Independent Hospital and a Large Network Hospital: Comparative Mixed Methods Study", journal="Online J Public Health Inform", year="2025", month="Mar", day="26", volume="17", pages="e63681", keywords="regulatory reporting", keywords="human factors", keywords="reporting burden", keywords="emergency response", keywords="COVID-19", keywords="hospital resilience", keywords="pandemic response", abstract="Background: During the COVID-19 pandemic in 2020, hospitals encountered numerous challenges that compounded their difficulties. Some of these challenges directly impacted patient care, such as the need to expand capacities, adjust services, and use new knowledge to save lives in an ever-evolving situation. In addition, hospitals faced regulatory challenges. Objective: This paper presents the findings of a qualitative study that aimed to compare the effects of reporting requirements on a small independent hospital and a large network hospital during the COVID-19 pandemic. Methods: We used both quantitative and qualitative analyses and conducted 51 interviews, which were thematically analyzed. We quantified the changes in regulatory reporting requirements during the first 14 months of the pandemic. Results: Reporting requirements placed a substantial time burden on key clinical personnel at the small independent hospital, consequently reducing the time available for patient care. Conversely, the large network hospital had dedicated nonclinical staff responsible for reporting duties, and their robust health information system facilitated this work. Conclusions: The discrepancy in health IT capabilities suggests that there may be significant institutional inequities affecting smaller hospitals' ability to respond to a pandemic and adequately support public health efforts. Electronic certification guidelines are essential to addressing the substantial equity issues. We discuss in detail the health care policy implications of these findings. ", doi="10.2196/63681", url="https://ojphi.jmir.org/2025/1/e63681", url="http://www.ncbi.nlm.nih.gov/pubmed/40137048" } @Article{info:doi/10.2196/57237, author="Li, Lan and Back, Emma and Lee, Suna and Shipley, Rebecca and Mapitse, N{\'e}o and Elbe, Stefan and Smallman, Melanie and Wilson, James and Yasin, Ifat and Rees, Geraint and Gordon, Ben and Murray, Virginia and Roberts, L. Stephen and Cupani, Anna and Kostkova, Patty", title="Balancing Risks and Opportunities: Data-Empowered-Health Ecosystems", journal="J Med Internet Res", year="2025", month="Mar", day="25", volume="27", pages="e57237", keywords="health policy", keywords="data sharing", keywords="digital healthcare", keywords="healthcare system", keywords="ecosystems", keywords="technologies", keywords="decision-making", keywords="data privacy", keywords="data protection", keywords="social media", keywords="application programming interfaces", doi="10.2196/57237", url="https://www.jmir.org/2025/1/e57237" } @Article{info:doi/10.2196/65241, author="Holetzek, Tim and H{\"a}usler, Andreas and G{\"o}dde, Kathrin and Rapp, Michael and Spallek, Jacob and Holmberg, Christine", title="The Role of the Installed Base in Information Exchange Among General Practitioners in Germany: Mixed Methods Study", journal="J Med Internet Res", year="2025", month="Mar", day="24", volume="27", pages="e65241", keywords="digitalization", keywords="general practitioners", keywords="Germany", keywords="information and communication technologies", keywords="information exchange", keywords="primary health care", keywords="digital transformation", keywords="mixed methods study", keywords="digital health", keywords="health application", keywords="qualitative interview", abstract="Background: Digitalization is steadily advancing on a global scale, exerting a profound influence on health care systems. To facilitate acceptance of the digital transformation, guiding principles emphasize the need for digital health structures to be person-centered and promote high-quality care. This paper examines the implementation challenges within the German health care system, with a particular focus on how change initiatives engage with existing infrastructures and organizational modes of health care delivery. This approach provides a framework for analyzing how established infrastructure determines new developments while also highlighting the procedural dynamics of change and the integration of innovations within existing information infrastructures. These established infrastructures are referred to as the installed base. Objective: The aim of the study is to examine the installed base encountered by the digital transformation within the German health care system by investigating information exchange practices among general practitioners (GPs) and their communication with other health care actors. Methods: A mixed methods study including a quantitative survey and semistructured qualitative interviews was conducted. The study sample consisted of all publicly accessible GP practices (N=1348) situated in the state of Brandenburg, Germany. The survey captured demographic data, communication practices, and perceived barriers to digitalization. The interviews explored experiences with digital applications. Quantitative data were analyzed using R (R Foundation for Statistical Computing), and qualitative data were managed and analyzed in MAXQDA (VERBI Software GmbH) through content analysis. Results: A total of 250 questionnaires (response rate 18.5\%) and 10 interviews with GPs were included in the analysis. GPs primarily use the telephone (n=138, 55.2\%, SD 24.64), fax (n=109, 43.9\%, SD 25.40), or post (n=50, 20.2\%, SD 9.46) to exchange information. Newer digital communication channels such as messenger applications (n=2, 0.8\%, SD 0.72) and Communication in the Medical Sector (n=1, 0.5\%, SD 0.97) play a minor role. We identified three intertwined clusters displaying diverse barriers to the digitalization of GPs' communication practices: (1) incompatibility issues and technical immaturity, (2) lack of knowledge and technical requirements, and (3) additional technical, financial, and time-related burdens. These barriers were perceived as significant deterrents to the adoption of digital tools, with older GPs more reliant on analog systems and more likely to view digitalization as a source of frustration. Conclusions: Newly established communication channels in the German health care system compete with the existing information infrastructure, which is deeply integrated into GPs' practice routines and care processes. However, this installed base has been largely overlooked in digital transformation initiatives. While newer channels hold potential, they often malfunction and are incompatible with long-established, individualized GP workflows. Addressing these issues rather than imposing coercive measures is crucial for increasing adoption. Incorporating health care providers' perspectives and aligning new channels with established routines can prevent frustration and facilitate a smoother digital transformation. ", doi="10.2196/65241", url="https://www.jmir.org/2025/1/e65241" } @Article{info:doi/10.2196/56836, author="Reed, Julie and Svedberg, Petra and Nygren, Jens", title="Enhancing the Innovation Ecosystem: Overcoming Challenges to Introducing Information-Driven Technologies in Health Care", journal="J Med Internet Res", year="2025", month="Mar", day="24", volume="27", pages="e56836", keywords="artificial intelligence", keywords="ecosystem", keywords="health care", keywords="implementation", keywords="technology adoption", keywords="improvement", keywords="complex-systems", doi="10.2196/56836", url="https://www.jmir.org/2025/1/e56836" } @Article{info:doi/10.2196/66273, author="Gyrard, Amelie and Abedian, Somayeh and Gribbon, Philip and Manias, George and van Nuland, Rick and Zatloukal, Kurt and Nicolae, Emilia Irina and Danciu, Gabriel and Nechifor, Septimiu and Marti-Bonmati, Luis and Mallol, Pedro and Dalmiani, Stefano and Autexier, Serge and Jendrossek, Mario and Avramidis, Ioannis and Garcia Alvarez, Eva and Holub, Petr and Blanquer, Ignacio and Boden, Anna and Hussein, Rada", title="Lessons Learned From European Health Data Projects With Cancer Use Cases: Implementation of Health Standards and Internet of Things Semantic Interoperability", journal="J Med Internet Res", year="2025", month="Mar", day="24", volume="27", pages="e66273", keywords="artificial intelligence", keywords="cancer", keywords="European Health Data Space", keywords="health care standards", keywords="interoperability", keywords="AI", keywords="health data", keywords="cancer use cases", keywords="IoT", keywords="Internet of Things", keywords="primary data", keywords="diagnosis", keywords="prognosis", keywords="decision-making", doi="10.2196/66273", url="https://www.jmir.org/2025/1/e66273", url="http://www.ncbi.nlm.nih.gov/pubmed/40126534" } @Article{info:doi/10.2196/60019, author="Yu, Tianzhi and Li, Wanyu and Liu, Yingchun and Jin, Chunjie and Wang, Zimin and Cao, Hailong", title="Application of Internet Hospitals in the Disease Management of Patients With Ulcerative Colitis: Retrospective Study", journal="J Med Internet Res", year="2025", month="Mar", day="18", volume="27", pages="e60019", keywords="inflammatory bowel disease", keywords="ulcerative colitis", keywords="intelligent diagnosis and treatment service", keywords="internet hospital", keywords="chronic disease management", abstract="Background: Ulcerative colitis (UC) is a chronic disease characterized by frequent relapses, requiring long-term management and consuming substantial medical and social resources. Effective management of UC remains challenging due to the need for sustainable remission strategies, continuity of care, and access to medical services. Intelligent diagnosis refers to the use of artificial intelligence--driven algorithms to analyze patient-reported symptoms, generate diagnostic probabilities, and provide treatment recommendations through interactive tools. This approach could potentially function as a method for UC management. Objective: This study aimed to analyze the diagnosis and treatment data of UC from both physical hospitals and internet hospitals, highlighting the potential benefits of the intelligent diagnosis and treatment service model offered by internet hospitals. Methods: We collected data on the visits of patients with UC to the Department of Gastroenterology at Tianjin Medical University General Hospital. A total of 852 patients with UC were included between July 1, 2020, and June 31, 2023. Statistical methods, including chi-square tests for categorical variables, t tests for continuous variables, and rank-sum tests for visit numbers, were used to evaluate the medical preferences and expenses of patients with UC. Results: We found that internet hospitals and physical hospitals presented different medical service models due to the different distribution of medical needs and patient groups. Patients who chose internet hospitals focused on disease consultation and prescription medication (3295/3528, 93.40\%). Patients' medical preferences gradually shifted to web-based services provided by internet hospitals. Over time, 58.57\% (270/461) of patients chose either web-based services or a combination of web-based and offline services for UC diagnosis and treatment. The number of visits in the combination of web-based and offline service modes was the highest (mean 13.83, SD 11.07), and younger patients were inclined to visit internet hospitals (49.66\%>34.71\%). In addition, compared with physical hospitals, there was no difference in testing fees and examination fees for patients with UC in internet hospitals, but medicine fees were lower. Conclusions: The intelligent diagnosis and treatment model provided by internet hospitals demonstrates the potential benefits in managing UC, including feasibility, accessibility, convenience, and economics. ", doi="10.2196/60019", url="https://www.jmir.org/2025/1/e60019" } @Article{info:doi/10.2196/59801, author="Park, Adam and Jung, Young Se and Yune, Ilha and Lee, Ho-Young", title="Applying Robotic Process Automation to Monitor Business Processes in Hospital Information Systems: Mixed Method Approach", journal="JMIR Med Inform", year="2025", month="Mar", day="7", volume="13", pages="e59801", keywords="robotic process automation", keywords="RPA", keywords="electronic medical records", keywords="EMR", keywords="system monitoring", keywords="health care information systems", keywords="user-centric monitoring", keywords="performance evaluation", keywords="business process management", keywords="BPM", keywords="healthcare technology", keywords="mixed methods research", keywords="process automation in health care", abstract="Background: Electronic medical records (EMRs) have undergone significant changes due to advancements in technology, including artificial intelligence, the Internet of Things, and cloud services. The increasing complexity within health care systems necessitates enhanced process reengineering and system monitoring approaches. Robotic process automation (RPA) provides a user-centric approach to monitoring system complexity by mimicking end user interactions, thus presenting potential improvements in system performance and monitoring. Objective: This study aimed to explore the application of RPA in monitoring the complexities of EMR systems within a hospital environment, focusing on RPA's ability to perform end-to-end performance monitoring that closely reflects real-time user experiences. Methods: The research was conducted at Seoul National University Bundang Hospital using a mixed methods approach. It included the iterative development and integration of RPA bots programmed to simulate and monitor typical user interactions with the hospital's EMR system. Quantitative data from RPA process outputs and qualitative insights from interviews with system engineers and managers were used to evaluate the effectiveness of RPA in system monitoring. Results: RPA bots effectively identified and reported system inefficiencies and failures, providing a bridge between end user experiences and engineering assessments. The bots were particularly useful in detecting delays and errors immediately following system updates or interactions with external services. Over 3 years, RPA monitoring highlighted discrepancies between user-reported experiences and traditional engineering metrics, with the bots frequently identifying critical system issues that were not evident from standard component-level monitoring. Conclusions: RPA enhances system monitoring by providing insights that reflect true end user experiences, which are often overlooked by traditional monitoring methods. The study confirms the potential of RPA to act as a comprehensive monitoring tool within complex health care systems, suggesting that RPA can significantly contribute to the maintenance and improvement of EMR systems by providing a more accurate and timely reflection of system performance and user satisfaction. ", doi="10.2196/59801", url="https://medinform.jmir.org/2025/1/e59801", url="http://www.ncbi.nlm.nih.gov/pubmed/40053771" } @Article{info:doi/10.2196/57858, author="Cresswell, Kathrin and Jahn, Franziska and Silsand, Line and Woods, Leanna and Postema, Tim and Logan, Marion and Malkic, Sevala and Ammenwerth, Elske", title="Assessing Digital Maturity of Hospitals: Viewpoint Comparing National Approaches in Five Countries", journal="J Med Internet Res", year="2025", month="Mar", day="6", volume="27", pages="e57858", keywords="digital maturity", keywords="hospitals", keywords="assessment", keywords="decision making", keywords="health systems", keywords="infancy", keywords="Australia", keywords="Australian", keywords="data collection", keywords="data", keywords="qualitative thematic analysis", keywords="self-reporting", keywords="practical feasibility", keywords="long-term tracking", keywords="local data", keywords="monitoring", doi="10.2196/57858", url="https://www.jmir.org/2025/1/e57858", url="http://www.ncbi.nlm.nih.gov/pubmed/40053724" } @Article{info:doi/10.2196/65932, author="Li, Xuezhu and Huang, Lifeng and Zhang, Hui and Liang, Zhanming", title="Enabling Telemedicine From the System-Level Perspective: Scoping Review", journal="J Med Internet Res", year="2025", month="Mar", day="5", volume="27", pages="e65932", keywords="telemedicine", keywords="telehealth", keywords="digital health", keywords="success factors", keywords="challenges", abstract="Background: Telemedicine is a strategy for providing health care services remotely that improves service accessibility. Telemedicine has attracted growing research interest in the past 10 years, including systematic reviews that synthesize evidence to share experiences and enhance knowledge. However, most of the published systematic reviews have focused on synthesizing evidence from studies on telemedicine at the organizational level. A collected understanding of factors on the system level that influence the successful implementation and adoption of telemedicine needs to be developed, especially in regional and rural areas. Objective: This scoping review aims to explore key success factors and challenges that influence the implementation and adoption of telemedicine at the system level, particularly in regional and rural areas. Methods: This scoping review was conducted in accordance with the framework by Arksey and O'Malley and reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A total of 5 databases (CINAHL, Cochrane, Medline, Ovid, and Scopus) were searched for research articles published in English between January 2010 and 2023, using the established inclusion criteria. Results: Of the 10,691 papers identified, 89 were included in this review, including 16 (17.98\%) studies conducted in regional and rural areas and 13 (14.61\%) in metropolitan areas. Another 13 (14.61\%) studies were conducted in both metropolitan areas and regional and rural areas. Overall, 6 categories with more than 70 key success factors, including system-level requirements (n=13, 18.40\%), economic considerations and funding (n=6, 8.70\%), technological requirements (n=6, 8.70\%), organizational requirements (n=19, 27.54\%), understanding and supporting clinicians (n=12, 17.39\%), and understanding and improving patients' perceptions (n=13, 18.84\%), were identified. Additionally, 5 categories containing over 50 challenges, including those related to system levels (n=11, 23.91\%), technological requirements (n=6, 13.04\%), organizational requirements (n=13, 28.26\%), clinicians (n=10, 21.74\%), and patients (n=6, 13.04\%), were identified. Among the identified factors, 11 (9.57\%) were specific to regional and rural areas. Conclusions: This scoping review confirms that the successful implementation of telemedicine requires collective efforts at both the system and organizational levels, including coordination and collaboration across different regions and organizations. It underscores the importance of establishing a national network that enhances public awareness of telemedicine and clarity in payment and benefit distribution models and strengthens data security protection measures. The review also highlights the necessity of addressing infrastructural deficiencies, including internet connectivity in regional and rural areas, and suggests the implementation of targeted incentives and support measures. The required collective efforts are detailed in the proposed framework that promotes popularizing telemedicine, enhancing the overall quality and efficiency of health care services, and achieving broader health equity. ", doi="10.2196/65932", url="https://www.jmir.org/2025/1/e65932", url="http://www.ncbi.nlm.nih.gov/pubmed/40053725" } @Article{info:doi/10.2196/68083, author="Parciak, Marcel and Pierlet, No{\"e}lla and Peeters, M. Liesbet", title="Empowering Health Care Actors to Contribute to the Implementation of Health Data Integration Platforms: Retrospective of the medEmotion Project", journal="J Med Internet Res", year="2025", month="Mar", day="4", volume="27", pages="e68083", keywords="data science", keywords="health data integration", keywords="health data platform", keywords="real-world evidence", keywords="health care", keywords="health data", keywords="data", keywords="integration platforms", keywords="collaborative", keywords="platform", keywords="Belgium", keywords="Europe", keywords="personas", keywords="communication", keywords="health care providers", keywords="hospital-specific requirements", keywords="digital health", doi="10.2196/68083", url="https://www.jmir.org/2025/1/e68083", url="http://www.ncbi.nlm.nih.gov/pubmed/40053761" } @Article{info:doi/10.2196/63927, author="Li, Zhi and Xiang, Lianrui and Ning, Jing and Li, Wenbo and Huang, Yong and Xiao, Xue", title="Pathways to Sustainable Health Care Development: Study on the Carbon Reduction Potential of Telemedicine in China", journal="J Med Internet Res", year="2025", month="Feb", day="24", volume="27", pages="e63927", keywords="telemedicine", keywords="carbon reduction potential", keywords="carbon emissions", keywords="energy consumption", keywords="sustainable development", abstract="Background: Carbon emissions are a global concern due to their significant greenhouse effect. The health care sector's greenhouse gas (GHG) emissions must be controlled. Telemedicine in China continued to grow between 2020 and 2022, offering a promising solution for reducing carbon emissions in the country's health sector. Objective: This study explores the potential of telemedicine for reducing GHG emissions and saving energy through a life cycle assessment. Methods: This study used the Chinese Environmentally Extended Input-Output database, which is based on input-output models, to quantify the GHG emissions and energy consumption associated with care outpatient and telemedicine from a life cycle perspective. Data collected from the West China Second University Hospital of Sichuan University between 2020 and 2022 were incorporated into the analyses. Results: The findings indicated that telemedicine could reduce GHG emissions by 36 tCO2e. The GHG emissions per telemedicine session were only 19.14 kgCO2e and are expected to decrease from 2025 to 2030. Replacing in-person treatments with telemedicine can lead to an average reduction of 85.51 kgCO2e emissions. Conclusions: In the future, the widespread adoption of telemedicine could help achieve carbon neutrality in the health care sector. Telemedicine is crucial for establishing the sustainable development of the health care sector. ", doi="10.2196/63927", url="https://www.jmir.org/2025/1/e63927" } @Article{info:doi/10.2196/60810, author="Mess, Veronica Elisabeth and Regner, Matthias and Balic, Sabahudin and Kleybolte, Lukas and Daufratshofer, Lisa and Mahler, Andreas and Tilmes, Sabrina and Werlitz, Viktor and Reuter, Claudia and Teynor, Alexandra", title="Detailed Analysis and Road Map Proposal for Care Transition Records and Their Transmission Process: Mixed Methods Study", journal="JMIR Nursing", year="2025", month="Feb", day="21", volume="8", pages="e60810", keywords="care transition record", keywords="transmission management", keywords="observations", keywords="process modeling", keywords="telematics infrastructure", keywords="TI", keywords="Fast Healthcare Interoperability Resources", keywords="FHIR", keywords="Health Level 7", keywords="HL7", keywords="medical information object", keywords="MIO", keywords="care information object care transition record", keywords="CIO-CTR", keywords="Pflegerisches Informationsobjekt-{\"U}berleitungsbogen", keywords="PIO-ULB", keywords="artificial intelligence", keywords="AI", abstract="Background: The digitalization of health care in Germany holds great potential to improve patient care, resource management, and efficiency. However, strict data protection regulations, fragmented infrastructures, and resistance to change hinder progress. These challenges leave care institutions reliant on outdated paper-based workflows, particularly for patient data transmission, despite the pressing need for efficient tools to support health care professionals amid a nursing shortage and rising demand for care. Objective: This paper aims to analyze Germany's care transition record (CTR) and CTR transmission process as part of transition management and suggests improvements toward a seamless digital solution. Methods: To understand the current challenges of manual CTR transfers, we used a mixed methods approach, which included a web-based questionnaire with nursing professionals, field observations, business process model and notation modeling, semantic and frequency analysis of CTR entries, and user story mapping. Results: A web-based questionnaire involving German nursing professionals (N=59) revealed considerable delays in patient care due to manual, patient-transferred CTRs. Of the 33 usable responses (n=33), 70\% (n=23) of the respondents advocating for digital transmission to improve efficiency. Observations (N=11) in care facilities (n=5, 45\%) and a hospital (n=6, 55\%) confirmed the high administrative burden, averaging 34.67 (SD 10.78) minutes per CTR within a hospital and 44.6 (SD 20.5) minutes in care facilities. A semantic analysis of various CTRs (N=4) highlighted their differences and complexity, stressing the need for standardization. Analyzing a new CTR standard (care information object CTR) and manually mapping an existing CTR to it showed that the procedure was ambiguous, and some associations remained unclear. A frequency analysis of CTR entities revealed which were most used. In addition, discussions with care staff pointed out candidates for the most relevant entities. On the basis of the key findings, a stepwise transition approach toward a road map proposal for a standardized, secure transfer of CTRs was conceptualized. This road map in the form of a user story map, encompassing a ``CTR transformer'' (mapping of traditional CTRs to a new standard) and ``care information object CTR viewer/editor'' (in short, CIO-CTR viewer and editor; a new standard for viewing, editing, and exporting), shows a possibility to bridge the transition time until all institutions fully support the new standard. Conclusions: A future solution should simplify the overall CTR transmission process by minimizing manual transfers into in-house systems, standardizing the CTR, and providing a secure digital transfer. This could positively impact the overall care process and patient experience. With our solutions, we attempt to support care staff in their daily activities and processes until nationwide state regulations are implemented successfully, though the timeline for this remains uncertain. ", doi="10.2196/60810", url="https://nursing.jmir.org/2025/1/e60810", url="http://www.ncbi.nlm.nih.gov/pubmed/39982779" } @Article{info:doi/10.2196/62935, author="Lee, Hocheol", title="Assessment of Digital Capabilities by 9 Countries in the Alliance for Healthy Cities Using AI: Cross-Sectional Analysis", journal="JMIR Form Res", year="2025", month="Feb", day="7", volume="9", pages="e62935", keywords="digital capabilities", keywords="digital health cities", keywords="digital transformation", keywords="Asian Forum of Healthy Cities", keywords="assessment", keywords="digital health", keywords="artificial intelligence", keywords="AI", keywords="World Health Organization", keywords="WHO", keywords="healthy city", keywords="data", keywords="health management", keywords="digital era", keywords="qualitative analysis", keywords="cross-sectional survey", keywords="database", keywords="digital health database", keywords="effectiveness", keywords="digital literacy", abstract="Background: The Alma-Ata Declaration of 1978 initiated a global focus on universal health, supported by the World Health Organization (WHO) through healthy cities policies. The concept emerged at the 1984 Toronto ``Beyond Health Care'' conference, leading to WHO's first pilot project in Lisbon in 1986. The WHO continues to support regional healthy city networks, emphasizing digital transformation and data-driven health management in the digital era. Objective: This study explored the capabilities of digital healthy cities within the framework of digital transformation, focusing on member countries of the Asian Forum of Healthy Cities. It examined the cities' preparedness and policy needs for transitioning to digital health. Methods: A cross-sectional survey was conducted of 9 countries---Australia, Cambodia, China, Japan, South Korea, Malaysia, Mongolia, the Philippines, and Vietnam---from August 1 to September 21, 2023. The 6-section SPIRIT (setting approach and sustainability; political commitment, policy, and community participation; information and innovation; resources and research; infrastructure and intersectoral; and training) checklist was modified to assess healthy cities' digital capabilities. With input from 3 healthy city experts, the checklist was revised for digital capabilities, renaming ``healthy city'' to ``digital healthy city.'' The revised tool comprises 8 sections with 33 items. The survey leveraged ChatGPT (version 4.0; OpenAI, Microsoft), accessed via Python (Python Software Foundation) application programming interface. The openai library was installed, and an application programming interface key was entered to use ChatGPT (version 4.0). The ``GPT-4 Turbo'' model command was applied. A qualitative analysis of the collected data was conducted by 5 healthy city experts through group deep-discussions. Results: The results indicate that these countries should establish networks and committees for sustainable digital healthy cities. Cambodia showed the lowest access to electricity (70\%) and significant digital infrastructure disparities. Efforts to sustain digital health initiatives varied, with countries such as Korea focusing on telemedicine, while China aimed to build a comprehensive digital health database, highlighting the need for tailored strategies in promoting digital healthy cities. Life expectancy was the highest in the Republic of Korea and Japan (both 84 y). Access to electricity was the lowest in Cambodia (70\%) with the remaining countries having had 95\% or higher access. The internet use rate was the highest in Malaysia (97.4\%), followed by the Republic of Korea (97.2\%), Australia (96.2\%), and Japan (82.9\%). Conclusions: This study highlights the importance of big data-driven policies and personal information protection systems. Collaborative efforts across sectors for effective implementation of digital healthy cities. The findings suggest that the effectiveness of digital healthy cities is diminished without adequate digital literacy among managers and users, suggesting the need for policies to improve digital literacy. ", doi="10.2196/62935", url="https://formative.jmir.org/2025/1/e62935" } @Article{info:doi/10.2196/53483, author="Tran, Minh Duc and Thanh Dung, Nguyen and Minh Duc, Chau and Ngoc Hon, Huynh and Minh Khoi, Le and Phuc Hau, Nguyen and Thi Thu Huyen, Duong and Thi Le Thu, Huynh and Van Duc, Tran and and Minh Yen, Lam and Thwaites, Louise C. and Paton, Chris", title="Status of Digital Health Technology Adoption in 5 Vietnamese Hospitals: Cross-Sectional Assessment", journal="JMIR Form Res", year="2025", month="Feb", day="6", volume="9", pages="e53483", keywords="electronic health record", keywords="electronic medical record", keywords="digital maturity", keywords="clinical decision support", keywords="digital infrastructure", keywords="Vietnam", keywords="health information technology", keywords="digital health technology", keywords="low- and middle-income country", abstract="Background: Digital health technologies (DHTs) have been recognized as a key solution to help countries, especially those in the low- and middle-income group, to achieve the Sustainable Development Goals (SDGs) and the World Health Organization's (WHO) Triple Billion Targets. In hospital settings, DHTs need to be designed and implemented, considering the local context, to achieve usability and sustainability. As projects such as the Vietnam ICU Translational Applications Laboratory are seeking to integrate new digital technologies in the Vietnamese critical care settings, it is important to understand the current status of DHT adoption in Vietnamese hospitals. Objective: We aimed to explore the current digital maturity in 5 Vietnamese public hospitals to understand their readiness in implementing new DHTs. Methods: We assessed the adoption of some key DHTs and infrastructure in 5 top-tier public hospitals in Vietnam using a questionnaire adapted from the Vietnam Health Information Technology (HIT) Maturity Model. The questionnaire was answered by the heads of the hospitals' IT departments, with follow-up for clarifications and verifications on some answers. Descriptive statistics demonstrated on radar plots and tile graphs were used to visualize the data collected. Results: Hospital information systems (HIS), laboratory information systems (LIS), and radiology information systems--picture archiving and communication systems (RIS-PACS) were implemented in all 5 hospitals, albeit at varied digital maturity levels. At least 50\% of the criteria for LIS in the Vietnam HIT Maturity Model were satisfied by the hospitals in the assessment. However, this threshold was only met by 80\% and 60\% of the hospitals with regard to HIS and RIS-PACS, respectively. Two hospitals were not using any electronic medical record (EMR) system or fulfilling any extra digital capability, such as implementing clinical data repositories (CDRs) and clinical decision support systems (CDSS). No hospital reported sharing clinical data with other organizations using Health Level Seven (HL7) standards, such as Continuity of Care Document (CCD) and Clinical Document Architecture (CDA), although 2 (40\%) reported their systems adopted these standards. Of the 5 hospitals, 4 (80\%) reported their RIS-PACS adopted the Digital Imaging and Communications in Medicine (DICOM) standard. Conclusions: The 5 major Vietnamese public hospitals in this assessment have widely adopted information systems, such as HIS, LIS, and RIS-PACS, to support administrative and clinical tasks. Although the adoption of EMR systems is less common, their implementation revolves around data collection, management, and access to clinical data. Secondary use of clinical data for decision support through the implementation of CDRs and CDSS is limited, posing a potential barrier to the integration of external DHTs into the existing systems. However, the wide adoption of international standards, such as HL7 and DICOM, is a facilitator for the adoption of new DHTs in these hospitals. ", doi="10.2196/53483", url="https://formative.jmir.org/2025/1/e53483" } @Article{info:doi/10.2196/58338, author="Kaushik, Aprajita and Barcellona, Capucine and Mandyam, Kanumoory Nikita and Tan, Ying Si and Tromp, Jasper", title="Challenges and Opportunities for Data Sharing Related to Artificial Intelligence Tools in Health Care in Low- and Middle-Income Countries: Systematic Review and Case Study From Thailand", journal="J Med Internet Res", year="2025", month="Feb", day="4", volume="27", pages="e58338", keywords="artificial intelligence", keywords="data sharing", keywords="health care", keywords="low- and middle-income countries", keywords="AI tools", keywords="systematic review", keywords="case study", keywords="Thailand", keywords="computing machinery", keywords="academic experts", keywords="technology developers", keywords="health care providers", keywords="internet connectivity", keywords="data systems", keywords="low health data literacy", keywords="cybersecurity", keywords="standardized data formats", keywords="AI development", keywords="PRISMA", abstract="Background: Health care systems in low- and middle-income countries (LMICs) can greatly benefit from artificial intelligence (AI) interventions in various use cases such as diagnostics, treatment, and public health monitoring but face significant challenges in sharing data for developing and deploying AI in health care. Objective: This study aimed to identify barriers and enablers to data sharing for AI in health care in LMICs and to test the relevance of these in a local context. Methods: First, we conducted a systematic literature search using PubMed, SCOPUS, Embase, Web of Science, and ACM using controlled vocabulary. Primary research studies, perspectives, policy landscape analyses, and commentaries performed in or involving an LMIC context were included. Studies that lacked a clear connection to health information exchange systems or were not reported in English were excluded from the review. Two reviewers independently screened titles and abstracts of the included articles and critically appraised each study. All identified barriers and enablers were classified according to 7 categories as per the predefined framework---technical, motivational, economic, political, legal and policy, ethical, social, organisational, and managerial. Second, we tested the local relevance of barriers and enablers in Thailand through stakeholder interviews with 15 academic experts, technology developers, regulators, policy makers, and health care providers. The interviewers took notes and analyzed data using framework analysis. Coding procedures were standardized to enhance the reliability of our approach. Coded data were reverified and themes were readjusted where necessary to avoid researcher bias. Results: We identified 22 studies, the majority of which were conducted across Africa (n=12, 55\%) and Asia (n=6, 27\%). The most important data-sharing challenges were unreliable internet connectivity, lack of equipment, poor staff and management motivation, uneven resource distribution, and ethical concerns. Possible solutions included improving IT infrastructure, enhancing funding, introducing user-friendly software, and incentivizing health care organizations and personnel to share data for AI-related tools. In Thailand, inconsistent data systems, limited staff time, low health data literacy, complex and unclear policies, and cybersecurity issues were important data-sharing challenges. Key solutions included building a conducive digital ecosystem---having shared data input platforms for health facilities to ensure data uniformity and to develop easy-to-understand consent forms, having standardized guidelines for data sharing, and having compensation policies for data breach victims. Conclusions: Although AI in LMICs has the potential to overcome health inequalities, these countries face technical, political, legal, policy, and organizational barriers to sharing data, which impede effective AI development and deployment. When tested in a local context, most of these barriers were relevant. Although our findings might not be generalizable to other contexts, this study can be used by LMICs as a framework to identify barriers and strengths within their health care systems and devise localized solutions for enhanced data sharing. Trial Registration: PROSPERO CRD42022360644; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=360644 ", doi="10.2196/58338", url="https://www.jmir.org/2025/1/e58338" } @Article{info:doi/10.2196/60138, author="Figueroa, A. Caroline and Torkamaan, Helma and Bhattacharjee, Ananya and Hauptmann, Hanna and Guan, W. Kathleen and Sedrakyan, Gayane", title="Designing Health Recommender Systems to Promote Health Equity: A Socioecological Perspective", journal="J Med Internet Res", year="2025", month="Jan", day="30", volume="27", pages="e60138", keywords="digital health", keywords="health promotion", keywords="health recommender systems", keywords="artificial intelligence", keywords="health equity", keywords="AI", keywords="digital devices", keywords="socioecological", keywords="health inequities", keywords="health behavior", keywords="health behaviors", keywords="patient centric", keywords="digital health intervention", doi="10.2196/60138", url="https://www.jmir.org/2025/1/e60138" } @Article{info:doi/10.2196/54777, author="Sch{\"u}rmann, Fiona and Westmattelmann, Daniel and Schewe, Gerhard", title="Factors Influencing Telemedicine Adoption Among Health Care Professionals: Qualitative Interview Study", journal="JMIR Form Res", year="2025", month="Jan", day="27", volume="9", pages="e54777", keywords="trust referents", keywords="multidimensional risk", keywords="benefits", keywords="transparency", keywords="technology adoption", keywords="telemedicine", keywords="extended valence framework", abstract="Background: Telemedicine is transforming health care by enabling remote diagnosis, consultation, and treatment. Despite rapid adoption during the COVID-19 pandemic, telemedicine uptake among health care professionals (HCPs) remains inconsistent due to perceived risks and lack of tailored policies. Existing studies focus on patient perspectives or general adoption factors, neglecting the complex interplay of contextual variables and trust constructs influencing HCPs' telemedicine adoption. This gap highlights the need for a framework integrating risks, benefits, and trust in telemedicine adoption, while addressing health care's unique dynamics. Objective: This study aimed to adapt and extend the extended valence framework (EVF) to telemedicine, deconstructing factors driving adoption from an HCP perspective. Specifically, it investigated the nuanced roles of perceived risks, benefits, and trust referents (eg, technology, treatment, technology provider, and patient) in shaping behavioral intentions, while integrating contextual factors. Methods: We used a qualitative research design involving semistructured interviews with 14 HCPs experienced in offering video consultations. The interview data were analyzed with deductive and inductive coding based on the EVF. Two coders conducted the coding process independently, achieving an intercoder reliability of 86.14\%. The qualitative content analysis aimed to uncover the nuanced perspectives of HCPs, identifying key risk and benefit dimensions and trust referents relevant to telemedicine adoption. Results: The study reveals the complex considerations HCPs have when adopting telemedicine. Perceived risks were multidimensional, including performance risks such as treatment limitations (mentioned by 7/14, 50\% of the participants) and reliance on technical proficiency of patients (5/14, 36\%), privacy risks related to data security (10/14, 71\%), and time and financial risks associated with training (7/14, 50\%) and equipment costs (4/14, 29\%). Perceived benefits encompassed convenience through reduced travel time (5/14, 36\%), improved care quality due to higher accessibility (8/14, 57\%), and operational efficiency (7/14, 50\%). Trust referents played a pivotal role; trust in technology was linked to functionality (6/14, 43\%) and reliability (5/14, 36\%), while trust in treatment depended on effective collaboration (9/14, 64\%). Transparency emerged as a critical antecedent of trust across different referents, comprising disclosure, clarity, and accuracy. In addition, the study highlighted the importance of context-specific variables such as symptom characteristics (10/14, 71\%) and prior professional experience with telemedicine (11/14, 79\%). Conclusions: This study expands the EVF for telemedicine, providing a framework integrating multidimensional risks, benefits, trust, and contextual factors. It advances theory by decomposing trust referents and transparency into actionable subdimensions and emphasizing context-specific variables. Practically, the findings guide stakeholders: policy makers should prioritize transparent regulations and data security, health care organizations should provide training and support for HCPs, and technology developers must design telemedicine solutions aligning with trust and usability needs. This understanding equips health care to address barriers, optimize adoption, and leverage telemedicine's potential for sustainable clinical integration. ", doi="10.2196/54777", url="https://formative.jmir.org/2025/1/e54777" } @Article{info:doi/10.2196/58177, author="Kim, Hoon Ji and Kim, Joung Min and Kim, Chang Hyeon and Kim, Yan Ha and Sung, Min Ji and Chang, Hyuk-Jae", title="A Novel Artificial Intelligence--Enhanced Digital Network for Prehospital Emergency Support: Community Intervention Study", journal="J Med Internet Res", year="2025", month="Jan", day="23", volume="27", pages="e58177", keywords="emergency patient transport", keywords="transport time", keywords="artificial intelligence", keywords="smartphone", keywords="mobile phone", abstract="Background: Efficient emergency patient transport systems, which are crucial for delivering timely medical care to individuals in critical situations, face certain challenges. To address this, CONNECT-AI (CONnected Network for EMS Comprehensive Technical-Support using Artificial Intelligence), a novel digital platform, was introduced. This artificial intelligence (AI)--based network provides comprehensive technical support for the real-time sharing of medical information at the prehospital stage. Objective: This study aimed to evaluate the effectiveness of this system in reducing patient transport delays. Methods: The CONNECT-AI system provided 3 key AI services to prehospital care providers by collecting real-time patient data from the scene and hospital resource information, such as bed occupancy and the availability of emergency surgeries or procedures, using 5G communication technology and internet of things devices. These services included guidance on first aid, prediction of critically ill patients, and recommendation of the optimal transfer hospital. In addition, the platform offered emergency department medical staff real-time clinical information, including live video of patients during transport to the hospital. This community-based, nonrandomized controlled intervention study was designed to evaluate the effectiveness of the CONNECT-AI system in 2 regions of South Korea, each of which operated an intervention and a control period, each lasting 16 weeks. The impact of the system was assessed based on the proportion of patients experiencing transfer delays. Results: A total of 14,853 patients transported by public ambulance were finally selected for analysis. Overall, the median transport time was 10 (IQR 7-14) minutes in the intervention group and 9 (IQR 6-13) minutes in the control group. When comparing the incidence of transport time outliers (>75\%), which was the primary outcome of this study, the rate was higher in the intervention group in region 1, but significantly reduced in region 2, with the overall outlier rate being higher in the intervention group (27.5\%-29.7\%, P=.04). However, for patients with fever or respiratory symptoms, the group using the system showed a statistically significant reduction in outlier cases (36.5\%-30.1\%, P=.01). For patients who received real-time acceptance signals from the hospital, the reduction in the percentage of 75\% outliers was statistically significant compared with those without the system (27.5\%-19.6\%, P=.02). As a result of emergency department treatment, 1.5\% of patients in the control group and 1.1\% in the intervention group died (P=.14). In the system-guided optimal hospital transfer group, the mortality rate was significantly lower than in the control group (1.54\%-0.64\%, P=.01). Conclusions: The present digital emergency medical system platform offers a novel approach to enhancing emergency patient transport by leveraging AI, real-time information sharing, and decision support. While the system demonstrated improvements for certain patient groups facing transfer challenges, further research and modifications are necessary to fully realize its benefits in diverse health care contexts. Trial Registration: ClinicalTrials.gov NCT04829279; https://clinicaltrials.gov/study/NCT04829279 ", doi="10.2196/58177", url="https://www.jmir.org/2025/1/e58177", url="http://www.ncbi.nlm.nih.gov/pubmed/39847421" } @Article{info:doi/10.2196/57385, author="Zhang, Lan and Bullen, Christopher and Chen, Jinsong", title="Digital Health Innovations to Catalyze the Transition to Value-Based Health Care", journal="JMIR Med Inform", year="2025", month="Jan", day="20", volume="13", pages="e57385", keywords="digital health", keywords="value-based health care", keywords="VBHC", keywords="patient-reported outcome measures", keywords="PROM", keywords="digital transformation", keywords="health care innovation", keywords="patient-centric care", keywords="health technology", keywords="patient-reported outcome", keywords="PRO", keywords="outcome measure", keywords="telehealth", keywords="telemedicine", keywords="eHealth", keywords="personalized", keywords="customized", keywords="engagement", keywords="patient-centered care", keywords="standardization", keywords="implementation", doi="10.2196/57385", url="https://medinform.jmir.org/2025/1/e57385" } @Article{info:doi/10.2196/64940, author="Zhang, Hua and Yang, Cheng and Deng, Xiuxian and Luo, Chunyan", title="How Authoritative Media and Personal Social Media Influence Policy Compliance Through Trust in Government and Risk Perception: Quantitative Cross-Sectional Survey Study", journal="J Med Internet Res", year="2025", month="Jan", day="20", volume="27", pages="e64940", keywords="paradox of trust", keywords="risk perception", keywords="trust in government", keywords="policy compliance", keywords="pandemic", keywords="authoritative media", keywords="social media", keywords="China", abstract="Background: Previous studies on public compliance with policies during pandemics have primarily explained it from the perspectives of motivation theory, focusing on normative motivation (trust in policy-making institutions) and calculative motivation (fear of contracting the disease). However, the social amplification of a risk framework highlights that the media plays a key role in this process. Objective: This study aims to integrate the motivation theory of compliance behavior and the social amplification of risk framework to uncover the ``black boxes'' of the mechanisms by which normative motivation and calculative motivation influence public policy compliance behavior through the use of media. Methods: During the COVID-19 pandemic, we conducted a web-based survey of 2309 Chinese citizens from December 4, 2022, to March 21, 2023. We treated the public's policy compliance behavior during the pandemic as the dependent variable. Media use, specifically the use of authoritative media and ``we-media,'' that is, personal social media accounts and media platforms operated by individuals, was set as the independent variable. Trust in government, representing normative motivation, and risk perception, representing calculative motivation, were included as mediating variables. A structural equation model was constructed and analyzed using Stata. Results: First, the mediation effect of trust in government indicates that the use of authoritative media can enhance trust in government, which significantly increases individuals' policy compliance behavior ($\beta$ coefficient=0.108, 95\% CI 0.080-0.135; P<.001). Second, the mediation effect of risk perception shows that the use of we-media heightened individual risk perception, thereby significantly enhancing policy compliance behavior ($\beta$ coefficient=0.012, 95\% CI 0.002-0.021; P=.02). Third, the study revealed the ``paradox of trust'': the chain mediation effect in which authoritative media increased trust in government and reduced risk perception, ultimately decreasing policy compliance behavior ($\beta$ coefficient=--0.005, 95\% CI --0.009 to --0.001; P=.008). Conclusions: By combining the motivation theory of compliance behavior with the social amplification of risk framework in risk communication, we found that trust in government, as a normative motivation, operates through authoritative media, while risk perception, as a calculative motivation, promotes compliance behavior through we-media. In addition, in major crises, the public's use of authoritative media can lead to the paradox of trust: on the one hand, trust in the government increases policy compliance; on the other hand, this trust reduces risk perception, thereby decreasing compliance behavior. Authoritative institutions need to balance providing authoritative information with maintaining the public's risk perception. ", doi="10.2196/64940", url="https://www.jmir.org/2025/1/e64940" } @Article{info:doi/10.2196/58271, author="Savaria, Virginie and Queenton, Johanne and Carrier, Annie", title="Decentralized Management of Home Care Services for Seniors: Protocol for a Participatory Action Research", journal="JMIR Res Protoc", year="2025", month="Jan", day="17", volume="14", pages="e58271", keywords="health system", keywords="decentralization", keywords="management", keywords="home care services", keywords="seniors", keywords="collaboration", abstract="Background: The centralization of decision-making power in the public health care system has a negative impact on the practice of professionals and the quality of home care services (HCS) for seniors. To improve HCS, decentralized management could be a particularly promising approach. To be effective, strategies designed to incorporate this management approach require attention to 3 elements: autonomy of local stakeholders, individual and organizational capacities, and accountability for actions and decisions. Not many studies have focused on strategies for integrating decentralized and collaborative management at the local level in HCS. Objective: The overall aim of this study is to coconstruct HCS management strategies and explore decentralized practices in the day-to-day work of low-level managers and professionals. The specific objectives, in collaboration with local HCS stakeholders, are to (1) identify concrete and achievable strategies for decentralized management, and (2) describe factors (facilitators and obstacles) that could potentially influence their integration. Methods: This participatory action research involves a cyclical process. Before initiating the cycles, a preliminary stage consists of forming a steering committee composed of managers (n=3), professionals (n=3), seniors (n=3), informal caregivers (n=3), and the research team (n=3). This committee will facilitate multistakeholder consultation to coconstruct local management strategies based on a real-life problem identified by the committee. The steering committee will also guide the research process. The first cycle will consist of establishing an initial plan of decentralized management strategies. During the observation phase, meetings of 4 homogeneous focus groups, including managers, professionals, seniors, and informal caregivers, will be held. During the reflection phase, a thematic analysis will be carried out, and data will be interpreted and validated by the steering committee. Then, in the action phase, results will be presented to managers and professionals so that they can coconstruct a plan of decentralized management strategies to prioritize. The second cycle will explore the factors involved. The observation, reflection, and action phases will be repeated. Ultimately, the results of the 2 cycles will be integrated in a model coconstructed by the steering committee. Results: Data collection is in progress; the partnership officially began on February 1, 2024, and the plan is to continue data collection through 2025. The steering committee will validate the data to ensure that they are accurate and that the results reflect the reality of local stakeholders. Conclusions: By identifying decentralized and collaborative management strategies at the local level as well as factors to facilitate their integration in HCS, this approach can be used for other decentralized management projects in different areas of the health care system. This study will give decision makers insight into strategies aimed at improving the management of their institution, which will enhance seniors' well-being and the quality of their health care services. International Registered Report Identifier (IRRID): DERR1-10.2196/58271 ", doi="10.2196/58271", url="https://www.researchprotocols.org/2025/1/e58271" } @Article{info:doi/10.2196/59111, author="Gille, Felix and Maa{\ss}, Laura and Ho, Benjamin and Srivastava, Divya", title="From Theory to Practice: Viewpoint on Economic Indicators for Trust in Digital Health", journal="J Med Internet Res", year="2025", month="Jan", day="15", volume="27", pages="e59111", keywords="trust", keywords="economics", keywords="digital health", keywords="digital health innovation", keywords="artificial intelligence", keywords="AI", keywords="economic evaluation", keywords="public trust", keywords="health data", keywords="medical apps", doi="10.2196/59111", url="https://www.jmir.org/2025/1/e59111" } @Article{info:doi/10.2196/63015, author="Laukka, Elina and Tuunanen, Tuure and Jansson, Miia and Vanhanen, Minna and Hirvonen, Nina and Palukka, Jenni and Vesinurm, M{\"a}rt and Torkki, Paulus", title="Value Cocreation and Codestruction in Digital Health Services: Protocol for a Systematic Review", journal="JMIR Res Protoc", year="2025", month="Jan", day="14", volume="14", pages="e63015", keywords="value cocreation", keywords="value codestruction", keywords="telemedicine", keywords="eHealth", keywords="systematic review", abstract="Background: To successfully design, develop, implement, and deliver digital health services that provide value, they should be cocreated with patients. However, occasionally, the value may also be codestructed. In the field of health care, the concepts of value cocreation and codestruction still need to be better established within emerging digital health services. Studying these concepts is essential for developing effective and sustainable patient-centered care. Objective: The aim of the study is (1) to understand the antecedents, decisions, and outcomes of value cocreation and codestruction in digital health services, (2) to define the dynamics between value cocreation and codestruction, and (3) to map future research areas of value cocreation and codestruction within digital health services. Methods: The systematic review will be conducted in accordance with the Joanna Briggs Institute methodology for mixed method systematic reviews and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The review considers scientific qualitative, quantitative, or mixed method studies published in English, Finnish, or Swedish that concern either value cocreation or codestruction in digital health services. Studies focusing on physical robotics and online health communities, as well as non--peer-reviewed and nonscientific papers, will be excluded. The searches were conducted using Scopus and MEDLINE during this protocol creation. Critical appraisal will be done using suitable checklists for qualitative, quantitative, and mixed method studies. The review will adhere to a convergent integrated approach as outlined in the Joanna Briggs Institute methodology for mixed methods systematic reviews. Results: The searches resulted in a total of 837 records. The antecedents, decisions, and outcomes of value cocreation and codestruction in the context of digital health services will be described in a finalized systematic review. In the outcomes, our main interest is the effect on patient outcomes and experiences and professional experiences. Conclusions: Since our study involves diverse scientific fields, there is a risk that our search does not capture all relevant papers. To mitigate this risk, we used 2 large databases for the searches. In addition, the value cocreation or codestruction terms may not have been used in all studies focusing on the collaborative roles of patients and providers, especially in the medical field, and that may be difficult to capture. The review reveals the current understanding of value cocreation and codestruction in digital health services and shapes the research agenda for these phenomena. Value cocreation can be used to both design and efficiently use digital health services trying to maximize the value for patients. International Registered Report Identifier (IRRID): DERR1-10.2196/63015 ", doi="10.2196/63015", url="https://www.researchprotocols.org/2025/1/e63015" } @Article{info:doi/10.2196/65725, author="Weimar, Noel Sascha and Martjan, Sophie Rahel and Terzidis, Orestis", title="Business Venturing in Regulated Markets---Taxonomy and Archetypes of Digital Health Business Models in the European Union: Mixed Methods Descriptive and Exploratory Study", journal="J Med Internet Res", year="2025", month="Jan", day="9", volume="27", pages="e65725", keywords="digital health", keywords="telemedicine", keywords="mobile health", keywords="business model", keywords="European Union", keywords="classification", keywords="archetypes", keywords="medical device regulations", keywords="mobile phone", keywords="artificial intelligence", keywords="AI", abstract="Background: Digital health technology (DHT) has the potential to revolutionize the health care industry by reducing costs and improving the quality of care in a sector that faces significant challenges. However, the health care industry is complex, involving numerous stakeholders, and subject to extensive regulation. Within the European Union, medical device regulations impose stringent requirements on various ventures. Concurrently, new reimbursement pathways are also being developed for DHTs. In this dynamic context, establishing a sustainable and innovative business model around DHTs is fundamental for their successful commercialization. However, there is a notable lack of structured understanding regarding the overarching business models within the digital health sector. Objective: This study aims to address this gap and identify key elements and configurations of business models for DHTs in the European Union, thereby establishing a structured understanding of the archetypal business models in use. Methods: The study was conducted in 2 phases. First, a business model taxonomy for DHTs was developed based on a systematic literature review, the analysis of 169 European real-world business models, and qualitative evaluation through 13 expert interviews. Subsequently, a 2-step clustering analysis was conducted on the 169 DHT business models to identify distinct business model archetypes. Results: The developed taxonomy of DHT business models revealed 11 central dimensions organized into 4 meta-dimensions. Each dimension comprises 2 to 9 characteristics capturing relevant aspects of DHT business models. In addition, 6 archetypes of DHT business models were identified: administration and communication supporter (A1), insurer-to-consumer digital therapeutics and care (A2), diagnostic and treatment enabler (A3), professional monitoring platforms (A4), clinical research and solution accelerators (A5), and direct-to-consumer wellness and lifestyle (A6). Conclusions: The findings highlight the critical elements constituting business models in the DHT domain, emphasizing the substantial impact of medical device regulations and revenue models, which often involve reimbursement from stakeholders such as health insurers. Three drivers contributing to DHT business model innovation were identified: direct targeting of patients and private individuals, use of artificial intelligence as an enabler, and development of DHT-specific reimbursement pathways. The study also uncovered surprising business model patterns, including shifts between regulated medical devices and unregulated research applications, as well as wellness and lifestyle solutions. This research enriches the understanding of business models in digital health, offering valuable insights for researchers and digital health entrepreneurs. ", doi="10.2196/65725", url="https://www.jmir.org/2025/1/e65725" } @Article{info:doi/10.2196/46257, author="Kraushaar, Judith and Bohnet-Joschko, Sabine", title="The Role of the Organization in Promoting Information Security--Related Behavior Among Resident Physicians in Hospitals in Germany: Cross-Sectional Questionnaire Study", journal="J Med Internet Res", year="2025", month="Jan", day="7", volume="27", pages="e46257", keywords="information security", keywords="compliance", keywords="work engagement", keywords="awareness", keywords="leadership", keywords="communication", keywords="education and training", keywords="security", keywords="privacy", keywords="structural equation modeling", keywords="resident", keywords="fellow", keywords="medical education", keywords="continuing education", keywords="professional development", abstract="Background: Nowadays, optimal patient care should be based on data-driven decisions. In the course of digitization, hospitals, in particular, are becoming complex organizations with an enormously high density of digital information. Ensuring information security is, therefore, essential and has become a major challenge. Researchers have shown that---in addition to technological and regulatory measures---it is also necessary for all employees to follow security policies and consciously use information technology (compliance), because noncompliance can lead to security breaches with far-reaching consequences for the organization. There is little empirical research on information security--related behavior in hospitals and its organizational antecedents. Objective: This study aimed to explore the impact of specific job demands and resources on resident physicians' information security--related compliance in hospitals through the mediating role of work engagement and information security--related awareness. Methods: We used a cross-sectional, survey-based study design to collect relevant data from our target population, namely resident physicians in hospitals. For data analysis, we applied structural equation modeling. Our research model consisted of a total of 7 job demands and resources as exogenous variables, 2 mediators, and information security--related compliance as the endogenous variable. Results: Overall, data from 281 participating physicians were included in the analyses. Both mediators---work engagement and awareness---had a significant positive effect on information security--related compliance ($\beta$=.208, P=.001 vs $\beta$=.552, P<.001). Quality of leadership was found to be the only resource with a significant indirect effect on physicians' compliance, mediated by work engagement ($\beta$=.086, P=.03). Furthermore, awareness mediated the relationships between information security--related communication and information security--related compliance ($\beta$=.192, P<.001), as well as between further education and training and the endogenous variable ($\beta$=.096, P=.02). Contrary to our hypothesis, IT resources had a negative effect on compliance, mediated by awareness ($\beta$=--.114, P=.02). Conclusions: This study provides new insights into how a high standard of information security compliance among resident physicians could be achieved through strengthening physicians' security work engagement and awareness. Hospital management is required to establish an information security culture that is informative and motivating and that raises awareness. Particular attention should be paid to the quality of leadership, further education and training, as well as clear communication. ", doi="10.2196/46257", url="https://www.jmir.org/2025/1/e46257" } @Article{info:doi/10.2196/62768, author="Yu, Zhongguang and Hu, Ning and Zhao, Qiuyi and Hu, Xiang and Jia, Cunbo and Zhang, Chunyu and Liu, Bing and Li, Yanping", title="The Willingness of Doctors to Adopt Artificial Intelligence--Driven Clinical Decision Support Systems at Different Hospitals in China: Fuzzy Set Qualitative Comparative Analysis of Survey Data", journal="J Med Internet Res", year="2025", month="Jan", day="7", volume="27", pages="e62768", keywords="artificial intelligence", keywords="clinical decision support systems", keywords="willingness", keywords="technology adoption", keywords="fuzzy set qualitative comparative analysis", keywords="fsQCA", keywords="pathways", abstract="Background: Artificial intelligence--driven clinical decision support systems (AI-CDSSs) are pivotal tools for doctors to improve diagnostic and treatment processes, as well as improve the efficiency and quality of health care services. However, not all doctors trust artificial intelligence (AI) technology, and many remain skeptical and unwilling to adopt these systems. Objective: This study aimed to explore in depth the factors influencing doctors' willingness to adopt AI-CDSSs and assess the causal relationships among these factors to gain a better understanding for promoting the clinical application and widespread implementation of these systems. Methods: Based on the unified?theory?of acceptance and use of technology (UTAUT) and the technology-organization-environment (TOE) framework, we have proposed and designed a framework for doctors' willingness to adopt AI-CDSSs. We conducted a nationwide questionnaire survey in China and performed fuzzy set qualitative comparative analysis to explore the willingness of doctors to adopt AI-CDSSs in different types of medical institutions and assess the factors influencing their willingness. Results: The survey was administered to doctors working in tertiary hospitals and primary/secondary hospitals across China. We received 450 valid responses out of 578 questionnaires distributed, indicating a robust response rate of 77.9\%. Our analysis of the influencing factors and adoption pathways revealed that doctors in tertiary hospitals exhibited 6 distinct pathways for AI-CDSS adoption, which were centered on technology-driven pathways, individual-driven pathways, and technology-individual dual-driven pathways. Doctors in primary/secondary hospitals demonstrated 3 adoption pathways, which were centered on technology-individual and organization-individual dual-driven pathways. There were commonalities in the factors influencing adoption across different medical institutions, such as the positive perception of AI technology's utility and individual readiness to try new technologies. There were also variations in the influence of facilitating conditions among doctors at different medical institutions, especially primary/secondary hospitals. Conclusions: From the perspective of the 6 pathways for doctors at tertiary hospitals and the 3 pathways for doctors at primary/secondary hospitals, performance expectancy and personal innovativeness were 2 indispensable and core conditions in the pathways to achieving favorable willingness to adopt AI-CDSSs. ", doi="10.2196/62768", url="https://www.jmir.org/2025/1/e62768" } @Article{info:doi/10.2196/66356, author="Gehder, Sara and Goeldner, Moritz", title="Unpacking Performance Factors of Innovation Systems and Studying Germany's Attempt to Foster the Role of the Patient Through a Market Access Pathway for Digital Health Applications (DiGAs): Exploratory Mixed Methods Study", journal="J Med Internet Res", year="2025", month="Jan", day="6", volume="27", pages="e66356", keywords="regulatory market access pathways", keywords="digital health application", keywords="DiGA", keywords="patient-relevant structural and procedural improvement", keywords="pSVV pathway analysis", keywords="qualitative and systemic analysis", keywords="policy and stakeholder insights", keywords="innovation system analysis", abstract="Background: Health care innovation faces significant challenges, including system inertia and diverse stakeholders, making regulated market access pathways essential for facilitating the adoption of new technologies. The German Digital Healthcare Act, introduced in 2019, offers a model by enabling digital health applications (DiGAs) to be reimbursed by statutory health insurance, improving market access and patient empowerment. However, the factors influencing the success of these pathways in driving innovation remain unclear. Objective: This study aims to identify the key performance factors of the innovation system shaped by the patient-relevant structural and procedural improvement (pSVV) pathway within the DiGA model. By examining how this pathway supports the entry of innovative digital health technologies, we seek to uncover the systemic dynamics that influence its effectiveness in fostering patient-centered digital health solutions. Methods: This study, conducted from May 2023 to November 2024, used a mixed methods approach. A descriptive analysis assessed how DiGA manufacturers use positive health care effects, giving a market overview of the pSVV technology. A qualitative analysis using grounded theory and Gioia methodology provided insights into stakeholder perspectives, focusing on manufacturers and regulatory bodies. A functional-structural analysis examined how components of the innovation system, such as actors, institutions, interactions, and infrastructure, interact and impact the effectiveness of the pathway. Results: The descriptive analysis showed that only 11 (20\%) of the 56 DiGAs available in Germany used the pSVV pathway, with only 1 (2\%) provisionally listed DiGA using pSVV as a primary end point; 6 of 9 (67\%) pSVV key areas were used. The qualitative analysis revealed that manufacturers prioritize demonstrating medical benefits over pSVV due to evidence requirements and uncertainties around pSVV acceptance. Operational barriers hindered the adoption of pSVV, despite a positive reception among stakeholders. The systemic analysis identified key issues, including a lack of entrepreneurial focus on pSVV, limited regulatory experience, inadequate measurement methods, and entrenched practices prioritizing medical benefits, that hinder market formation and legitimacy. Conclusions: This study identifies key factors for effectively implementing innovation systems through regulated market access pathways, including content and format security, clearer framework specification, active innovation process management, and market formation stimulation. Addressing these factors can reduce uncertainties and promote wider adoption of digital health technologies. The findings highlight the need for future research on patient empowerment and the development of methodologies beyond traditional therapeutic outcomes. ", doi="10.2196/66356", url="https://www.jmir.org/2025/1/e66356" } @Article{info:doi/10.2196/60832, author="Powell, Daniel and Asad, Laiba and Zavaglia, Elissa and Ferrari, Manuela", title="Promoting Digital Health Data Literacy: The Datum Project", journal="JMIR Form Res", year="2025", month="Jan", day="3", volume="9", pages="e60832", keywords="health data", keywords="digital data", keywords="medical records", keywords="legislation", keywords="ethics", keywords="knowledge dissemination", keywords="learning health system", keywords="data bank", doi="10.2196/60832", url="https://formative.jmir.org/2025/1/e60832" } @Article{info:doi/10.2196/57332, author="Izumida, Yoshihiko and Omura, Takashi and Fujiwara, Masahiro and Nukaya, Shoko and Yoneyama, Akio and Boubacar, Sow and Yabe, Shinichiro and Noguchi, Rika and Nakayama, Shima and Muraoka, Wataru and Okuno, Yuki and Miyashita, Sho and Ishihara, Yurika and Moriwaki, Yuto and Otani, Ryoji and Adachi, Junichiro and Tanabe, Kenichiro and Yamano, Yoshihisa and Takai, Yasushi and Honjo, Masaru", title="Patient-Centric Approach to Personalized Electronic Medical Records via QR Code in Japan", journal="Interact J Med Res", year="2024", month="Dec", day="23", volume="13", pages="e57332", keywords="Sync for Science-J", keywords="S4S-J", keywords="electronic medical record", keywords="personal health record", keywords="privacy preference manager", keywords="patient-generated health data", keywords="Health Level 7 Fast Health Care Interoperability Resources", keywords="HL7-FHIR", keywords="logical observation identifiers names and codes", keywords="LOINC", keywords="open science", keywords="mobile health", keywords="app", keywords="digital health", keywords="digital intervention", doi="10.2196/57332", url="https://www.i-jmr.org/2024/1/e57332" } @Article{info:doi/10.2196/63054, author="Wang, Yining and Ren, Hui and Xiao, Shaotan and Meng, Tian and Sun, Shuyue and Yu, Siyu and Liu, Qing and Wang, Fan", title="Factors Associated With Digital Capacity for Health Promotion Among Primary Care Workers: Cross-Sectional Survey Study", journal="J Med Internet Res", year="2024", month="Dec", day="20", volume="26", pages="e63054", keywords="health promotion", keywords="digital capacity", keywords="primary care workers", keywords="Digital Capabilities Framework", keywords="online survey", abstract="Background: Health education and promotion are recognized as effective strategies for fostering healthy ageing, reducing the disease burden, and addressing health inequalities, particularly when delivered through digital media. Primary care workers are often regarded as the key providers of these interventions. Despite the strong practical significance and substantial individual demand, the use of digital media for delivering health promotion practices was not widespread in China. One of the main challenges identified is the providers' inadequate capacities. However, little is known about the digital capacity for health promotion among primary care workers. Objective: This study aimed to investigate the levels of digital capacity for health promotion and its associated factors among community health workers. Methods: A total of 1346 community health workers were recruited from across 47 communities in Shanghai, China, through cluster-stratified random sampling. The digital capacity for health promotion was measured using the revised version of the Digital Capabilities Framework. Web-based questionnaires were distributed to collect data from March 20 to March 29, 2024. Data were analyzed using descriptive statistics, independent t tests, one-way ANOVA, and linear hierarchical regression using Stata MP (version 17.0; StataCorp). Results: We included 1199 participants. Among them, 47.5\% (570/1199) had high digital media use for more than 19.6 hours per week, whereas 31.8\% (381/1199) demonstrated high digital media trust. The average level of digital capacity for health promotion was 16.71 (SD 2.94) out of 25 points. Demographics, digital media usage--related characteristics, perceived usefulness and usability, attitudes, and behaviors were significant predictors of the capacities, explaining 44.4\% of the total variance. Master's degree or above ($\beta$=.077; P=.013), perceived usability ($\beta$=.235; P<.001), attitudes toward digital media health promotion ($\beta$=.095; P=.002), and past digital media health promotion practices ($\beta$=.377; P<.001) had significantly positive associations with digital capacities for health promotion. However, senior ($\beta$=--.076; P=.008) or median ($\beta$=--.074; P=.01) titles had a significant negative association with capacity levels. Conclusions: A digitally capable workforce is required for primary health care systems to take full advantage of digital media health promotion. Therefore, solutions are necessary to achieve enhanced capacities among health professionals, including public health policy making, community empowerment, and individual practices. ", doi="10.2196/63054", url="https://www.jmir.org/2024/1/e63054" } @Article{info:doi/10.2196/60535, author="Jeanmougin, Pauline and Larramendy, St{\'e}phanie and Fournier, Jean-Pascal and Gaultier, Aur{\'e}lie and Rat, C{\'e}dric", title="Effect of a Feedback Visit and a Clinical Decision Support System Based on Antibiotic Prescription Audit in Primary Care: Multiarm Cluster-Randomized Controlled Trial", journal="J Med Internet Res", year="2024", month="Dec", day="18", volume="26", pages="e60535", keywords="antibacterial agents", keywords="feedback", keywords="clinical decision support system", keywords="prescriptions", keywords="primary health care", keywords="clinical decision", keywords="antibiotic prescription", keywords="antimicrobial", keywords="antibiotic stewardship", keywords="interventions", keywords="health insurance", keywords="systematic antibiotic prescriptions", abstract="Background: While numerous antimicrobial stewardship programs aim to decrease inappropriate antibiotic prescriptions, evidence of their positive impact is needed to optimize future interventions. Objective: This study aimed to evaluate 2 multifaceted antibiotic stewardship interventions for inappropriate systemic antibiotic prescription in primary care. Methods: An open-label, cluster-randomized controlled trial of 2501 general practitioners (GPs) working in western France was conducted from July 2019 to January 2021. Two interventions were studied: the standard intervention, consisting of a visit by a health insurance representative who gave prescription feedback and provided a leaflet for treating cystitis and tonsillitis; and a clinical decision support system (CDSS)--based intervention, consisting of a visit with prescription feedback and a CDSS demonstration on antibiotic prescribing. The control group received no intervention. Data on systemic antibiotic dispensing was obtained from the National Health Insurance System (Syst{\`e}me National d'Information Inter-R{\'e}gimes de l'Assurance Maladie) database. The overall antibiotic volume dispensed per GP at 12 months was compared between arms using a 2-level hierarchical analysis of covariance adjusted for annual antibiotic prescription volume at baseline. Results: Overall, 2501 GPs were randomized (n=1099, 43.9\% women). At 12 months, the mean volume of systemic antibiotics per GP decreased by 219.2 (SD 61.4; 95\% CI ?339.5 to ?98.8; P<.001) defined daily doses in the CDSS-based visit group compared with the control group. The decrease in the mean volume of systemic antibiotics dispensed per GP was not significantly different between the standard visit group and the control group (?109.7, SD 62.4; 95\% CI ?232.0 to 12.5 defined daily doses; P=.08). Conclusions: A visit by a health insurance representative combining feedback and a CDSS demonstration resulted in a 4.4\% (-219.2/4930) reduction in the total volume of systemic antibiotic prescriptions in 12 months. Trial Registration: ClinicalTrials.gov NCT04028830; https://clinicaltrials.gov/study/NCT04028830 ", doi="10.2196/60535", url="https://www.jmir.org/2024/1/e60535", url="http://www.ncbi.nlm.nih.gov/pubmed/39693139" } @Article{info:doi/10.2196/65626, author="Hasavari, Shirin and Esmaeilzadeh, Pouyan", title="Appropriately Matching Transport Care Units to Patients in Interhospital Transport Care: Implementation Study", journal="JMIR Form Res", year="2024", month="Dec", day="13", volume="8", pages="e65626", keywords="interfacility transport care", keywords="electronic health records", keywords="data sharing", keywords="blockchain", keywords="hyperledger fabric", keywords="privacy", keywords="implementation", keywords="EMS", keywords="emergency medical services", abstract="Background: In interfacility transport care, a critical challenge exists in accurately matching ambulance response levels to patients' needs, often hindered by limited access to essential patient data at the time of transport requests. Existing systems cannot integrate patient data from sending hospitals' electronic health records (EHRs) into the transfer request process, primarily due to privacy concerns, interoperability challenges, and the sensitive nature of EHR data. We introduce a distributed digital health platform, Interfacility Transport Care (ITC)--InfoChain, designed to solve this problem without compromising EHR security or data privacy. Objective: This study aimed to detail the implementation of ITC-InfoChain, a secure, blockchain-based platform designed to enhance real-time data sharing without compromising data privacy or EHR security. Methods: The ITC-InfoChain platform prototype was implemented on Amazon Web Services cloud infrastructure, using Hyperledger Fabric as a permissioned blockchain. Key elements included participant registration, identity management, and patient data collection isolated from the sending hospital's EHR system. The client program submits encrypted patient data to a distributed ledger, accessible to the receiving facility's critical care unit at the time of transport request and emergency medical services (EMS) teams during transport through the PatienTrack web app. Performance was evaluated through key performance indicators such as data transaction times and scalability across transaction loads. Results: The ITC-InfoChain demonstrated strong performance and scalability. Data transaction times averaged 3.1 seconds for smaller volumes (1-20 transactions) and 6.4 seconds for 100 transactions. Optimized configurations improved processing times to 1.8-1.9 seconds for 400 transactions. These results confirm the platform's capacity to handle high transaction volumes, supporting timely, real-time data access for decision-making during transport requests and patient transfers. Conclusions: The ITC-InfoChain platform addresses the challenge of matching appropriate transport units to patient needs by ensuring data privacy, integrity, and real-time data sharing, enhancing the coordination of patient care. The platform's success suggests potential for regional pilots and broader adoption in secure health care systems. Stakeholder resistance due to blockchain unfamiliarity and data privacy concerns remains. Funding has been sought to support a pilot program to address these challenges through targeted education and engagement. ", doi="10.2196/65626", url="https://formative.jmir.org/2024/1/e65626", url="http://www.ncbi.nlm.nih.gov/pubmed/39540868" } @Article{info:doi/10.2196/56699, author="Li, Qingqing and Cheng, Feng and Zeng, Huatang and Xu, Junfang", title="Health Insurance Payment for Telehealth Services: Scoping Review and Narrative Synthesis", journal="J Med Internet Res", year="2024", month="Dec", day="9", volume="26", pages="e56699", keywords="telehealth", keywords="internet-based health care", keywords="reimbursement", keywords="health insurance payment", keywords="health care", keywords="scoping review", keywords="narrative synthesis", keywords="mobile phone", abstract="Background: As telehealth services have demonstrated significant advantages in providing qualified and accessible care, health insurance payments for telehealth services have been issued by various countries. However, the optimization of health insurance payments for telehealth services remains uncertain. Objective: We conducted a scoping review of the current situation regarding health insurance payments for telehealth services, with the aim of providing evidence to enhance policies related to health insurance payments for such services. Methods: This scoping review was conducted by comprehensively retrieving data from 6 electronic bibliographic databases from inception to October 2023. The databases included China National Knowledge Infrastructure, Wan Fang, Weipu, Web of Science, PubMed, and Embase, following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Two authors independently assessed search results, extracted data, and evaluated the quality of the included studies using the Critical Appraisal Skills Programme checklist. After the initial screening of titles and abstracts, full texts were obtained and examined. The data regarding the first author, date of publication, country, type of telehealth services introduced in health insurance, health insurance reimbursement providers, reimbursement standards for telehealth (eg, the condition for the reimbursement and reimbursement rate), and key findings of studies were extracted and analyzed. Moreover, we also conducted a narrative synthesis to summarize and report the findings. Results: A total of 7232 papers were retrieved. Following quality assessment, 23 papers were finally included, with the covered countries including China, the United States, Australia, France, Japan, the United Kingdom, and Germany. The forms of the services vary across different regions, mainly including consultation services, medical monitoring services, mental health services, health education services, and other services. Payment standards are generally categorized into fee-for-service and global budget payment, with clear health insurance payment quotas or proportions and certain restrictions (eg, specifying the location of medical visits and setting the limitation on distance from home to hospitals). The paying entities for health insurance payment include national health insurance and commercial health insurance. In addition, there are 2 kinds of reimbursement rates---a comparable rate for both telehealth and in-person health care services, and a lower rate for telehealth services compared to in-person health care services. Conclusions: To enhance the accessibility of telehealth services through health insurance payment, it is crucial to further refine the design of health insurance payment for telehealth and strengthen the supervision of services quality, bridging the gap between telehealth and in-person health care services. Additionally, this review did not include studies from all countries, and we recommend that future reviews should include a broader range of countries to provide a more comprehensive view of global telehealth insurance systems. ", doi="10.2196/56699", url="https://www.jmir.org/2024/1/e56699" } @Article{info:doi/10.2196/59717, author="Linstad, Helen Line and Bj{\o}rn{\aa}, Hilde and Moen, Anne and Tunby Kristiansen, Truls and Hansen, Helen Anne", title="Investigating the Norwegian eHealth Governance Model: Document Study", journal="J Med Internet Res", year="2024", month="Dec", day="4", volume="26", pages="e59717", keywords="eHealth policy", keywords="fragmented decision authority", keywords="top-down governance", keywords="bottom-up network", keywords="participation", keywords="electronic health record", abstract="Background: Governments and policy makers struggle to achieve a balance between hierarchical steering and horizontal governance in systems characterized by fragmented decision authority and multiple interests. To realize its One Citizen--One Journal eHealth policy vision, the Norwegian government established a special eHealth board of stakeholders to create an inclusive governance model that aligned stakeholders' interests with the?government's ambitions through coordination and consensus. Little empirical knowledge exists on how countries realize inclusive governance models. Objective: This study aims to investigate how the Norwegian inclusive eHealth governance model was developed as a tool to align the government's policy ambitions with stakeholders' concerns from January 2012 to December 2022. Methods: This document study used a thematic analysis based on a constructivist research approach. We included 16 policy documents and 175 consultation response documents issued between January 2012 and December 2022 related to the Norwegian One Citizen--One Journal policy implementation process. The themes were constructed deductively from a review of governance models and public governance theory and were applied as our analytical lens to each document. The findings were interpreted, analyzed, and synthesized. Results: The national policy implementation process progressed through 3 phases, with changes in stakeholder inclusion and perceived influence on the decision-making process characterizing transitions from phase to phase. Tension developed between 2 contrasting views regarding top-down government authority and stakeholders' autonomy. The view of the regional health trusts, municipalities, health care professional organizations, and industry actors contrasted with that of the patient organizations. Governmental insensitivity to participation, lack of transparency, and decreasing trust by stakeholder groups challenged the legitimacy of the inclusive governance model. Conclusions: We illustrated that Norway's One Citizen--One Journal policy trajectory was characterized by a process that unfolded across 3 distinct phases. The process was characterized by 2 contrasting stakeholder perspectives. Finally, it was shaped by diminishing trust in the inclusive governance model. The National eHealth Governance Board faced challenges in establishing legitimacy as a top-down inclusive governance model, primarily attributed to its addressing of participation, transparency, and trust dilemmas. Such dilemmas represent significant obstacles to inclusive governance models and require ongoing governmental vigilance and responsiveness from governmental entities. ", doi="10.2196/59717", url="https://www.jmir.org/2024/1/e59717" } @Article{info:doi/10.2196/60258, author="Chen, You and Lehmann, U. Christoph and Malin, Bradley", title="Digital Information Ecosystems in Modern Care Coordination and Patient Care Pathways and the Challenges and Opportunities for AI Solutions", journal="J Med Internet Res", year="2024", month="Dec", day="2", volume="26", pages="e60258", keywords="patient care pathway", keywords="care journey", keywords="care coordination", keywords="digital information ecosystem", keywords="digital technologies", keywords="artificial intelligence", keywords="information interoperability", keywords="information silos", keywords="workload", keywords="information retrieval", keywords="care transitions", keywords="patient-reported outcome measures", keywords="clinical workflow", keywords="usability", keywords="user experience workflow", keywords="health care information systems", keywords="networks of health care professionals", keywords="patient information flow", doi="10.2196/60258", url="https://www.jmir.org/2024/1/e60258" } @Article{info:doi/10.2196/58007, author="Allers, Sanne and Carboni, Chiara and Eijkenaar, Frank and Wehrens, Rik", title="A Cross-Disciplinary Analysis of the Complexities of Scaling Up eHealth Innovation", journal="J Med Internet Res", year="2024", month="Dec", day="2", volume="26", pages="e58007", keywords="innovation", keywords="eHealth", keywords="remote patient monitoring", keywords="scale-up", keywords="cross-disciplinary", keywords="qualitative case study", keywords="health care systems", keywords="adaptation", keywords="complexity", keywords="health care", keywords="framework", keywords="ecological perspective", keywords="barriers and facilitators", doi="10.2196/58007", url="https://www.jmir.org/2024/1/e58007" } @Article{info:doi/10.2196/65281, author="Bellei, Andrei Ericles and Domenighi, Rafael Pedro and Freitas, Sasso Carla Maria Dal and De Marchi, Bertoletti Ana Carolina", title="Digital Solutions for Health Services and Systems Management: Narrative Review of Certified Software Features in the Brazilian Market", journal="JMIR Med Inform", year="2024", month="Nov", day="29", volume="12", pages="e65281", keywords="health services administration", keywords="health information management", keywords="decision support systems", keywords="digital health", keywords="Brazil", keywords="certified software", keywords="features", keywords="systems management", keywords="health services", keywords="interoperability", keywords="digital solutions", doi="10.2196/65281", url="https://medinform.jmir.org/2024/1/e65281" } @Article{info:doi/10.2196/64726, author="Yang, Rick and Yang, Alina", title="Strengthening the Backbone: Government-Academic Data Collaborations for Crisis Response", journal="JMIR Public Health Surveill", year="2024", month="Nov", day="28", volume="10", pages="e64726", keywords="data infrastructure", keywords="data sharing", keywords="cross-sector collaboration", keywords="government-academic partnerships", keywords="public health", keywords="crisis response", doi="10.2196/64726", url="https://publichealth.jmir.org/2024/1/e64726" } @Article{info:doi/10.2196/66479, author="Lee, Jian-Sin and Tyler, B. Allison R. and Veinot, Christine Tiffany and Yakel, Elizabeth", title="Authors' Reply to: Strengthening the Backbone: Government-Academic Data Collaborations for Crisis Response", journal="JMIR Public Health Surveill", year="2024", month="Nov", day="28", volume="10", pages="e66479", keywords="COVID-19", keywords="crisis response", keywords="cross-sector collaboration", keywords="data infrastructures", keywords="data science", keywords="data sharing", keywords="pandemic", keywords="public health informatics", doi="10.2196/66479", url="https://publichealth.jmir.org/2024/1/e66479" } @Article{info:doi/10.2196/56494, author="McGowan, J. Laura and Graham, Fiona and Lecouturier, Jan and Goffe, Louis and Echevarria, Carlos and Kelly, P. Michael and Sniehotta, F. Falko", title="The Views and Experiences of Integrated Care System Commissioners About the Adoption and Implementation of Virtual Wards in England: Qualitative Exploration Study", journal="J Med Internet Res", year="2024", month="Nov", day="27", volume="26", pages="e56494", keywords="virtual wards", keywords="remote monitoring", keywords="whole systems", keywords="qualitative", keywords="implementation science", keywords="integrated care system", keywords="England", keywords="digital technology", keywords="acute care", keywords="clinical practice", keywords="semistructured interviews", keywords="thematic analysis", keywords="patient-centered care", keywords="hospital-centric language", keywords="eHealth", keywords="health services", abstract="Background: Virtual wards (VWs) are being introduced within the National Health Service (NHS) in England as a new way of delivering care to patients who would otherwise be hospitalized. Using digital technologies, patients can receive acute care, remote monitoring, and treatment in their homes. Integrated care system commissioners are employees involved in the planning of, agreeing to, and monitoring of services within NHS England and have an important role in the adoption and implementation of VWs in clinical practice. Objective: This study aims to develop an understanding of the acceptability and feasibility of adopting and implementing VWs in England from integrated care system commissioners' perspectives, including the identification of barriers and facilitators to implementation. Methods: Qualitative semistructured interviews were conducted with 20 commissioners employed by NHS England (NHSE) in various geographic regions of England. Thematic analysis was conducted, structured using the framework approach, and informed by the Consolidated Framework for Implementation Research. The COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines were followed. Results: Four overarching themes were identified reflecting the acceptability and feasibility of key adoption and implementation processes: (1) assessing the need for VWs, (2) coordinating a system approach, (3) agreeing to Program Outcomes: NHSE Versus Organizational Goals, and (4) planning and adapting services. Commissioners expressed the need for system-level change in care provision within the NHS, with VWs perceived as a promising model that could reform patient-centered care. However, there was uncertainty over the financial sustainability of VWs, with questions raised as to whether they would be funded by the closure of hospital beds. There was also uncertainty over the extent to which VWs should be technology-enabled, and the specific ways technology may enhance condition-specific pathways. Differing interpretations of the NHSE instructions between different health care sectors and a lack of clarity in definitions, as well as use of hospital-centric language within national guidance, were considered hindrances to convening a system approach. Furthermore, narrow parameters of success measures in terms of goals and outcomes of VWs, unrealistic timescales for planning and delivery, lack of interoperability of technology and time-consuming procurement procedures, liability concerns, and patient suitability for technology-enabled home-based care were identified as barriers to implementation. Motivated and passionate clinical leads were considered key to successful implementation. Conclusions: VWs have the potential to reform patient-centered care in England and were considered a promising approach by commissioners in this study. However, there should be greater clarity over definitions and specifications for technology enablement and evidence provided about how technology can enhance patient care. The use of less hospital-centric language, a greater focus on patient-centered measures of success, and more time allowance to ensure the development of technology-enabled VW services that meet the needs of patients and staff could enhance adoption and implementation. ", doi="10.2196/56494", url="https://www.jmir.org/2024/1/e56494" } @Article{info:doi/10.2196/57612, author="Yi, Siyan and Yam, Yan Esabelle Lo and Cheruvettolil, Kochukoshy and Linos, Eleni and Gupta, Anshika and Palaniappan, Latha and Rajeshuni, Nitya and Vaska, Gopal Kiran and Schulman, Kevin and Eggleston, N. Karen", title="Perspectives of Digital Health Innovations in Low- and Middle-Income Health Care Systems From South and Southeast Asia", journal="J Med Internet Res", year="2024", month="Nov", day="25", volume="26", pages="e57612", keywords="digital health innovations", keywords="public health", keywords="South and Southeast Asia", keywords="health care challenges", keywords="low- and middle-income countries", keywords="LMICs", keywords="global health", keywords="health AI", keywords="artificial intelligence", keywords="public health responses", keywords="global health contexts", keywords="digital health", doi="10.2196/57612", url="https://www.jmir.org/2024/1/e57612" } @Article{info:doi/10.2196/63031, author="Maa{\ss}, Laura and Badino, Manuel and Iyamu, Ihoghosa and Holl, Felix", title="Assessing the Digital Advancement of Public Health Systems Using Indicators Published in Gray Literature: Narrative Review", journal="JMIR Public Health Surveill", year="2024", month="Nov", day="20", volume="10", pages="e63031", keywords="digital public health", keywords="health system", keywords="indicator", keywords="interdisciplinary", keywords="information and communications technology", keywords="maturity assessment", keywords="readiness assessment", keywords="narrative review", keywords="gray literature", keywords="digital health", keywords="mobile phone", abstract="Background: Revealing the full potential of digital public health (DiPH) systems requires a wide-ranging tool to assess their maturity and readiness for emerging technologies. Although a variety of indices exist to assess digital health systems, questions arise about the inclusion of indicators of information and communications technology maturity and readiness, digital (health) literacy, and interest in DiPH tools by the society and workforce, as well as the maturity of the legal framework and the readiness of digitalized health systems. Existing tools frequently target one of these domains while overlooking the others. In addition, no review has yet holistically investigated the available national DiPH system maturity and readiness indicators using a multidisciplinary lens. Objective: We used a narrative review to map the landscape of DiPH system maturity and readiness indicators published in the gray literature. Methods: As original indicators were not published in scientific databases, we applied predefined search strings to the DuckDuckGo and Google search engines for 11 countries from all continents that had reached level 4 of 5 in the latest Global Digital Health Monitor evaluation. In addition, we searched the literature published by 19 international organizations for maturity and readiness indicators concerning DiPH. Results: Of the 1484 identified references, 137 were included, and they yielded 15,806 indicators. We deemed 286 indicators from 90 references relevant for DiPH system maturity and readiness assessments. The majority of these indicators (133/286, 46.5\%) had legal relevance (targeting big data and artificial intelligence regulation, cybersecurity, national DiPH strategies, or health data governance), and the smallest number of indicators (37/286, 12.9\%) were related to social domains (focusing on internet use and access, digital literacy and digital health literacy, or the use of DiPH tools, smartphones, and computers). Another 14.3\% (41/286) of indicators analyzed the information and communications technology infrastructure (such as workforce, electricity, internet, and smartphone availability or interoperability standards). The remaining 26.2\% (75/286) of indicators described the degree to which DiPH was applied (including health data architecture, storage, and access; the implementation of DiPH interventions; or the existence of interventions promoting health literacy and digital inclusion). Conclusions: Our work is the first to conduct a multidisciplinary analysis of the gray literature on DiPH maturity and readiness assessments. Although new methods for systematically researching gray literature are needed, our study holds the potential to develop more comprehensive tools for DiPH system assessments. We contributed toward a more holistic understanding of DiPH. Further examination is required to analyze the suitability and applicability of all identified indicators in diverse health care settings. By developing a standardized method to assess DiPH system maturity and readiness, we aim to foster informed decision-making among health care planners and practitioners to improve resource distribution and continue to drive innovation in health care delivery. ", doi="10.2196/63031", url="https://publichealth.jmir.org/2024/1/e63031", url="http://www.ncbi.nlm.nih.gov/pubmed/39566910" } @Article{info:doi/10.2196/47311, author="Hasegawa, Kaede and O'Brien, Niki and Prendergast, Mabel and Ajah, Agape Chris and Neves, Luisa Ana and Ghafur, Saira", title="Cybersecurity Interventions in Health Care Organizations in Low- and Middle-Income Countries: Scoping Review", journal="J Med Internet Res", year="2024", month="Nov", day="20", volume="26", pages="e47311", keywords="computer security", keywords="internet security", keywords="network security", keywords="digital health", keywords="digital health technology", keywords="cybersecurity", keywords="health data", keywords="global health", keywords="security", keywords="data science", keywords="LMIC", keywords="low income", keywords="low resource", keywords="scoping review", keywords="review methodology", keywords="implementation", keywords="barrier", keywords="facilitator", abstract="Background: Health care organizations globally have seen a significant increase in the frequency of cyberattacks in recent years. Cyberattacks cause massive disruptions to health service delivery and directly impact patient safety through disruption and treatment delays. Given the increasing number of cyberattacks in low- and middle-income countries (LMICs), there is a need to explore the interventions put in place to plan for cyberattacks and develop cyber resilience. Objective: This study aimed to describe cybersecurity interventions, defined as any intervention to improve cybersecurity in a health care organization, including but not limited to organizational strategy(ies); policy(ies); protocol(s), incident plan(s), or assessment process(es); framework(s) or guidelines; and emergency planning, implemented in LMICs to date and to evaluate their impact on the likelihood and impact of attacks. The secondary objective was to describe the main barriers and facilitators for the implementation of such interventions, where reported. Methods: A systematic search of the literature published between January 2017 and July 2024 was performed on Ovid Medline, Embase, Global Health, and Scopus using a combination of controlled terms and free text. A search of the gray literature within the same time parameters was undertaken on the websites of relevant stakeholder organizations to identify possible additional studies that met the inclusion criteria. Findings from included papers were mapped against the dimensions of the Essentials of Cybersecurity in Health Care Organizations (ECHO) framework and presented as a narrative synthesis. Results: We included 20 studies in this review. The sample size of the majority of studies (13/20, 65\%) was 1 facility to 5 facilities, and the studies were conducted in 14 countries. Studies were categorized into the thematic dimensions of the ECHO framework, including context; governance; organizational strategy; risk management; awareness, education, and training; and technical capabilities. Few studies (6/20, 30\%) discussed cybersecurity intervention(s) as the primary focus of the paper; therefore, information on intervention(s) implemented had to be deduced. There was no attempt to report on the impact and outcomes in all papers except one. Facilitators and barriers identified were grouped and presented across national or regional, organizational, and individual staff levels. Conclusions: This scoping review's findings highlight the limited body of research published on cybersecurity interventions implemented in health care organizations in LMICs and large heterogeneity across existing studies in interventions, research objectives, methods, and outcome measures used. Although complex and challenging, future research should specifically focus on the evaluation of cybersecurity interventions and their impact in order to build a robust evidence base to inform evidence-based policy and practice. ", doi="10.2196/47311", url="https://www.jmir.org/2024/1/e47311" } @Article{info:doi/10.2196/57754, author="Liu, Shuimei and Guo, Raymond L.", title="Data Ownership in the AI-Powered Integrative Health Care Landscape", journal="JMIR Med Inform", year="2024", month="Nov", day="19", volume="12", pages="e57754", keywords="data ownership", keywords="integrative healthcare", keywords="artificial intelligence", keywords="AI", keywords="ownership", keywords="data science", keywords="governance", keywords="consent", keywords="privacy", keywords="security", keywords="access", keywords="model", keywords="framework", keywords="transparency", doi="10.2196/57754", url="https://medinform.jmir.org/2024/1/e57754" } @Article{info:doi/10.2196/58933, author="Piera-Jim{\'e}nez, Jordi and Carot-Sans, Gerard and Ramiro-Pareta, Marina and Nogueras, Mercedes Maria and Folguera-Profit{\'o}s, J{\'u}lia and R{\'o}denas, Pepi and Jim{\'e}nez-Rueda, Alba and de Pando Navarro, Thais and Mira Palacios, Antoni Josep and Fajardo, Carles Joan and Ustrell Campillo, Joan and Vela, Emili and Monterde, David and Valero-Bover, Dami{\`a} and Bonet, Tara and Tarras{\'o}-Urios, Guillermo and Cantenys-Sab{\`a}, Roser and Fabregat-Fabregat, Pau and G{\'o}mez Oliveros, Beatriz and Berd{\'u}n, Jes{\'u}s and Michelena, Xabier and Cano, Isaac and Gonz{\'a}lez-Colom, Rub{\`e}n and Roca, Josep and Solans, Oscar and Pontes, Caridad and P{\'e}rez-Sust, Pol", title="A 25-Year Retrospective of Health IT Infrastructure Building: The Example of the Catalonia Region", journal="J Med Internet Res", year="2024", month="Nov", day="18", volume="26", pages="e58933", keywords="health ITs", keywords="eHealth", keywords="integrated care", keywords="open platforms", keywords="interoperability", keywords="Catalonia", keywords="digitalization", keywords="health care structure", keywords="health care delivery", keywords="integrated pathway", keywords="integrated treatment plan", keywords="process management", doi="10.2196/58933", url="https://www.jmir.org/2024/1/e58933", url="http://www.ncbi.nlm.nih.gov/pubmed/39556831" } @Article{info:doi/10.2196/54018, author="Zhang, Guang-Wei and Li, Bin and Gu, Zheng-Min and Yang, Wei-Feng and Wang, Yi-Ran and Li, Hui-Jun and Zheng, Han-Bing and Yue, Ying-Xu and Wang, Kui-Zhong and Gong, Mengchun and Gong, Da-Xin", title="In-Depth Examination of the Functionality and Performance of the Internet Hospital Information Platform: Development and Usability Study", journal="J Med Internet Res", year="2024", month="Nov", day="8", volume="26", pages="e54018", keywords="internet hospital", keywords="smart hospital", keywords="mobile applications", keywords="operational data", keywords="information system", keywords="online service", keywords="patient service", keywords="management tool", keywords="electronic prescriptions", keywords="medical education", keywords="integration", abstract="Background: Internet hospitals (IHs) have rapidly developed as a promising strategy to address supply-demand imbalances in China's medical industry, with their capabilities directly dependent on information platform functionality. Furthermore, a novel theory of ``Trinity'' smart hospital has provided advanced guidelines on IH constructions. Objective: This study aimed to explore the construction experience, construction models, and development prospects based on operational data from IHs. Methods: Based on existing information systems and internet service functionalities, our hospital has built a ``Smart Hospital Internet Information Platform (SHIIP)'' for IH operations, actively to expand online services, digitalize traditional health care, and explore health care services modes throughout the entire process and lifecycle. This article encompasses the platform architecture design, technological applications, patient service content and processes, health care professional support features, administrative management tools, and associated operational data. Results: Our platform has presented a set of data, including 82,279,669 visits, 420,120 online medical consultations, 124,422 electronic prescriptions, 92,285 medication deliveries, 6,965,566 prediagnosis triages, 4,995,824 offline outpatient appointments, 2025 medical education articles with a total of 15,148,310 views, and so on. These data demonstrate the significant role of IH as an indispensable component of our physical hospital services, with deep integration between online and offline health care systems. Conclusions: The upward trends in various data metrics indicate that our IH has gained significant recognition and usage among both the public and healthcare workers, and may have promising development prospects. Additionally, the platform construction approach, which prioritizes comprehensive service digitization and the 'Trinity' of the public, healthcare workers, and managers, serves as an effective means of promoting the development of Internet Hospitals. Such insights may prove invaluable in guiding the development of IH and facilitating the continued evolution of the Internet healthcare sector. ", doi="10.2196/54018", url="https://www.jmir.org/2024/1/e54018", url="http://www.ncbi.nlm.nih.gov/pubmed/39168813" } @Article{info:doi/10.2196/59674, author="Subramanian, Hemang and Sengupta, Arijit and Xu, Yilin", title="Patient Health Record Protection Beyond the Health Insurance Portability and Accountability Act: Mixed Methods Study", journal="J Med Internet Res", year="2024", month="Nov", day="6", volume="26", pages="e59674", keywords="security", keywords="privacy", keywords="security breach", keywords="breach report", keywords="health care", keywords="health care infrastructure", keywords="regulatory", keywords="law enforcement", keywords="Omnibus Rule", keywords="qualitative analysis", keywords="AI-generated data", keywords="artificial intelligence", keywords="difference-in-differences", keywords="best practice", keywords="data privacy", keywords="safe practice", abstract="Background: The security and privacy of health care information are crucial for maintaining the societal value of health care as a public good. However, governance over electronic health care data has proven inefficient, despite robust enforcement efforts. Both federal (HIPAA [Health Insurance Portability and Accountability Act]) and state regulations, along with the ombudsman rule, have not effectively reduced the frequency or impact of data breaches in the US health care system. While legal frameworks have bolstered data security, recent years have seen a concerning increase in breach incidents. This paper investigates common breach types and proposes best practices derived from the data as potential solutions. Objective: The primary aim of this study is to analyze health care and hospital breach data, comparing it against HIPAA compliance levels across states (spatial analysis) and the impact of the Omnibus Rule over time (temporal analysis). The goal is to establish guidelines for best practices in handling sensitive information within hospitals and clinical environments. Methods: The study used data from the Department of Health and Human Services on reported breaches, assessing the severity and impact of each breach type. We then analyzed secondary data to examine whether HIPAA's storage and retention rule amendments have influenced security and privacy incidents across all 50 states. Finally, we conducted a qualitative analysis of textual data from vulnerability and breach reports to identify actionable best practices for health care settings. Results: Our findings indicate that hacking or IT incidents have the most significant impact on the number of individuals affected, highlighting this as a primary breach category. The overall difference-in-differences trend reveals no significant reduction in breach rates (P=.50), despite state-level regulations exceeding HIPAA requirements and the introduction of the ombudsman rule. This persistence in breach trends implies that even strengthened protections and additional guidelines have not effectively curbed the rising number of affected individuals. Through qualitative analysis, we identified 15 unique values and associated best practices from industry standards. Conclusions: Combining quantitative and qualitative insights, we propose the ``SecureSphere framework'' to enhance data security in health care institutions. This framework presents key security values structured in concentric circles: core values at the center and peripheral values around them. The core values include employee management, policy, procedures, and IT management. Peripheral values encompass the remaining security attributes that support these core elements. This structured approach provides a comprehensive security strategy for protecting patient health information and is designed to help health care organizations develop sustainable practices for data security. ", doi="10.2196/59674", url="https://www.jmir.org/2024/1/e59674" } @Article{info:doi/10.2196/60056, author="Rousaki, Anastasia and Zamani, D. Efpraxia and Sbaffi, Laura and Hamblin, Kate and Black, Rachael", title="The Digitalization of Social Care in England and Implications for Older, Unpaid Carers: Constructionist Thematic Analysis", journal="J Med Internet Res", year="2024", month="Oct", day="24", volume="26", pages="e60056", keywords="social care", keywords="England", keywords="digitalization", keywords="digital transformation", keywords="unpaid care", keywords="mobile phone", abstract="Background: Globally, populations are aging, generating concerns about the sustainability of health and social care provision. In terms of the public provision of social care in particular, unpaid carers provide much of the support to people with disabilities and older people. In addition, there is an increased onus in many countries on digital transformation projects, in the hope that the digitalization of services can create efficiencies and savings in both costs and care labor. In England, the focus of this paper, the shift to digital services is also framed as a means to enhance choice and control for older unpaid carers, while being part of a broader offering that includes nondigital alternatives and support to mitigate digital exclusion. Objective: This study examines the impact of digitalization on older, unpaid carers---a group more likely to be both expected to engage digitally with services and at risk of digital exclusion---in England, focusing on their lived experiences in terms of caring and access to social care. Methods: We used a constructionist approach to thematic analysis, where data from 48 older unpaid carers collected through focus groups were analyzed using thematic analysis, resulting in 4 prevailing themes. Results: Our findings indicated that while unpaid carers largely acknowledge the benefits of digitalization, they also highlight several points of failure, whereby engagement with digital spaces is experienced as coercive and exacerbates feelings of exclusion. These are further worsened by government failures to address issues of connectivity, imposing additional financial burdens and complicating tasks such as benefit applications. Conclusions: In this study, we have highlighted the need for greater involvement in shaping both policy and technological solutions, which in turn will be more inclusive and aligned to the aspirations and circumstances of older carers. ", doi="10.2196/60056", url="https://www.jmir.org/2024/1/e60056" } @Article{info:doi/10.2196/52404, author="Chen, Baozhan and Shi, Xiaobing and Feng, Tianyi and Jiang, Shuai and Zhai, Yunkai and Ren, Mingxing and Liu, Dongqing and Wang, Chengzeng and Gao, Jinghong", title="Construction and Application of a Private 5G Standalone Medical Network in a Smart Health Environment: Exploratory Practice From China", journal="J Med Internet Res", year="2024", month="Oct", day="24", volume="26", pages="e52404", keywords="5G", keywords="medical private network", keywords="construction", keywords="application", keywords="performance test", abstract="Background: To date, the differentiated requirements for network performance in various health care service scenarios---within, outside, and between hospitals---remain a key challenge that restricts the development and implementation of digital medical services. Objective: This study aims to construct and implement a private 5G (the 5th generation mobile communication technology) standalone (SA) medical network in a smart health environment to meet the diverse needs of various medical services. Methods: Based on an analysis of network differentiation requirements in medical applications, the system architecture and functional positioning of the proposed private 5G SA medical network are designed and implemented. The system architecture includes the development of exclusive and preferential channels for medical use, as well as an ordinary user channel. A 3-layer network function architecture is designed, encompassing resource, control, and intelligent operation layers to facilitate management arrangements and provide network open services. Core technologies, including edge cloud collaboration; service awareness; and slicing of access, bearer, and core networks, are employed in the construction and application of the 5G SA network. Results: The construction of the private 5G SA medical network primarily involves system architecture, standards, and security measures. The system, featuring exclusive, preferential, and common channels, supports a variety of medical applications. Relevant standards are adhered to in order to ensure the interaction and sharing of medical service information. Security is achieved through mechanisms such as authentication, abnormal behavior analysis, and dynamic access control. Three typical medical applications that rely on the 5G network in intrahospital, interhospital, and out-of-hospital scenarios---namely, mobile ward rounds, remote first aid, and remote ultrasound---were conducted. Testing of the 5G-enabled mobile ward rounds showed an average download rate of 790 Mbps and an average upload rate of 91 Mbps. Compared with 4G, the 5G network more effectively meets the diverse requirements of various business applications in prehospital emergency scenarios. For remote ultrasound, the average downlink rate of the 5G network is 4.82 Mbps, and the average uplink rate is 2 Mbps, with an average fluctuation of approximately 8 ms. The bandwidth, performance, and delay of the 5G SA network were also examined and confirmed to be effective. Conclusions: The proposed 5G SA medical network demonstrates strong performance in typical medical applications. Its construction and application could lead to the development of new medical service models and provide valuable references for the further advancement and implementation of 5G networks in other industries, both in China and globally. ", doi="10.2196/52404", url="https://www.jmir.org/2024/1/e52404", url="http://www.ncbi.nlm.nih.gov/pubmed/39446419" } @Article{info:doi/10.2196/59409, author="Lake, Kaitlyn and Mc Kittrick, Andrea and Desselle, Mathilde and Padilha Lanari Bo, Antonio and Abayasiri, M. R. Achintha and Fleming, Jennifer and Baghaei, Nilufar and Kim, Dongseong Dan", title="Cybersecurity and Privacy Issues in Extended Reality Health Care Applications: Scoping Review", journal="JMIR XR Spatial Comput", year="2024", month="Oct", day="17", volume="1", pages="e59409", keywords="cyberattacks", keywords="cyber defence", keywords="cyber security", keywords="extended reality", keywords="health care", keywords="privacy", keywords="risk mitigation", keywords="virtual reality", keywords="cybersecurity", abstract="Background: Virtual reality (VR) is a type of extended reality (XR) technology that is seeing increasing adoption in health care. There is robust evidence articulating how consumer-grade VR presents significant cybersecurity and privacy risks due to the often ubiquitous and wide range of data collection and user monitoring, as well as the unique user impact of attacks due to the immersive nature of the technology. However, little is known about how these risks translate in the use of VR systems in health care settings. Objective: The objective of this scoping review is to identify potential cybersecurity risks associated with clinical XR systems, with a focus on VR, and potential mitigations for them. Methods: The scoping review followed the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews), and publications were reviewed using Covidence software. The Google Scholar database was searched using the predefined search terms. The inclusion criteria of the articles were restricted to relevant primary studies published from 2017 to 2024. Furthermore, reviews, abstracts, viewpoints, opinion pieces, and low-quality studies were excluded. Additionally, data on publication statistics, topic, technology, cyber threats, and risk mitigation were extracted. These data were synthesized and analyzed using the STRIDE (spoofing, tampering, repudiation, information disclosure, denial of service, and elevation of privilege) framework, enterprise risk management framework, and National Institute of Standards and Technology Cybersecurity Framework, as well as developing threat taxonomies. Results: Google Scholar returned 482 articles that matched the search criteria. After title and abstract screening, 53 studies were extracted for a full-text review, of which 29 were included for analysis. Of these, the majority were published in the last 4 years and had a focus on VR. The greatest cyber threat identified to XR components was information disclosure followed by tampering when mapped against the STRIDE framework. The majority of risk mitigation strategies provide confidentiality and integrity and can potentially address these threats. Only 3 of 29 papers mention XR in the context of health care and none of the identified threats or mitigations have been studied in a clinical setting. Conclusions: This scoping review identified privacy threats where personal and health-related data may be inferred from VR usage data, potentially breaching confidentiality, as the most significant threat posited for health care VR systems. Additionally, immersive manipulation threats were highlighted, which could potentially risk user safety when launched from a compromised VR system. Many potential mitigations were identified for these threats, but these mitigations must first be assessed for their effectiveness and suitability for health care services. Furthermore, health care services should consider the usage and governance of XR for each individual application based on risk threshold and perceived benefits. Finally, it is also important to note that this scoping review was limited by the quality and scope of the studies returned by Google Scholar. ", doi="10.2196/59409", url="https://xr.jmir.org/2024/1/e59409" } @Article{info:doi/10.2196/57148, author="Mesk{\'o}, Bertalan and Krist{\'o}f, Tam{\'a}s and Dhunnoo, Pranavsingh and {\'A}rvai, N{\'o}ra and Katonai, Gell{\'e}rt", title="Exploring the Need for Medical Futures Studies: Insights From a Scoping Review of Health Care Foresight", journal="J Med Internet Res", year="2024", month="Oct", day="9", volume="26", pages="e57148", keywords="foresight", keywords="futures studies", keywords="health care future", keywords="medical futures", keywords="technology foresight", abstract="Background: The historical development and contemporary instances of futures studies, an interdisciplinary field that focuses on exploring and formulating alternative futures, exemplify the increasing significance of using futures methods in shaping the health care domain. Despite the wide array of these methodologies, there have been limited endeavors to employ them within the medical community thus far. Objective: We undertook the first scoping review to date about the application of futures methodologies and published foresight projects in health care. Methods: Through the use of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) method, we identified 59 studies that were subsequently categorized into the following 5 distinct themes: national strategies (n=19), strategic health care foresight (n=15), health care policy and workforce dynamics (n=6), pandemic preparedness and response (n=7), and specialized medical domains (n=12). Results: Our scoping review revealed that the application of futures methods and foresight has been successfully demonstrated in a wide range of fields, including national strategies, policy formulation, global threat preparedness, and technological advancements. The results of our review indicate that a total of 8 futures methods have already been used in medicine and health care, while there are more than 50 futures methods available. It may underscore the notion that the field is unexploited. Furthermore, the absence of structured methodologies and principles for employing foresight and futures techniques in the health care domain warrants the creation of medical futures studies as a separate scientific subfield within the broad domains of health care, medicine, and life sciences. This subfield would focus on the analysis of emerging technological trends, the evaluation of policy implications, and the proactive anticipation and mitigation of potential challenges. Conclusions: Futures studies can significantly enhance medical science by addressing a crucial deficiency in the promotion of democratic participation, facilitating interdisciplinary dialogue, and shaping alternative futures. To further contribute to the development of a new research community in medical futures studies, it is recommended to establish a specialized scientific journal. Additionally, appointing dedicated futurists in decision-making and national strategy, and incorporating futures methods into the medical curriculum could be beneficial. ", doi="10.2196/57148", url="https://www.jmir.org/2024/1/e57148" } @Article{info:doi/10.2196/45122, author="Peiffer-Smadja, Nathan and Descousse, Sophie and Courr{\`e}ges, Elsa and Nganbou, Audrey and Jeanmougin, Pauline and Birgand, Gabriel and L{\'e}naud, S{\'e}verin and Beaumont, Anne-Lise and Durand, Claire and Delory, Tristan and Le Bel, Josselin and Bouvet, Elisabeth and Lariven, Sylvie and D'Ortenzio, Eric and Konat{\'e}, Issa and Bouyou-Akotet, Karine Marielle and Ouedraogo, Abdoul-Salam and Kouakou, Affoue Gis{\`e}le and Poda, Armel and Akpovo, Corinne and Lescure, Fran{\c{c}}ois-Xavier and Tanon, Aristophane", title="Implementation of a Clinical Decision Support System for Antimicrobial Prescribing in Sub-Saharan Africa: Multisectoral Qualitative Study", journal="J Med Internet Res", year="2024", month="Oct", day="7", volume="26", pages="e45122", keywords="antimicrobial resistance", keywords="implementation research", keywords="Consolidated Framework for Implementation Research", keywords="CDSS", keywords="mobile health", keywords="mHealth", keywords="eHealth", keywords="mobile phone", abstract="Background: Suboptimal use of antimicrobials is a driver of antimicrobial resistance in West Africa. Clinical decision support systems (CDSSs) can facilitate access to updated and reliable recommendations. Objective: This study aimed to assess contextual factors that could facilitate the implementation of a CDSS for antimicrobial prescribing in West Africa and Central Africa and to identify tailored implementation strategies. Methods: This qualitative study was conducted through 21 semistructured individual interviews via videoconference with health care professionals between September and December 2020. Participants were recruited using purposive sampling in a transnational capacity-building network for hospital preparedness in West Africa. The interview guide included multiple constructs derived from the Consolidated Framework for Implementation Research. Interviews were transcribed, and data were analyzed using thematic analysis. Results: The panel of participants included health practitioners (12/21, 57\%), health actors trained in engineering (2/21, 10\%), project managers (3/21, 14\%), antimicrobial resistance research experts (2/21, 10\%), a clinical microbiologist (1/21, 5\%), and an anthropologist (1/21, 5\%). Contextual factors influencing the implementation of eHealth tools existed at the individual, health care system, and national levels. At the individual level, the main challenge was to design a user-centered CDSS adapted to the prescriber's clinical routine and structural constraints. Most of the participants stated that the CDSS should not only target physicians in academic hospitals who can use their network to disseminate the tool but also general practitioners, primary care nurses, midwives, and other health care workers who are the main prescribers of antimicrobials in rural areas of West Africa. The heterogeneity in antimicrobial prescribing training among prescribers was a significant challenge to the use of a common CDSS. At the country level, weak pharmaceutical regulations, the lack of official guidelines for antimicrobial prescribing, limited access to clinical microbiology laboratories, self-medication, and disparity in health care coverage lead to inappropriate antimicrobial use and could limit the implementation and diffusion of CDSS for antimicrobial prescribing. Participants emphasized the importance of building a solid eHealth ecosystem in their countries by establishing academic partnerships, developing physician networks, and involving diverse stakeholders to address challenges. Additional implementation strategies included conducting a local needs assessment, identifying early adopters, promoting network weaving, using implementation advisers, and creating a learning collaborative. Participants noted that a CDSS for antimicrobial prescribing could be a powerful tool for the development and dissemination of official guidelines for infectious diseases in West Africa. Conclusions: These results suggest that a CDSS for antimicrobial prescribing adapted for nonspecialized prescribers could have a role in improving clinical decisions. They also confirm the relevance of adopting a cross-disciplinary approach with participants from different backgrounds to assess contextual factors, including social, political, and economic determinants. ", doi="10.2196/45122", url="https://www.jmir.org/2024/1/e45122", url="http://www.ncbi.nlm.nih.gov/pubmed/39374065" } @Article{info:doi/10.2196/51198, author="Tao, Youyou and Zhu, Ruilin and Wu, Dezhi", title="Harnessing the Power of Complementarity Between Smart Tracking Technology and Associated Health Information Technologies: Longitudinal Study", journal="JMIR Form Res", year="2024", month="Oct", day="1", volume="8", pages="e51198", keywords="health IT", keywords="smart tracking technology", keywords="mobile IT", keywords="health information exchange", keywords="electronic health record", keywords="readmission risk", keywords="complementarity effects", keywords="mobile phone", abstract="Background: Smart tracking technology (STT) that was applied for clinical use has the potential to reduce 30-day all-cause readmission risk through streamlining clinical workflows with improved accuracy, mobility, and efficiency. However, previously published literature has inadequately addressed the joint effects of STT for clinical use and its complementary health ITs (HITs) in this context. Furthermore, while previous studies have discussed the symbiotic and pooled complementarity effects among different HITs, there is a lack of evidence-based research specifically examining the complementarity effects between STT for clinical use and other relevant HITs. Objective: Through a complementarity theory lens, this study aims to examine the joint effects of STT for clinical use and 3 relevant HITs on 30-day all-cause readmission risk. These HITs are STT for supply chain management, mobile IT, and health information exchange (HIE). Specifically, this study examines whether the pooled complementarity effect exists between STT for clinical use and STT for supply chain management, and whether symbiotic complementarity effects exist between STT for clinical use and mobile IT and between STT for clinical use and HIE. Methods: This study uses a longitudinal in-patient dataset, including 879,122 in-patient hospital admissions for 347,949 patients in 61 hospitals located in Florida and New York in the United States, from 2014 to 2015. Logistic regression was applied to assess the effect of HITs on readmission risks. Time and hospital fixed effects were controlled in the regression model. Robust standard errors (SEs) were used to account for potential heteroskedasticity. These errors were further clustered at the patient level to consider possible correlations within the patient groups. Results: The interaction between STT for clinical use and STT for supply chain management, mobile IT, and HIE was negatively associated with 30-day readmission risk, with coefficients of --0.0352 (P=.003), --0.0520 (P<.001), and --0.0216 (P=.04), respectively. These results indicate that the pooled complementarity effect exists between STT for clinical use and STT for supply chain management, and symbiotic complementarity effects exist between STT for clinical use and mobile IT and between STT for clinical use and HIE. Furthermore, the joint effects of these HITs varied depending on the hospital affiliation and patients' disease types. Conclusions: Our results reveal that while individual HIT implementations have varying impacts on 30-day readmission risk, their joint effects are often associated with a reduction in 30-day readmission risk. This study substantially contributes to HIT value literature by quantifying the complementarity effects among 4 different types of HITs: STT for clinical use, STT for supply chain management, mobile IT, and HIE. It further offers practical implications for hospitals to maximize the benefits of their complementary HITs in reducing the 30-day readmission risk in their respective care scenarios. ", doi="10.2196/51198", url="https://formative.jmir.org/2024/1/e51198" } @Article{info:doi/10.2196/54814, author="Maa{\ss}, Laura and Hrynyschyn, Robert and Lange, Martin and L{\"o}we, Alexandra and Burdenski, Kathrin and Butten, Kaley and Vorberg, Sebastian and Hachem, Mariam and Gorga, Aldo and Grieco, Vittorio and Restivo, Vincenzo and Vella, Giuseppe and Varnfield, Marlien and Holl, Felix", title="Challenges and Alternatives to Evaluation Methods and Regulation Approaches for Medical Apps as Mobile Medical Devices: International and Multidisciplinary Focus Group Discussion", journal="J Med Internet Res", year="2024", month="Sep", day="30", volume="26", pages="e54814", keywords="medical apps", keywords="mobile medical devices", keywords="evaluation methods", keywords="mobile medical device regulation", keywords="focus group study", keywords="alternative approaches", keywords="logic model", keywords="mobile phone", abstract="Background: The rapid proliferation of medical apps has transformed the health care landscape by giving patients and health care providers unprecedented access to personalized health information and services. However, concerns regarding the effectiveness and safety of medical apps have raised questions regarding the efficacy of randomized controlled trials (RCTs) in the evaluation of such apps and as a requirement for their regulation as mobile medical devices. Objective: This study aims to address this issue by investigating alternative methods, apart from RCTs, for evaluating and regulating medical apps. Methods: Using a qualitative approach, a focus group study with 46 international and multidisciplinary public health experts was conducted at the 17th World Congress on Public Health in May 2023 in Rome, Italy. The group was split into 3 subgroups to gather in-depth insights into alternative approaches for evaluating and regulating medical apps. We conducted a policy analysis on the current regulation of medical apps as mobile medical devices for the 4 most represented countries in the workshop: Italy, Germany, Canada, and Australia. We developed a logic model that combines the evaluation and regulation domains on the basis of these findings. Results: The focus group discussions explored the strengths and limitations of the current evaluation and regulation methods and identified potential alternatives that could enhance the quality and safety of medical apps. Although RCTs were only explicitly mentioned in the German regulatory system as one of many options, an analysis of chosen evaluation methods for German apps on prescription pointed toward a ``scientific reflex'' where RCTs are always the chosen evaluation method. However, this method has substantial limitations when used to evaluate digital interventions such as medical apps. Comparable results were observed during the focus group discussions, where participants expressed similar experiences with their own evaluation approaches. In addition, the participants highlighted numerous alternatives to RCTs. These alternatives can be used at different points during the life cycle of a digital intervention to assess its efficacy and potential harm to users. Conclusions: It is crucial to recognize that unlike analog tools, digital interventions constantly evolve, posing challenges to inflexible evaluation methods such as RCTs. Potential risks include high dropout rates, decreased adherence, and nonsignificant results. However, existing regulations do not explicitly advocate for other evaluation methodologies. Our research highlighted the necessity of overcoming the gap between regulatory demands to demonstrate safety and efficacy of medical apps and evolving scientific practices, ensuring that digital health innovation is evaluated and regulated in a way that considers the unique characteristics of mobile medical devices. ", doi="10.2196/54814", url="https://www.jmir.org/2024/1/e54814" } @Article{info:doi/10.2196/59830, author="Pugh, Jo Mary and Haun, N. Jolie and White, Jon P. and Cochran, Gerald and Mohanty, F. April and McAndrew, M. Lisa and Gordon, J. Adam and Nelson, E. Richard and Vanneman, E. Megan and Naranjo, E. Diana and Benzinger, C. Rachel and Jones, L. Audrey and Kean, Jacob and Zickmund, L. Susan and Fagerlin, Angela", title="Developing Evidence to Support Policy: Protocol for the StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT)", journal="JMIR Res Protoc", year="2024", month="Sep", day="19", volume="13", pages="e59830", keywords="evidence-based policy-making", keywords="policy evaluation", keywords="knowledge translation", keywords="veterans", keywords="implementation science", abstract="Background: All federal agencies are required to support appropriation requests with evidence and evaluation (US Public Law 115-435; the Evidence Act). The StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT) is 1 of 6 centers that help the Department of Veterans Affairs (VA) meet this requirement. Objective: Working with the existing VA evaluation structure, SALIENT evaluations will contribute to (1) optimize policies and programs for veteran populations; (2) improve outcomes regarding health, equity, cost, and provider well-being; (3) advance the science of dissemination and knowledge translation; and (4) expand the implementation and dissemination science workforce. Methods: We leverage the Lean Sprint methodology (iterative, incremental, rule-governed approach to clearly defined, and time-boxed work) and 3 cores to develop our evaluation plans collaboratively with operational partners and key stakeholders including veterans, policy experts, and clinicians. The Operations Core will work with evaluation teams to develop timelines, facilitate work, monitor progress, and guide quality improvement within SALIENT. The Methods Core will work with evaluation teams to identify the most appropriate qualitative, quantitative, and mixed methods approaches to address each evaluation, ensure that the analyses are conducted appropriately, and troubleshoot when problems with data acquisition and analysis arise. The Knowledge Translation (KT) Core will target key partners and decision makers using a needs-based market segmentation approach to ensure that needs are incorporated in the dissemination of knowledge. The KT Core will create communications briefs, playbooks, and other materials targeted at these market segments to facilitate implementation of evidence-based practices and maximize the impact of evaluation results. Results: The SALIENT team has developed a center infrastructure to support high-priority evaluations, often to be responsive to shifting operational needs and priorities. Our team has engaged in our core missions and operations to rapidly evaluate a high-priority areas, develop a comprehensive Lean Sprint systems redesign approach to training, and accelerate rapid knowledge translation. Conclusions: With an array of interdisciplinary expertise, operational partnerships, and integrated resources, SALIENT has an established and evolving infrastructure to rapidly develop and implement high-impact evaluations. Projects are developed with sustained efficiency approaches that can pivot to new priorities as needed and effectively translate knowledge for key stakeholders and policy makers, while creating a learning health system infrastructure to foster the next generation of evaluation and implementation scientists. International Registered Report Identifier (IRRID): PRR1-10.2196/59830 ", doi="10.2196/59830", url="https://www.researchprotocols.org/2024/1/e59830" } @Article{info:doi/10.2196/56591, author="Loh, Yee Xin and Woo, Ling Ai and Haris, Azwa and Pereira, Shajini Cheryl and Tan, Kim Bee", title="Acceptance of Electronic Labeling for Medicinal Product Information Among Malaysian Hospital Patients: Cross-Sectional Study", journal="J Med Internet Res", year="2024", month="Sep", day="18", volume="26", pages="e56591", keywords="electronic labeling", keywords="e-labeling", keywords="electronic medication information", keywords="patient preference", keywords="acceptance", keywords="hospital ambulatory care patient", abstract="Background: While perceptions of electronic labeling (e-labeling) in developed countries have been generally positive, existing data primarily come from studies involving hospital pharmacists, community pharmacy customers who may not be frequent medication users, and individuals receiving COVID-19 vaccines. Objective: This study aims to assess e-labeling acceptance, perceptions of its benefits, challenges with its implementation, and preferences among hospital ambulatory care patients in Malaysia. Additionally, the study investigates the factors influencing patients' acceptance of e-labeling. Methods: A cross-sectional study using a 28-item questionnaire was conducted at the outpatient pharmacy department of a quaternary hospital in Kuala Lumpur, Malaysia, from May to June 2023. The questionnaire was developed based on a review of published literature related to e-labeling and was guided by the Unified Theory of Acceptance and Use of Technology, second version (UTAUT2). Patients aged 18 years and above were recruited using a stratified sampling method to ensure representative age-related medication usage. A mobile tablet was provided to patients for self-completion of the e-survey in their preferred language (English, Malay, or Mandarin). Categorical data on e-labeling acceptance, perceptions, and preferences were analyzed using descriptive statistics. Qualitative content analysis was performed to characterize participants' responses to open-ended questions. Univariate and multivariate binomial logistic regression analyses were conducted to identify predictors of e-labeling acceptance. Results: Out of 462 patients approached, 387 (83.8\%) participated in the survey, with 283 (73.1\%) accepting e-labeling. Most participants perceived the electronic version of the package insert as beneficial, particularly for understanding their medication better through the choice of language (352/387, 91.0\%). However, around half of the participants (197/387, 50.9\%) expressed concerns about the potential risks of obtaining illegal medication information via e-labeling. Most participants (302/387, 78.0\%) preferred to access electronic leaflets through government websites. However, 221/387 (57.1\%) still wanted the option to request printed leaflets. Significant predictors of e-labeling acceptance included perceived benefits such as better understanding of medication (adjusted odds ratio [AOR] 8.02, 95\% CI 2.80-22.97, P<.001), environmental protection (AOR 7.24, 95\% CI 3.00-17.51, P<.001), and flexibility in information retrieval (AOR 2.66, 95\% CI 1.11-6.35, P=.03). Conversely, being of Chinese ethnicity compared with Malay (AOR 0.28, 95\% CI 0.13-0.60, P=.005) and perceived lack of self-efficacy in browsing electronic leaflets (AOR 0.25, 95\% CI 0.11-0.56, P<.001) were associated with lower acceptance. Conclusions: The acceptance rate for e-labeling among hospital ambulatory care patients was moderately high and was significantly influenced by ethnicity as well as patients' perceived benefits and challenges related to its implementation. Future strategies to enhance e-labeling uptake should address patient concerns regarding the challenges of using the digital platform and emphasize the benefits of e-labeling. ", doi="10.2196/56591", url="https://www.jmir.org/2024/1/e56591" } @Article{info:doi/10.2196/46901, author="Anderson, Ekaterina and Moldestad, Megan and Brunner, Julian and Ball, Sherry and Helfrich, Christian and Orlander, Jay and Rinne, Seppo and Sayre, George", title="User Experiences of Transitioning From a Homegrown Electronic Health Record to a Vendor-Based Product in the Department of Veterans Affairs: Qualitative Findings From a Mixed Methods Evaluation", journal="JMIR Form Res", year="2024", month="Sep", day="10", volume="8", pages="e46901", keywords="electronic health records", keywords="United States Department of Veterans Affairs", keywords="Veterans Affairs", keywords="organizational change", keywords="delivery of health care", keywords="integrated", keywords="medical informatics", abstract="Background: The Department of Veterans Affairs (VA), the largest nationally integrated health system in the United States, is transitioning from its homegrown electronic health record (EHR) to a new vendor-based EHR, Oracle Cerner. Experiences of the first VA site to transition have been widely discussed in the media, but in-depth accounts based on rigorous research are lacking. Objective: We sought to explore employee perspectives on the rationale for, and value of, transitioning from a VA-tailored EHR to a vendor-based product. Methods: As part of a larger mixed methods, multisite, formative evaluation of VA clinician and staff experiences with the EHR transition, we conducted semistructured interviews at the Mann-Grandstaff VA Medical Center before, during, and after going live in October 2020. In total, we completed 122 interviews with 26 participants across multiple departments. Results: Before the new vendor-based EHR went live, participants initially expressed cautious optimism about the transition. However, in subsequent interviews following the go-live, participants increasingly critiqued the vendor's understanding of VA's needs, values, and workflows, as well as what they perceived as an inadequate fit between the functionalities of the new vendor-based EHR system and VA's characteristic approach to care. As much as a year after going live, participants reiterated these concerns while also expressing a desire for substantive changes to the transition process, with some questioning the value of continuing with the transition. Conclusions: VA's transition from a homegrown EHR to a vendor-based EHR system has presented substantial challenges, both practical and cultural in nature. Consequently, it is a valuable case study for understanding the sociotechnical dimension of EHR-to-EHR transitions. These findings have implications for both VA leadership and the broader community of policy makers, vendors, informaticists, and others involved in large-scale health information technology implementations. ", doi="10.2196/46901", url="https://formative.jmir.org/2024/1/e46901", url="http://www.ncbi.nlm.nih.gov/pubmed/39255006" } @Article{info:doi/10.2196/58080, author="Svempe, Liga", title="Exploring Impediments Imposed by the Medical Device Regulation EU 2017/745 on Software as a Medical Device", journal="JMIR Med Inform", year="2024", month="Sep", day="5", volume="12", pages="e58080", keywords="software", keywords="artificial intelligence", keywords="medical device regulation", keywords="rights", keywords="digital health", doi="10.2196/58080", url="https://medinform.jmir.org/2024/1/e58080", url="http://www.ncbi.nlm.nih.gov/pubmed/39235850" } @Article{info:doi/10.2196/59013, author="Goeldner, Moritz and Gehder, Sara", title="Digital Health Applications (DiGAs) on a Fast Track: Insights From a Data-Driven Analysis of Prescribable Digital Therapeutics in Germany From 2020 to Mid-2024", journal="J Med Internet Res", year="2024", month="Aug", day="29", volume="26", pages="e59013", keywords="digital health application", keywords="DiGA", keywords="data-driven analysis", keywords="clinical evidence", keywords="health economics", keywords="positive care effect", keywords="medical benefit", keywords="patient-relevant structural and procedural improvements", keywords="pSVV", keywords="digital health care act", abstract="Background: This study aimed to analyze the rapidly evolving ecosystem of digital health applications (Digitale Gesundheitsanwendung; DiGAs) in Germany, spurred by the 2019 Digital Healthcare Act. With over 73 million people in Germany now having access to DiGAs, these prescribable digital health apps and web-based applications represent a substantial stride in health care modernization, supporting both patients and health care providers with digital solutions for disease management and care improvement. Objective: Through a data-driven approach, this research aimed to unpack the complexities of DiGA market dynamics, economic factors, and clinical evidence, offering insights into their impact over the past years. Methods: The analysis draws from a range of public data sources, including the DiGA directory, statutory health insurance reports, app store feedback, and clinical study results. Results: As of July 1, 2024, there are 56 DiGAs listed by the Federal Institute for Drugs and Medical Devices (Bundesinstitut f{\"u}r Arzneimittel und Medizinprodukte), divided into 35 permanently and 21 preliminarily listed applications. Our findings reveal that a majority of DiGAs extend beyond the intended 1-year period to achieve permanent listing, reflecting the extensive effort required to demonstrate clinical efficacy. Economic analysis uncovered a dynamic pricing landscape, with initial prices ranging from approximately {\texteuro}200 to {\texteuro}700 ({\texteuro}1=US \$1.07), averaging at a median of {\texteuro}514 for a 3-month DiGA prescription. Following negotiations or arbitration board decisions, prices typically see a 50\% reduction, settling at a median of {\texteuro}221. Prescription data offer valuable insights into DiGA acceptance, with total prescriptions jumping from around 41,000 in the first period to 209,000 in the latest reporting period. The analysis of the top 15 DiGAs, representing 82\% of the total prescriptions, shows that these best-performing apps receive from a minimum of 8 to a maximum of 77 daily prescriptions, with native apps and early market entrants achieving higher rates. Clinical evidence from all 35 permanently listed DiGAs indicates a uniform preference for randomized controlled trials to validate primary end points, with no noteworthy use of alternative study designs encouraged in the Digital Healthcare Act and related regulations. Moreover, all evaluated DiGAs focused on medical benefits, with health status improvement as a key end point, suggesting an underuse of patient-relevant structural and procedural improvement in demonstrating health care impact. Conclusions: This study highlights the growth and challenges within the DiGA sector, suggesting areas for future research, such as the exploration of new study designs and the potential impact of patient-relevant structural and procedural improvements. For DiGA manufacturers, the strategic advantage of early market entry is emphasized. Overall, this paper underscores the evolving landscape of digital health, advocating for a nuanced understanding of digital health technology integration in Germany and beyond. ", doi="10.2196/59013", url="https://www.jmir.org/2024/1/e59013" } @Article{info:doi/10.2196/54556, author="Sriharan, Abi and Sekercioglu, Nigar and Mitchell, Cheryl and Senkaiahliyan, Senthujan and Hertelendy, Attila and Porter, Tracy and Banaszak-Holl, Jane", title="Leadership for AI Transformation in Health Care Organization: Scoping Review", journal="J Med Internet Res", year="2024", month="Aug", day="14", volume="26", pages="e54556", keywords="AI implementation", keywords="innovation", keywords="health care", keywords="leadership", keywords="AI", keywords="artificial intelligence", keywords="management", keywords="organization", keywords="health care organization", keywords="strategy", abstract="Background: The leaders of health care organizations are grappling with rising expenses and surging demands for health services. In response, they are increasingly embracing artificial intelligence (AI) technologies to improve patient care delivery, alleviate operational burdens, and efficiently improve health care safety and quality. Objective: In this paper, we map the current literature and synthesize insights on the role of leadership in driving AI transformation within health care organizations. Methods: We conducted a comprehensive search across several databases, including MEDLINE (via Ovid), PsycINFO (via Ovid), CINAHL (via EBSCO), Business Source Premier (via EBSCO), and Canadian Business \& Current Affairs (via ProQuest), spanning articles published from 2015 to June 2023 discussing AI transformation within the health care sector. Specifically, we focused on empirical studies with a particular emphasis on leadership. We used an inductive, thematic analysis approach to qualitatively map the evidence. The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines. Results: A comprehensive review of 2813 unique abstracts led to the retrieval of 97 full-text articles, with 22 included for detailed assessment. Our literature mapping reveals that successful AI integration within healthcare organizations requires leadership engagement across technological, strategic, operational, and organizational domains. Leaders must demonstrate a blend of technical expertise, adaptive strategies, and strong interpersonal skills to navigate the dynamic healthcare landscape shaped by complex regulatory, technological, and organizational factors. Conclusions: In conclusion, leading AI transformation in healthcare requires a multidimensional approach, with leadership across technological, strategic, operational, and organizational domains. Organizations should implement a comprehensive leadership development strategy, including targeted training and cross-functional collaboration, to equip leaders with the skills needed for AI integration. Additionally, when upskilling or recruiting AI talent, priority should be given to individuals with a strong mix of technical expertise, adaptive capacity, and interpersonal acumen, enabling them to navigate the unique complexities of the healthcare environment. ", doi="10.2196/54556", url="https://www.jmir.org/2024/1/e54556", url="http://www.ncbi.nlm.nih.gov/pubmed/39009038" } @Article{info:doi/10.2196/53369, author="Metsallik, Janek and Draheim, Dirk and Sabic, Zlatan and Novak, Thomas and Ross, Peeter", title="Assessing Opportunities and Barriers to Improving the Secondary Use of Health Care Data at the National Level: Multicase Study in the Kingdom of Saudi Arabia and Estonia", journal="J Med Internet Res", year="2024", month="Aug", day="8", volume="26", pages="e53369", keywords="health data governance", keywords="secondary use", keywords="health information sharing maturity", keywords="large-scale interoperability", keywords="health data stewardship", keywords="health data custodianship", keywords="health information purpose", keywords="health data policy", abstract="Background: Digitization shall improve the secondary use of health care data. The Government of the Kingdom of Saudi Arabia ordered a project to compile the National Master Plan for Health Data Analytics, while the Government of Estonia ordered a project to compile the Person-Centered Integrated Hospital Master Plan. Objective: This study aims to map these 2 distinct projects' problems, approaches, and outcomes to find the matching elements for reuse in similar cases. Methods: We assessed both health care systems' abilities for secondary use of health data by exploratory case studies with purposive sampling and data collection via semistructured interviews and documentation review. The collected content was analyzed qualitatively and coded according to a predefined framework. The analytical framework consisted of data purpose, flow, and sharing. The Estonian project used the Health Information Sharing Maturity Model from the Mitre Corporation as an additional analytical framework. The data collection and analysis in the Kingdom of Saudi Arabia took place in 2019 and covered health care facilities, public health institutions, and health care policy. The project in Estonia collected its inputs in 2020 and covered health care facilities, patient engagement, public health institutions, health care financing, health care policy, and health technology innovations. Results: In both cases, the assessments resulted in a set of recommendations focusing on the governance of health care data. In the Kingdom of Saudi Arabia, the health care system consists of multiple isolated sectors, and there is a need for an overarching body coordinating data sets, indicators, and reports at the national level. The National Master Plan of Health Data Analytics proposed a set of organizational agreements for proper stewardship. Despite Estonia's national Digital Health Platform, the requirements remain uncoordinated between various data consumers. We recommended reconfiguring the stewardship of the national health data to include multipurpose data use into the scope of interoperability standardization. Conclusions: Proper data governance is the key to improving the secondary use of health data at the national level. The data flows from data providers to data consumers shall be coordinated by overarching stewardship structures and supported by interoperable data custodians. ", doi="10.2196/53369", url="https://www.jmir.org/2024/1/e53369" } @Article{info:doi/10.2196/56316, author="Snowdon, Anne and Hussein, Abdulkadir and Danforth, Melissa and Wright, Alexandra and Oakes, Reid", title="Digital Maturity as a Predictor of Quality and Safety Outcomes in US Hospitals: Cross-Sectional Observational Study", journal="J Med Internet Res", year="2024", month="Aug", day="6", volume="26", pages="e56316", keywords="digital health", keywords="readiness", keywords="cross sectional", keywords="observational", keywords="regression", keywords="digital maturity", keywords="association", keywords="associations", keywords="correlation", keywords="correlations", keywords="quality and safety", keywords="hospital performance", keywords="workforce", keywords="health outcomes", keywords="safety", keywords="service", keywords="services", keywords="healthcare system", keywords="healthcare systems", keywords="hospital", keywords="hospitals", abstract="Background: This study demonstrates that digital maturity contributes to strengthened quality and safety performance outcomes in US hospitals. Advanced digital maturity is associated with more digitally enabled work environments with automated flow of data across information systems to enable clinicians and leaders to track quality and safety outcomes. This research illustrates that an advanced digitally enabled workforce is associated with strong safety leadership and culture and better patient health and safety outcomes. Objective: This study aimed to examine the relationship between digital maturity and quality and safety outcomes in US hospitals. Methods: The data sources were hospital safety letter grades as well as quality and safety scores on a continuous scale published by The Leapfrog Group. We used the digital maturity level (measured using the Electronic Medical Record Assessment Model [EMRAM]) of 1026 US hospitals. This was a cross-sectional, observational study. Logistic, linear, and Tweedie regression analyses were used to explore the relationships among The Leapfrog Group's Hospital Safety Grades, individual Leapfrog safety scores, and digital maturity levels classified as advanced or fully developed digital maturity (EMRAM levels 6 and 7) or underdeveloped maturity (EMRAM level 0). Digital maturity was a predictor while controlling for hospital characteristics including teaching status, urban or rural location, hospital size measured by number of beds, whether the hospital was a referral center, and type of hospital ownership as confounding variables. Hospitals were divided into the following 2 groups to compare safety and quality outcomes: hospitals that were digitally advanced and hospitals with underdeveloped digital maturity. Data from The Leapfrog Group's Hospital Safety Grades report published in spring 2019 were matched to the hospitals with completed EMRAM assessments in 2019. Hospital characteristics such as number of hospital beds were obtained from the CMS database. Results: The results revealed that the odds of achieving a higher Leapfrog Group Hospital Safety Grade was statistically significantly higher, by 3.25 times, for hospitals with advanced digital maturity (EMRAM maturity of 6 or 7; odds ratio 3.25, 95\% CI 2.33-4.55). Conclusions: Hospitals with advanced digital maturity had statistically significantly reduced infection rates, reduced adverse events, and improved surgical safety outcomes. The study findings suggest a significant difference in quality and safety outcomes among hospitals with advanced digital maturity compared with hospitals with underdeveloped digital maturity. ", doi="10.2196/56316", url="https://www.jmir.org/2024/1/e56316", url="http://www.ncbi.nlm.nih.gov/pubmed/39106100" } @Article{info:doi/10.2196/50749, author="Koenig, R. Leah and Ko, Jennifer and Upadhyay, D. Ushma", title="Virtual Clinic Telehealth Abortion Services in the United States One Year After Dobbs: Landscape Review", journal="J Med Internet Res", year="2024", month="Aug", day="5", volume="26", pages="e50749", keywords="medication abortion", keywords="telehealth", keywords="virtual clinics", keywords="abortion", keywords="access", keywords="policy", keywords="health equity", abstract="Background: Telehealth abortion has taken on a vital role in maintaining abortion access since the Dobbs v. Jackson Women's Health Organization Supreme Court decision. However, little remains known about the landscape of new telehealth-only virtual clinic abortion providers that have expanded since telehealth abortion first became widely available in the United States in 2021. Objective: This study aimed to (1) document the landscape of telehealth-only virtual clinic abortion care in the United States, (2) describe changes in the presence of virtual clinic abortion services between September 2022, following the Dobbs decision, and June 2023, and (3) identify structural factors that may perpetuate inequities in access to virtual clinic abortion care. Methods: We conducted a repeated cross-sectional study by reviewing web search results and abortion directories to identify virtual abortion clinics in September 2022 and June 2023 and described changes in the presence of virtual clinics between these 2 periods. In June 2023, we also described each virtual clinic's policies, including states served, costs, patient age limits, insurance acceptance, financial assistance available, and gestational limits. Results: We documented 11 virtual clinics providing telehealth abortion care in 26 states and Washington DC in September 2022. By June 2023, 20 virtual clinics were providing services in 27 states and Washington DC. Most (n=16) offered care to minors, 8 provided care until 10 weeks of pregnancy, and median costs were US \$259. In addition, 2 accepted private insurance and 1 accepted Medicaid, within a limited number of states. Most (n=16) had some form of financial assistance available. Conclusions: Virtual clinic abortion providers have proliferated since the Dobbs decision. We documented inequities in the availability of telehealth abortion care from virtual clinics, including age restrictions that exclude minors, gestational limits for care, and limited insurance and Medicaid acceptance. Notably, virtual clinic abortion care was not permitted in 11 states where in-person abortion is available. ", doi="10.2196/50749", url="https://www.jmir.org/2024/1/e50749" } @Article{info:doi/10.2196/45242, author="Bostan, Sarah and Johnson, A. Owen and Jaspersen, J. Lena and Randell, Rebecca", title="Contextual Barriers to Implementing Open-Source Electronic Health Record Systems for Low- and Lower-Middle-Income Countries: Scoping Review", journal="J Med Internet Res", year="2024", month="Aug", day="1", volume="26", pages="e45242", keywords="implementation", keywords="open source", keywords="electronic health records", keywords="digital health", keywords="low- and lower-middle-income countries", keywords="barriers", keywords="global health care", keywords="scoping", keywords="review", abstract="Background: Low- and lower-middle-income countries account for a higher percentage of global epidemics and chronic diseases. In most low- and lower-middle-income countries, there is limited access to health care. The implementation of open-source electronic health records (EHRs) can be understood as a powerful enabler for low- and lower-middle-income countries because it can transform the way health care technology is delivered. Open-source EHRs can enhance health care delivery in low- and lower-middle-income countries by improving the collection, management, and analysis of health data needed to inform health care delivery, policy, and planning. While open-source EHR systems are cost-effective and adaptable, they have not proliferated rapidly in low- and lower-middle-income countries. Implementation barriers slow adoption, with existing research focusing predominantly on technical issues preventing successful implementation. Objective: This interdisciplinary scoping review aims to provide an overview of contextual barriers affecting the adaptation and implementation of open-source EHR systems in low- and lower-middle-income countries and to identify areas for future research. Methods: We conducted a scoping literature review following a systematic methodological framework. A total of 7 databases were selected from 3 disciplines: medicine and health sciences, computing, and social sciences. The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The Mixed Methods Appraisal Tool and the Critical Appraisal Skills Programme checklists were used to assess the quality of relevant studies. Data were collated and summarized, and results were reported qualitatively, adopting a narrative synthesis approach. Results: This review included 13 studies that examined open-source EHRs' adaptation and implementation in low- and lower-middle-income countries from 3 interrelated perspectives: socioenvironmental, technological, and organizational barriers. The studies identified key issues such as limited funding, sustainability, organizational and management challenges, infrastructure, data privacy and protection, and ownership. Data protection, confidentiality, ownership, and ethics emerged as important issues, often overshadowed by technical processes. Conclusions: While open-source EHRs have the potential to enhance health care delivery in low- and lower-middle-income-country settings, implementation is fraught with difficulty. This scoping review shows that depending on the adopted perspective to implementation, different implementation barriers come into view. A dominant focus on technology distracts from socioenvironmental and organizational barriers impacting the proliferation of open-source EHRs. The role of local implementing organizations in addressing implementation barriers in low- and lower-middle-income countries remains unclear. A holistic understanding of implementers' experiences of implementation processes is needed. This could help characterize and solve implementation problems, including those related to ethics and the management of data protection. Nevertheless, this scoping review provides a meaningful contribution to the global health informatics discipline. ", doi="10.2196/45242", url="https://www.jmir.org/2024/1/e45242" } @Article{info:doi/10.2196/56275, author="Palmeirim, S. Marta and Houngbedji, A. Clarisse and Barth-Jaeggi, Tanja and Kouam{\'e}, Y. Jean-Pierre and Krouman, Aboubakar and Coulibaly, Daouda and Wyss, Kaspar", title="Key Characteristics and Perception of Different Outbreak Surveillance Systems in C{\^o}te d'Ivoire: Cross-Sectional Survey Among Users", journal="JMIR Public Health Surveill", year="2024", month="Jul", day="30", volume="10", pages="e56275", keywords="outbreak surveillance system", keywords="COVID-19", keywords="C{\^o}te d'Ivoire", keywords="SORMAS", keywords="MAGPI", keywords="DHIS2", keywords="outbreak surveillance", keywords="key characteristics", keywords="users' perception", keywords="infectious disease", keywords="infectious diseases", keywords="public health", keywords="disease surveillance", keywords="policy decision", keywords="cross-sectional study", keywords="descriptively analysis", keywords="Policymakers", keywords="health officials", keywords="healthcare system", keywords="Surveillance Outbreak Response Management and Analysis System", keywords="District Health Information Software 2", keywords="policy makers", keywords="health care system", abstract="Background: Accurate and timely infectious disease surveillance is pivotal for effective public health responses. An important component of this is the disease surveillance tools used. Understanding views and experiences of users is crucial for informing policy decisions and ensuring the seamless functioning of surveillance systems. Objective: In this study, we aimed to assess the user perceptions of 3 disease surveillance tools used in C{\^o}te d'Ivoire, namely, MAGPI, District Health Information Software 2 (DHIS2), and Surveillance Outbreak Response Management and Analysis System (SORMAS), the latter was implemented in 2021 within a pilot scheme. Methods: We conducted interviews and a web-based survey distributed to users of the 3 surveillance tools. The survey assessed users' views of the surveillance tools' usefulness, ease of use, feelings toward the tool, conditions that may influence the use, and other characteristics. The descriptive analysis compared responses from SORMAS, MAGPI, and DHIS2 users, providing a comprehensive evaluation of their experiences. Results: Among the 159 respondents who actively use one of the systems, MAGPI was the most widely used surveillance tool among respondents (n=127, 79.9\%), followed by DHIS2 (n=108, 67.9\%), and SORMAS (n=25, 15.7\%). In terms of users' perceptions, SORMAS, despite its limited implementation, emerged as a tool that allows for data analysis and had the most comprehensive set of functionalities. DHIS2 was appreciated for its frequency of report provision, although users reported occasional IT system failures. MAGPI was recognized for its ease of use but was reported to lack certain functionalities offered by the other surveillance systems. Conclusions: This study offers valuable insights into the perceptions of disease surveillance tools users in C{\^o}te d'Ivoire. While all systems were positively regarded, each exhibited strengths and weaknesses addressing different needs and functionalities. Policy makers and health officials can use these findings to enhance existing tools or consider a unified approach for infectious disease surveillance systems. Understanding users' perspectives allows them to optimize the choice of surveillance tools, ultimately strengthening public health responses in C{\^o}te d'Ivoire and potentially serving as a model for other countries facing similar decisions in their health care systems. ", doi="10.2196/56275", url="https://publichealth.jmir.org/2024/1/e56275" } @Article{info:doi/10.2196/50375, author="Yilma, Melese Tesfahun and Taddese, Asefa and Mamuye, Adane and Endehabtu, Fikadie Berhanu and Alemayehu, Yibeltal and Senay, Asaye and Daka, Dawit and Abraham, Loko and Tadesse, Rabeal and Melkamu, Gemechis and Wendrad, Naod and Kaba, Oli and Mohammed, Mesoud and Denboba, Wubshet and Birhan, Dawit and Biru, Amanuel and Tilahun, Binyam", title="Maturity Assessment of District Health Information System Version 2 Implementation in Ethiopia: Current Status and Improvement Pathways", journal="JMIR Med Inform", year="2024", month="Jul", day="26", volume="12", pages="e50375", keywords="health information system", keywords="digital health system", keywords="District Health Information System version 2", keywords="DHIS2", keywords="maturity assessment", keywords="Stages of Continuous Improvement", keywords="Ethiopia", abstract="Background: Although Ethiopia has made remarkable progress in the uptake of the District Health Information System version 2 (DHIS2) for national aggregate data reporting, there has been no comprehensive assessment of the maturity level of the system. Objective: This study aims to assess the maturity level of DHIS2 implementation in Ethiopia and propose a road map that could guide the progress toward a higher level of maturity. We also aim to assess the current maturity status, implementation gaps, and future directions of DHIS2 implementation in Ethiopia. The assessment focused on digital health system governance, skilled human resources, information and communication technology (ICT) infrastructure, interoperability, and data quality and use. Methods: A collaborative assessment was conducted with the engagement of key stakeholders through consultative workshops using the Stages of Continuous Improvement tool to measure maturity levels in 5 core domains, 13 components, and 39 subcomponents. A 5-point scale (1=emerging, 2=repeatable, 3=defined, 4=managed, and 5=optimized) was used to measure the DHIS2 implementation maturity level. Results: The national DHIS2 implementation's maturity level is currently at the defined stage (score=2.81) and planned to move to the manageable stage (score=4.09) by 2025. The domain-wise maturity score indicated that except for ICT infrastructure, which is at the repeatable stage (score=2.14), the remaining 4 domains are at the defined stage (score=3). The development of a standardized and basic DHIS2 process at the national level, the development of a 10-year strategic plan to guide the implementation of digital health systems including DHIS2, and the presence of the required competencies at the facility level to accomplish specific DHIS2-related tasks are the major strength of the Ministry of Health of Ethiopia so far. The lack of workforce competency guidelines to support the implementation of DHIS2; the unavailability of core competencies (knowledge, skills, and abilities) required to accomplish DHIS2 tasks at all levels of the health system; and ICT infrastructures such as communication network and internet connectivity at the district, zonal, and regional levels are the major hindrances to effective DHIS2 implementation in the country. Conclusions: On the basis of the Stages of Continuous Improvement maturity model toolkit, the implementation status of DHIS2 in Ethiopia is at the defined stage, with the ICT infrastructure domain being at the lowest stage as compared to the other 4 domains. By 2025, the maturity status is planned to move from the defined stage to the managed stage by improving the identified gaps. Various action points are suggested to address the identified gaps and reach the stated maturity level. The responsible body, necessary resources, and methods of verification required to reach the specified maturity level are also listed. ", doi="10.2196/50375", url="https://medinform.jmir.org/2024/1/e50375" } @Article{info:doi/10.2196/50295, author="S{\'a}ez, Carlos and Ferri, Pablo and Garc{\'i}a-G{\'o}mez, M. Juan", title="Resilient Artificial Intelligence in Health: Synthesis and Research Agenda Toward Next-Generation Trustworthy Clinical Decision Support", journal="J Med Internet Res", year="2024", month="Jun", day="28", volume="26", pages="e50295", keywords="artificial intelligence", keywords="clinical decision support", keywords="resilience", keywords="clinical medicine", keywords="machine learning", keywords="data quality", keywords="fairness", keywords="trustworthy AI", keywords="regulation", keywords="AI regulation", keywords="AI Act", keywords="EHDS", keywords="European Health Data Space", keywords="emergency medical dispatch", keywords="clinical decision support systems", doi="10.2196/50295", url="https://www.jmir.org/2024/1/e50295", url="http://www.ncbi.nlm.nih.gov/pubmed/38941134" } @Article{info:doi/10.2196/49084, author="H{\"a}gglund, Maria and Kharko, Anna and B{\"a}rk{\aa}s, Annika and Blease, Charlotte and Cajander, {\AA}sa and DesRoches, Catherine and Fagerlund, Johansen Asbj{\o}rn and Hagstr{\"o}m, Josefin and Huvila, Isto and H{\"o}rhammer, Iiris and Kane, Bridget and Klein, O. Gunnar and Kristiansen, Eli and Moll, Jonas and Muli, Irene and Rexhepi, Hanife and Riggare, Sara and Ross, Peeter and Scandurra, Isabella and Simola, Saija and Soone, Hedvig and Wang, Bo and Ghorbanian Zolbin, Maedeh and {\AA}hlfeldt, Rose-Mharie and Kujala, Sari and Johansen, Alise Monika", title="A Nordic Perspective on Patient Online Record Access and the European Health Data Space", journal="J Med Internet Res", year="2024", month="Jun", day="27", volume="26", pages="e49084", keywords="patients' online record access", keywords="open notes", keywords="electronic health records", keywords="EHR", keywords="patient portals", keywords="European Health Data Space", keywords="digital health", keywords="health care", keywords="patient access", doi="10.2196/49084", url="https://www.jmir.org/2024/1/e49084", url="http://www.ncbi.nlm.nih.gov/pubmed/38935430" } @Article{info:doi/10.2196/51350, author="Richter, Gesine and Krawczak, Michael", title="How to Elucidate Consent-Free Research Use of Medical Data: A Case for ``Health Data Literacy''", journal="JMIR Med Inform", year="2024", month="Jun", day="18", volume="12", pages="e51350", keywords="health data literacy", keywords="informed consent", keywords="broad consent", keywords="data sharing", keywords="data collection", keywords="data donation", keywords="data linkage", keywords="personal health data", doi="10.2196/51350", url="https://medinform.jmir.org/2024/1/e51350" } @Article{info:doi/10.2196/56686, author="Shau, Wen-Yi and Santoso, Handoko and Jip, Vincent and Setia, Sajita", title="Integrated Real-World Data Warehouses Across 7 Evolving Asian Health Care Systems: Scoping Review", journal="J Med Internet Res", year="2024", month="Jun", day="11", volume="26", pages="e56686", keywords="Asia", keywords="health care databases", keywords="cross-country comparison", keywords="electronic health records", keywords="electronic medical records", keywords="data warehousing", keywords="information storage and retrieval", keywords="real-world data", keywords="real-world evidence", keywords="registries", keywords="scoping review", abstract="Background: Asia consists of diverse nations with extremely variable health care systems. Integrated real-world data (RWD) research warehouses provide vast interconnected data sets that uphold statistical rigor. Yet, their intricate details remain underexplored, restricting their broader applications. Objective: Building on our previous research that analyzed integrated RWD warehouses in India, Thailand, and Taiwan, this study extends the research to 7 distinct health care systems: Hong Kong, Indonesia, Malaysia, Pakistan, the Philippines, Singapore, and Vietnam. We aimed to map the evolving landscape of RWD, preferences for methodologies, and database use and archetype the health systems based on existing intrinsic capability for RWD generation. Methods: A systematic scoping review methodology was used, centering on contemporary English literature on PubMed (search date: May 9, 2023). Rigorous screening as defined by eligibility criteria identified RWD studies from multiple health care facilities in at least 1 of the 7 target Asian nations. Point estimates and their associated errors were determined for the data collected from eligible studies. Results: Of the 1483 real-world evidence citations identified on May 9, 2023, a total of 369 (24.9\%) fulfilled the requirements for data extraction and subsequent analysis. Singapore, Hong Kong, and Malaysia contributed to ?100 publications, with each country marked by a higher proportion of single-country studies at 51\% (80/157), 66.2\% (86/130), and 50\% (50/100), respectively, and were classified as solo scholars. Indonesia, Pakistan, Vietnam, and the Philippines had fewer publications and a higher proportion of cross-country collaboration studies (CCCSs) at 79\% (26/33), 58\% (18/31), 74\% (20/27), and 86\% (19/22), respectively, and were classified as global collaborators. Collaboration with countries outside the 7 target nations appeared in 84.2\% to 97.7\% of the CCCSs of each nation. Among target nations, Singapore and Malaysia emerged as preferred research partners for other nations. From 2018 to 2023, most nations showed an increasing trend in study numbers, with Vietnam (24.5\%) and Pakistan (21.2\%) leading the growth; the only exception was the Philippines, which declined by --14.5\%. Clinical registry databases were predominant across all CCCSs from every target nation. For single-country studies, Indonesia, Malaysia, and the Philippines favored clinical registries; Singapore had a balanced use of clinical registries and electronic medical or health records, whereas Hong Kong, Pakistan, and Vietnam leaned toward electronic medical or health records. Overall, 89.9\% (310/345) of the studies took >2 years from completion to publication. Conclusions: The observed variations in contemporary RWD publications across the 7 nations in Asia exemplify distinct research landscapes across nations that are partially explained by their diverse economic, clinical, and research settings. Nevertheless, recognizing these variations is pivotal for fostering tailored, synergistic strategies that amplify RWD's potential in guiding future health care research and policy decisions. International Registered Report Identifier (IRRID): RR2-10.2196/43741 ", doi="10.2196/56686", url="https://www.jmir.org/2024/1/e56686", url="http://www.ncbi.nlm.nih.gov/pubmed/38749399" } @Article{info:doi/10.2196/50274, author="Ball, Robert and Talal, H. Andrew and Dang, Oanh and Mu{\~n}oz, Monica and Markatou, Marianthi", title="Trust but Verify: Lessons Learned for the Application of AI to Case-Based Clinical Decision-Making From Postmarketing Drug Safety Assessment at the US Food and Drug Administration", journal="J Med Internet Res", year="2024", month="Jun", day="6", volume="26", pages="e50274", keywords="drug safety", keywords="artificial intelligence", keywords="machine learning", keywords="natural language processing", keywords="causal inference", keywords="case-based reasoning", keywords="clinical decision support", doi="10.2196/50274", url="https://www.jmir.org/2024/1/e50274", url="http://www.ncbi.nlm.nih.gov/pubmed/38842929" } @Article{info:doi/10.2196/47682, author="Janssen, Anna and Donnelly, Candice and Shaw, Tim", title="A Taxonomy for Health Information Systems", journal="J Med Internet Res", year="2024", month="May", day="31", volume="26", pages="e47682", keywords="eHealth", keywords="digital health", keywords="electronic health data", keywords="data revolution", keywords="actionable data", keywords="mobile phone", doi="10.2196/47682", url="https://www.jmir.org/2024/1/e47682", url="http://www.ncbi.nlm.nih.gov/pubmed/38820575" } @Article{info:doi/10.2196/56614, author="Yoon, Dukyong and Han, Changho and Kim, Won Dong and Kim, Songsoo and Bae, SungA and Ryu, An Jee and Choi, Yujin", title="Redefining Health Care Data Interoperability: Empirical Exploration of Large Language Models in Information Exchange", journal="J Med Internet Res", year="2024", month="May", day="31", volume="26", pages="e56614", keywords="health care interoperability", keywords="large language models", keywords="medical data transformation", keywords="data standardization", keywords="text-based", abstract="Background: Efficient data exchange and health care interoperability are impeded by medical records often being in nonstandardized or unstructured natural language format. Advanced language models, such as large language models (LLMs), may help overcome current challenges in information exchange. Objective: This study aims to evaluate the capability of LLMs in transforming and transferring health care data to support interoperability. Methods: Using data from the Medical Information Mart for Intensive Care III and UK Biobank, the study conducted 3 experiments. Experiment 1 assessed the accuracy of transforming structured laboratory results into unstructured format. Experiment 2 explored the conversion of diagnostic codes between the coding frameworks of the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), and Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) using a traditional mapping table and a text-based approach facilitated by the LLM ChatGPT. Experiment 3 focused on extracting targeted information from unstructured records that included comprehensive clinical information (discharge notes). Results: The text-based approach showed a high conversion accuracy in transforming laboratory results (experiment 1) and an enhanced consistency in diagnostic code conversion, particularly for frequently used diagnostic names, compared with the traditional mapping approach (experiment 2). In experiment 3, the LLM showed a positive predictive value of 87.2\% in extracting generic drug names. Conclusions: This study highlighted the potential role of LLMs in significantly improving health care data interoperability, demonstrated by their high accuracy and efficiency in data transformation and exchange. The LLMs hold vast potential for enhancing medical data exchange without complex standardization for medical terms and data structure. ", doi="10.2196/56614", url="https://www.jmir.org/2024/1/e56614", url="http://www.ncbi.nlm.nih.gov/pubmed/38819879" } @Article{info:doi/10.2196/52027, author="Li, Wenhao and O'Hara, Rebecca and Hull, Louise M. and Slater, Helen and Sirohi, Diksha and Parker, A. Melissa and Bidargaddi, Niranjan", title="Enabling Health Information Recommendation Using Crowdsourced Refinement in Web-Based Health Information Applications: User-Centered Design Approach and EndoZone Informatics Case Study", journal="JMIR Hum Factors", year="2024", month="May", day="29", volume="11", pages="e52027", keywords="information recommendation", keywords="crowdsourcing", keywords="health informatics", keywords="digital health", keywords="endometriosis", abstract="Background: In the digital age, search engines and social media platforms are primary sources for health information, yet their commercial interests--focused algorithms often prioritize irrelevant content. Web-based health applications by reputable sources offer a solution to circumvent these biased algorithms. Despite this advantage, there remains a significant gap in research on the effective integration of content-ranking algorithms within these specialized health applications to ensure the delivery of personalized and relevant health information. Objective: This study introduces a generic methodology designed to facilitate the development and implementation of health information recommendation features within web-based health applications. Methods: We detail our proposed methodology, covering conceptual foundation and practical considerations through the stages of design, development, operation, review, and optimization in the software development life cycle. Using a case study, we demonstrate the practical application of the proposed methodology through the implementation of recommendation functionalities in the EndoZone platform, a platform dedicated to providing targeted health information on endometriosis. Results: Application of the proposed methodology in the EndoZone platform led to the creation of a tailored health information recommendation system known as EndoZone Informatics. Feedback from EndoZone stakeholders as well as insights from the implementation process validate the methodology's utility in enabling advanced recommendation features in health information applications. Preliminary assessments indicate that the system successfully delivers personalized content, adeptly incorporates user feedback, and exhibits considerable flexibility in adjusting its recommendation logic. While certain project-specific design flaws were not caught in the initial stages, these issues were subsequently identified and rectified in the review and optimization stages. Conclusions: We propose a generic methodology to guide the design and implementation of health information recommendation functionality within web-based health information applications. By harnessing user characteristics and feedback for content ranking, this methodology enables the creation of personalized recommendations that align with individual user needs within trusted health applications. The successful application of our methodology in the development of EndoZone Informatics marks a significant progress toward personalized health information delivery at scale, tailored to the specific needs of users. ", doi="10.2196/52027", url="https://humanfactors.jmir.org/2024/1/e52027", url="http://www.ncbi.nlm.nih.gov/pubmed/38809588" } @Article{info:doi/10.2196/50857, author="Legg, David and Napierala, Hendrik and Holzinger, Felix and Slagman, Anna", title="Where Do I Go When My Doctor's Office Is Closed? The Availability of Out-of-Hours Care Information on Primary Care Practitioners' Websites", journal="JMIR Form Res", year="2024", month="May", day="29", volume="8", pages="e50857", keywords="out of hours", keywords="primary care", keywords="telephone triage", keywords="websites", keywords="care information", doi="10.2196/50857", url="https://formative.jmir.org/2024/1/e50857", url="http://www.ncbi.nlm.nih.gov/pubmed/38809600" } @Article{info:doi/10.2196/47500, author="de Weger, Esther and Drewes, Hanneke and Luijkx, Katrien and Baan, Caroline", title="Tracking the Development of Community Engagement Over Time: Realist Qualitative Study", journal="J Particip Med", year="2024", month="May", day="15", volume="16", pages="e47500", keywords="community engagement", keywords="citizen involvement", keywords="health care", keywords="decentralization", keywords="realist evaluation", abstract="Background: A growing interest in engaging communities in the development of health care services and communities has not automatically led to progress or consensus as to how to engage communities successfully, despite the evidence base showing how to leverage enablers and alleviate barriers. Objective: To bridge the gap between the evidence base and which community engagement (CE) approaches have actually been applied in practice over time, this study aims to investigate how CE approaches have changed over the past 4 years in 6 different regions in the Netherlands and citizens' and professionals' experiences underlying these changes. Methods: For the last stage of a multiple case study following the development of CE approaches in 6 different regions in the Netherlands, a realist qualitative case study was conducted. To investigate how CE approaches had changed over the past 4 years, data from the entire 4 years of the study were used, including documents, interview transcripts, and observations. To examine citizens' and professionals' experiences underlying these changes, new interviews were conducted. The latest interview results were discussed with a panel to ensure the results had face validity. Results: The regions had implemented different types of CE approaches over the past 4 years and were adapting these approaches over time. Many of the (remaining) approaches may be operating on a smaller scale. The study identified the following overarching themes along which CE had been adapted: fewer region-wide approaches and more community-focused approaches, more focus on building relationships with (already engaged) citizens and community-led initiatives, and more focus on practical and tangible health promotion and social cohesion activities and less focus on complex ``abstract'' programs. The study identified a further 4 overarching themes highlighting citizens' and professionals' experiences underlying these changes in the CE approaches: a lack of engagement environment, need for facilitative leadership from organizations, need for a clear and shared vision underscoring the importance of CE, and misalignment between citizens' and professionals' perspectives and motivations for CE. All participants had experienced the engagement environment as insufficient. To support CE, professionals experienced the need to develop and receive more facilitative leadership and to develop approaches better equipped to involve citizens in the decision-making process. Citizens experienced the need to better align citizens' and professionals' motivations and aims for CE approaches and to receive longer-term financial support for their community-led initiatives. Conclusions: This study suggests that CE has not yet been embedded within organizational cultures. This has arguably meant that the (remaining) CE approaches are operating on a smaller scale. To enable the further development of CE approaches, an investment in the engagement environment and a shared vision is required. Only then could CE within the regions move beyond the more seemingly smaller-scale CE approaches. ", doi="10.2196/47500", url="https://jopm.jmir.org/2024/1/e47500", url="http://www.ncbi.nlm.nih.gov/pubmed/38748458" } @Article{info:doi/10.2196/55415, author="Rad{\'o}, N{\'o}ra and B{\'e}k{\'a}si, S{\'a}ndor and Gy?rffy, Zsuzsa", title="Health Technology Access and Peer Support Among Digitally Engaged People Experiencing Homelessness: Qualitative Study", journal="JMIR Hum Factors", year="2024", month="May", day="14", volume="11", pages="e55415", keywords="digital health", keywords="homelessness", keywords="digital technology", keywords="internet", keywords="access", keywords="health equity", abstract="Background: Although the effects of digital health are receiving wide scientific attention, very little is known about the characteristics of digitally engaged people experiencing homelessness, especially in Central and Eastern Europe. Our previous research revealed a considerable level of internet use in the homeless population of Budapest, Hungary, for general purposes (350/662, 52.9\%) and medical purposes (229/664, 34.6\%). Moreover, a digitally engaged subgroup was identified (129/662, 19.5\%). Objective: The aim of this exploratory study was to map out the resources, attitudes, and behaviors of digitally engaged homeless individuals in relation to digital technology to set the basis for potential health policy interventions, which will enable better access to health services through strengthening of the digital components of the existing health care system. Methods: Between August 18, 2022, and October 27, 2022, a total of 12 in-depth semistructured interviews were conducted in 4 homeless shelters in Budapest, Hungary. Upon analysis by 3 independent evaluators, 2 interviews were excluded. The interviewees were chosen based on purposive sampling with predefined inclusion criteria. Thematic analysis of the transcripts was conducted. Results: In the thematic analysis, 4 main themes (attitude, access, usage patterns, and solutions for usage problems) emerged. Health-related technology use mostly appeared in health information--seeking behavior. Online search for prescribed medications (5 interviews), active ingredients of medications (4 interviews), medicinal herbs believed to replace certain pills (2 interviews) or foods, and natural materials (1 interview) were mentioned. Moreover, mobile health app use (3 interviews) was reported. The intention to circumvent or check on mainstream health care solutions was mainly associated with previous negative experiences in the health care system. Several gaps in the daily use of technology were identified by the interviewees; however, more than half of the interviewees (6/10) turned out to be contact points for their peers for digital problem-solving or basic digital literacy skill enhancement in the homeless shelters. Furthermore, a lack of institutional support or special programs targeting senior clients was noted. Conclusions: Digitally engaged homeless individuals might become mediators between their peers and comprehensive digital health programs. They have the trust of their peers, can recognize and harness the benefits of digital technology, and are able to provide meaningful help in technology- and usage-related issues through experience. Digital health services have great promise in community shelters for managing and preventing health issues, and digitally engaged individuals might be important for the success of such services. ", doi="10.2196/55415", url="https://humanfactors.jmir.org/2024/1/e55415", url="http://www.ncbi.nlm.nih.gov/pubmed/38743937" } @Article{info:doi/10.2196/53898, author="Zhou, Yaxu and Zhou, Ying and Xu, Di and Min, Jie and Du, Yu and Duan, Qi and Bao, Wen and Sun, Yingying and Xi, Huiqin and Wang, Chunming and Bischof, Evelyne", title="Practice Standards in International Medical Departments of Public Academic Hospitals in China: Cross-Sectional Study", journal="JMIR Form Res", year="2024", month="May", day="13", volume="8", pages="e53898", keywords="patients", keywords="international medical service", keywords="demand", keywords="satisfaction", keywords="strategy", keywords="health care optimization", keywords="smart hospital", abstract="Background: Improving health care in cities with a diverse, international population is crucial for ensuring health equity, particularly for foreigners facing challenges due to cultural and language barriers. This situation is especially relevant in China, a major destination for expatriates and travelers, where optimizing health care services and incorporating international standards in the public sector are vital. Achieving this involves understanding the operational details, cultural and linguistic nuances, and advancing medical digitalization. A strategic approach focusing on cultural competence and awareness of health care systems is essential for effectively navigating health care for foreigners and expatriates in China. Objective: The aim of this study was to perform an in-depth analysis of the subjective and objective experiences of local and international patients in public hospitals in China to provide a basis for enhancing the medical experience of all patients. Methods: A structured questionnaire was provided to patients at an international outpatient service of a top-tier university hospital in China. Qualitative analysis of the survey responses was performed to methodically categorize and analyze medical treatment, focusing on patient demand and satisfaction across four main category elements (``high demand, high satisfaction''; ``high demand, low satisfaction''; ``low demand, high satisfaction''; and ``low demand, low satisfaction''), enabling a detailed cross-sectional analysis to identify areas for improvement. Results: Elements falling under ``high demand, high satisfaction'' for both Chinese and international patients were primarily in the realms of medical quality and treatment processes. In contrast, elements identified as ``high demand, low satisfaction'' were significantly different between the two patient groups. Conclusions: The findings highlight the importance of systematic, objective research in advancing the quality of international health care services within China's leading academic medical centers. Key to this improvement is rigorous quality control involving both patients and providers. This study highlights the necessity of certifying such centers and emphasizes the role of digital platforms in disseminating information about medical services. This strategy is expected to cater to diverse patient needs, enhancing the overall patient experience. Furthermore, by developing comprehensive diagnosis and treatment services and highlighting the superior quality and costs associated with international health care, these efforts aim to foster a sense of belonging among international patients and increase the attractiveness of China's medical services for this demographic. ", doi="10.2196/53898", url="https://formative.jmir.org/2024/1/e53898", url="http://www.ncbi.nlm.nih.gov/pubmed/38739428" } @Article{info:doi/10.2196/50889, author="Hellstrand Tang, Ulla and Smith, Frida and Karilampi, Leyla Ulla and Gremyr, Andreas", title="Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool", journal="JMIR Hum Factors", year="2024", month="Apr", day="26", volume="11", pages="e50889", keywords="digital", keywords="bottom-up innovation", keywords="complexity", keywords="eHealth", keywords="health care", keywords="nonadoption, abandonment, scale-up, spread, and sustainability complexity assessment tool", keywords="NASSS-CAT", keywords="mobile phone", abstract="Background: New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations. Objective: This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up. Methods: A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region V{\"a}stra G{\"o}taland in Sweden were explored and compared to identify unique and shared complexity-related challenges. Results: The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting. Conclusions: Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations. ", doi="10.2196/50889", url="https://humanfactors.jmir.org/2024/1/e50889", url="http://www.ncbi.nlm.nih.gov/pubmed/38669076" } @Article{info:doi/10.2196/51880, author="Lee, Jian-Sin and Tyler, B. Allison R. and Veinot, Christine Tiffany and Yakel, Elizabeth", title="Now Is the Time to Strengthen Government-Academic Data Infrastructures to Jump-Start Future Public Health Crisis Response", journal="JMIR Public Health Surveill", year="2024", month="Apr", day="24", volume="10", pages="e51880", keywords="COVID-19", keywords="crisis response", keywords="cross-sector collaboration", keywords="data infrastructures", keywords="data science", keywords="data sharing", keywords="pandemic", keywords="public health", doi="10.2196/51880", url="https://publichealth.jmir.org/2024/1/e51880", url="http://www.ncbi.nlm.nih.gov/pubmed/38656780" } @Article{info:doi/10.2196/49982, author="Giebel, Denk Godwin and Abels, Carina and Plescher, Felix and Speckemeier, Christian and Schrader, Frederik Nils and B{\"o}rchers, Kirstin and Wasem, J{\"u}rgen and Neusser, Silke and Blase, Nikola", title="Problems and Barriers Related to the Use of mHealth Apps From the Perspective of Patients: Focus Group and Interview Study", journal="J Med Internet Res", year="2024", month="Apr", day="23", volume="26", pages="e49982", keywords="mobile health", keywords="mHealth", keywords="mHealth app", keywords="patient", keywords="problems", keywords="barriers", keywords="digital health applications", keywords="DiGA", keywords="app", keywords="barrier", keywords="mobile app", keywords="health care system", keywords="economic outcome", keywords="context", keywords="mobile phone", abstract="Background: Since fall 2020, mobile health (mHealth) apps have become an integral part of the German health care system. The belief that mHealth apps have the potential to make the health care system more efficient, close gaps in care, and improve the economic outcomes related to health is unwavering and already partially confirmed. Nevertheless, problems and barriers in the context of mHealth apps usually remain unconsidered. Objective: The focus groups and interviews conducted in this study aim to shed light on problems and barriers in the context of mHealth apps from the perspective of patients. Methods: Guided focus groups and individual interviews were conducted with patients with a disease for which an approved mHealth app was available at the time of the interviews. Participants were recruited via self-help groups. The interviews were recorded, transcribed, and subjected to a qualitative content analysis. The content analysis was based on 10 problem categories (``validity,'' ``usability,'' ``technology,'' ``use and adherence,'' ``data privacy and security,'' ``patient-physician relationship,'' ``knowledge and skills,'' ``individuality,'' ``implementation,'' and ``costs'') identified in a previously conducted scoping review. Participants were asked to fill out an additional questionnaire about their sociodemographic data and about their use of technology. Results: A total of 38 patients were interviewed in 5 focus groups (3 onsite and 2 web-based) and 5 individual web-based interviews. The additional questionnaire was completed by 32 of the participants. Patients presented with a variety of different diseases, such as arthrosis, tinnitus, depression, or lung cancer. Overall, 16\% (5/32) of the participants had already been prescribed an app. During the interviews, all 10 problem categories were discussed and considered important by patients. A myriad of problem manifestations could be identified for each category. This study shows that there are relevant problems and barriers in the context of mHealth apps from the perspective of patients, which warrant further attention. Conclusions: There are essentially 3 different areas of problems in the context of mHealth apps that could be addressed to improve care: quality of the respective mHealth app, its integration into health care, and the expandable digital literacy of patients. ", doi="10.2196/49982", url="https://www.jmir.org/2024/1/e49982", url="http://www.ncbi.nlm.nih.gov/pubmed/38652508" } @Article{info:doi/10.2196/50410, author="Choy, Ada Melinda and O'Brien, Kathleen and Barnes, Katelyn and Sturgiss, Ann Elizabeth and Rieger, Elizabeth and Douglas, Kirsty", title="Evaluating the Digital Health Experience for Patients in Primary Care: Mixed Methods Study", journal="J Med Internet Res", year="2024", month="Apr", day="11", volume="26", pages="e50410", keywords="digital health", keywords="eHealth", keywords="primary care", keywords="general practice", keywords="digital divide", keywords="health inequities", keywords="health inequality", keywords="disparities", keywords="digital cost", keywords="financial cost", keywords="health technology", keywords="mixed methods", keywords="barriers", keywords="barrier", abstract="Background: The digital health divide for socioeconomic disadvantage describes a pattern in which patients considered socioeconomically disadvantaged, who are already marginalized through reduced access to face-to-face health care, are additionally hindered through less access to patient-initiated digital health. A comprehensive understanding of how patients with socioeconomic disadvantage access and experience digital health is essential for improving the digital health divide. Primary care patients, especially those with chronic disease, have experience of the stages of initial help seeking and self-management of their health, which renders them a key demographic for research on patient-initiated digital health access. Objective: This study aims to provide comprehensive primary mixed methods data on the patient experience of barriers to digital health access, with a focus on the digital health divide. Methods: We applied an exploratory mixed methods design to ensure that our survey was primarily shaped by the experiences of our interviewees. First, we qualitatively explored the experience of digital health for 19 patients with socioeconomic disadvantage and chronic disease and second, we quantitatively measured some of these findings by designing and administering a survey to 487 Australian general practice patients from 24 general practices. Results: In our qualitative first phase, the key barriers found to accessing digital health included (1) strong patient preference for human-based health services; (2) low trust in digital health services; (3) high financial costs of necessary tools, maintenance, and repairs; (4) poor publicly available internet access options; (5) reduced capacity to engage due to increased life pressures; and (6) low self-efficacy and confidence in using digital health. In our quantitative second phase, 31\% (151/487) of the survey participants were found to have never used a form of digital health, while 10.7\% (52/487) were low- to medium-frequency users and 48.5\% (236/487) were high-frequency users. High-frequency users were more likely to be interested in digital health and had higher self-efficacy. Low-frequency users were more likely to report difficulty affording the financial costs needed for digital access. Conclusions: While general digital interest, financial cost, and digital health literacy and empowerment are clear factors in digital health access in a broad primary care population, the digital health divide is also facilitated in part by a stepped series of complex and cumulative barriers. Genuinely improving digital health access for 1 cohort or even 1 person requires a series of multiple different interventions tailored to specific sequential barriers. Within primary care, patient-centered care that continues to recognize the complex individual needs of, and barriers facing, each patient should be part of addressing the digital health divide. ", doi="10.2196/50410", url="https://www.jmir.org/2024/1/e50410", url="http://www.ncbi.nlm.nih.gov/pubmed/38602768" } @Article{info:doi/10.2196/50932, author="Kleinschmidt, Lara and Walendzik, Anke and Wasem, J{\"u}rgen and H{\"o}fer, Klemens and Nauendorf, Beatrice and Brittner, Matthias and Brandenburg, Paul and Aeustergerling, Andr{\'e} and Schneider, Udo and Wadeck, Anja and Sehlen, Stephanie and Liersch, Sebastian and Schwarze, Katharina and Schwenke, Carsten and H{\"u}er, Theresa", title="Preference-Based Implementation of Video Consultations in Urban and Rural Regions in Outpatient Care in Germany: Protocol for a Mixed Methods Study", journal="JMIR Res Protoc", year="2024", month="Apr", day="11", volume="13", pages="e50932", keywords="study protocol", keywords="video consultation", keywords="preference elicitation", keywords="discrete choice experiment", keywords="implementation", keywords="telemedicine", keywords="teleconsultation", keywords="e-consultation", keywords="outpatient", keywords="rural area", keywords="remote", keywords="preferences", keywords="strategy", abstract="Background: Particularly in rural regions, factors such as lower physician density and long travel distances complicate adequate outpatient care. However, urban regions can also be affected by deficits in care, for example, long waiting times. One model of care intending to improve the situation is the implementation of video consultations. The study protocol presents the methodology of the research project titled ``Preference-based implementation of the video consultation in urban and rural regions'' funded by the German Federal Joint Committee (funding number 01VSF20011). Objective: This study aims to identify existing barriers to the use of video consultation and the preferences of insured individuals and physicians as well as psychotherapists in order to optimize its design and thus increase acceptance and use of video consultations in urban and rural regions. Methods: Built on a mixed methods approach, this study first assesses the status quo of video consultation use through claims data analysis and carries out a systematic literature review on barriers and promoting factors for the use of video consultations. Based on this preliminary work, focus groups are conducted in order to prepare surveys with insureds as well as physicians and psychotherapists in the second study phase. The central element of the survey is the implementation of discrete choice experiments to elicit relevant preferences of (potential) user groups and service providers. The summarized findings are discussed in a stakeholder workshop and translated into health policy recommendations. Results: The methodological approach used in this study is the focus of this paper. The study is still ongoing and will continue until March 2024. The first study phase has already been completed, in which preliminary work has been done on potential applications and hurdles for the use of video consultations. Currently, the survey is being conducted and analyses are being prepared. Conclusions: This study is intended to develop a targeted strategy for health policy makers based on actual preferences and perceived obstacles to the use of video consultations. The results of this study will contribute to further user-oriented development of the implementation of video consultations in German statutory health insurance. Furthermore, the iterative and mixed methods approach used in this study protocol is also suitable for a variety of other research projects. International Registered Report Identifier (IRRID): DERR1-10.2196/50932 ", doi="10.2196/50932", url="https://www.researchprotocols.org/2024/1/e50932", url="http://www.ncbi.nlm.nih.gov/pubmed/38602749" } @Article{info:doi/10.2196/52198, author="Bychkov, David", title="Insider Threats to the Military Health System: A Systematic Background Check of TRICARE West Providers", journal="JMIRx Med", year="2024", month="Apr", day="9", volume="5", pages="e52198", keywords="TRICARE", keywords="health care fraud", keywords="Defense Health Agency", keywords="fraud", keywords="fraudulent", keywords="insurance", keywords="coverage", keywords="beneficiary", keywords="beneficiaries", keywords="background check", keywords="background checks", keywords="demographic", keywords="security clearance", keywords="FDA", keywords="Medicaid", keywords="Medicare", keywords="provider", keywords="provider referral", keywords="military", keywords="false claims act", keywords="HIPAA breach", keywords="OIG-LEIE", keywords="inspector general", keywords="misconduct", keywords="insider threat", keywords="information system", keywords="zero trust", keywords="data management", keywords="Food and Drug Administration", keywords="Health Insurance Portability and Accountability Act breach", keywords="Office of the Inspector General's List of Excluded Individuals and Entities", abstract="Background: To address the pandemic, the Defense Health Agency (DHA) expanded its TRICARE civilian provider network by 30.1\%. In 2022, the DHA Annual Report stated that TRICARE's provider directories were only 80\% accurate. Unlike Medicare, the DHA does not publicly reveal National Provider Identification (NPI) numbers. As a result, TRICARE's 9.6 million beneficiaries lack the means to verify their doctor's credentials. Since 2013, the Department of Health and Human Services' (HHS) Office of Inspector General (OIG) has excluded 17,706 physicians and other providers from federal health programs due to billing fraud, neglect, drug-related convictions, and other offenses. These providers and their NPIs are included on the OIG's List of Excluded Individuals and Entities (LEIE). Patients who receive care from excluded providers face higher risks of hospitalization and mortality. Objective: We sought to assess the extent to which TRICARE screens health care provider names on their referral website against criminal databases. Methods: Between January 1-31, 2023, we used TRICARE West's provider directory to search for all providers within a 5-mile radius of 798 zip codes (38 per state, ?10,000 residents each, randomly entered). We then copied and pasted all directory results' first and last names, business names, addresses, phone numbers, fax numbers, degree types, practice specialties, and active or closed statuses into a CSV file. We cross-referenced the search results against US and state databases for medical and criminal misconduct, including the OIG-LEIE and General Services Administration's (GSA) SAM.gov exclusion lists, the HHS Office of Civil Rights Health Insurance Portability and Accountability Act (HIPAA) breach reports, 15 available state Medicaid exclusion lists (state), the International Trade Administration's Consolidated Screening List (CSL), 3 Food and Drug Administration (FDA) debarment lists, the Federal Bureau of Investigation's (FBI) list of January 6 federal defendants, and the OIG-HHS list of fugitives (FUG). Results: Our provider search yielded 111,619 raw results; 54 zip codes contained no data. After removing 72,156 (64.65\%) duplicate entries, closed offices, and non-TRICARE West locations, we identified 39,463 active provider names. Within this baseline sample group, there were 2398 (6.08\%) total matches against all exclusion and sanction databases, including 2197 on the OIG-LEIE, 2311 on the GSA-SAM.gov list, 2 on the HIPAA list, 54 on the state Medicaid exclusion lists, 69 on the CSL, 3 on the FDA lists, 53 on the FBI list, and 10 on the FUG. Conclusions: TRICARE's civilian provider roster merits further scrutiny by law enforcement. Following the National Institute of Standards and Technology 800, the DHA can mitigate privacy, safety, and security clearance threats by implementing an insider threat management model, robust enforcement of the False Claims Act, and mandatory security risk assessments. These are the views of the author, not the Department of Defense or the US government. ", doi="10.2196/52198", url="https://xmed.jmir.org/2024/1/e52198" } @Article{info:doi/10.2196/51084, author="Russo, Sara and Caruso, Rosario and Conte, Gianluca and Magon, Arianna and Vangone, Ida and Bascape', Barbara and Maga, Giulia and Pasek, Malgorzata and Arrigoni, Cristina", title="Development of a Core Outcome Set for Family and Community Nursing: Protocol for a Delphi Study", journal="JMIR Res Protoc", year="2024", month="Mar", day="29", volume="13", pages="e51084", keywords="clinical knowledge", keywords="core outcomes set", keywords="Delphi survey", keywords="family and community nurse", keywords="health interventions", keywords="health promotion", keywords="primary care", keywords="stakeholder engagement", abstract="Background: Family and community nurses (FCNs) play a crucial role in delivering primary care to patients within their homes and communities. A key aspect of their role involves various health interventions, which are influenced by their unique competencies, such as health promotion, advanced clinical knowledge, and strong interpersonal skills. However, it is essential to understand which specific health outcomes these interventions impact to better understand the relationship between FCNs' skills and the health results. Objective: This study aims to outline the steps we will take to develop a set of core outcomes. These outcomes will be particularly sensitive to the health interventions carried out by FCNs, providing a clearer picture of their practice's impact. Methods: A Delphi survey will be used for this research, conducted from January to December 2024. The process will involve 5 steps and input from 3 stakeholder categories. These stakeholders will help identify a preliminary list of outcomes that will form the basis of our core outcome set (COS). Results: This guideline will be beneficial for a wide range of stakeholders involved in COS development, including COS developers, trialists, systematic reviewers, journal editors, policy makers, and patient groups. As of January 2024, we have successfully completed the first stage of the study, with the stakeholder group approving the reported outcomes and assigning participant lists for each stakeholder group. Conclusions: This study will provide a roadmap for identifying the key health outcomes influenced by the interventions of FCNs. The multistakeholder, multiphase approach will ensure a comprehensive and inclusive process. Ultimately, the findings will enhance our understanding of FCNs' impact on health outcomes, leading to more effective primary care strategies and policies. International Registered Report Identifier (IRRID): PRR1-10.2196/51084 ", doi="10.2196/51084", url="https://www.researchprotocols.org/2024/1/e51084", url="http://www.ncbi.nlm.nih.gov/pubmed/38551623" } @Article{info:doi/10.2196/46412, author="Saravanakumar, Sanjeev and Ostrovsky, Andrey", title="Evaluation of Telehealth Services that are Clinically Appropriate for Reimbursement in the US Medicaid Population: Mixed Methods Study", journal="J Med Internet Res", year="2024", month="Mar", day="28", volume="26", pages="e46412", keywords="mobile phone", keywords="telehealth", keywords="Medicaid reimbursement", keywords="health equity", keywords="Center for Medicare \& Medicaid Services", keywords="telemedicine", keywords="reimbursement", keywords="digital health", keywords="Medicaid", keywords="Public Health Emergency", keywords="access", keywords="equity", keywords="health insurance", keywords="coverage", keywords="reimburse", keywords="equitable", keywords="health policy", keywords="telehealth expansion", abstract="Background: When the US Department of Health and Human Services instituted a State of Public Health Emergency (PHE) during the COVID-19 pandemic, many telehealth flexibilities were fast-tracked to allow state Medicaid agencies to reimburse new specialty services, sites of care, and mediums such as FaceTime to communicate with patients.. This resulted in expanded access to care for financially vulnerable Medicaid patients, as evidenced by an uptick in telehealth use. Research has mostly focused on telehealth reimbursement for limited use cases such as rural primary care, without broader consideration for how telehealth can be appropriately mainstreamed and maintained. Objective: This study sought to (1) evaluate the continuation of flexible telehealth reimbursement broadly, beyond the COVID-19 pandemic; (2) analyze the clinical effectiveness of the new telehealth services; and (3) offer code-by-code reimbursement guidance to state Medicaid leaders. Methods: We surveyed 10 state Medicaid medical directors (MMDs) who are responsible for the scientific and clinical appropriateness of Medicaid policies in their respective states. Participants were asked to complete an internet-based survey with a list of medical billing codes, grouped by service type, and asked if they believed they should be reimbursed by Medicaid on a permanent basis. Additional questions covered more detailed recommendations, such as reimbursing video with audio versus audio-only, guardrails for certain specialty services, and motivations behind responses. Results: The MMDs felt that the majority of services should be reimbursed via some modality of telehealth after the PHE, with the most support for video combined with audio compared to audio-only. There were exceptions on both ends of the spectrum, where services such as pulmonary diagnostics were not recommended to be reimbursed in any form and services such as psychotherapy for mental health had the most support for audio-only. The vast majority of MMDs were supportive of reimbursement for remote monitoring services, but some preferred to have some reimbursement guardrails. We found that 90\% (n=9) of MMDs were supportive of reimbursement for telehealth interprofessional services, while half (n=5) of the respondents felt that there should be continued guardrails for reimbursement. Motivations for continuing reimbursement flexibility were largely attributed to improving access to care, improving outcomes, and improving equity among the Medicaid patient population. Conclusions: There is a strong clinical endorsement to continue the telehealth flexibility enabled by the PHE, primarily for video combined with audio telehealth, with caution against audio-only telehealth in situations where hands-on intervention is necessary for diagnosis or treatment. There is also support for reimbursing remote monitoring services and telehealth interprofessional services, albeit with guardrails. These results are primarily from a perspective of improving access, outcomes, and equity; other state-specific factors such as fiscal impact and technical implementation may need to be taken into account when considering reimbursement decisions on telehealth. ", doi="10.2196/46412", url="https://www.jmir.org/2024/1/e46412", url="http://www.ncbi.nlm.nih.gov/pubmed/38546706" } @Article{info:doi/10.2196/50337, author="Aboye, Tadese Genet and Simegn, Lamesgin Gizeaddis and Aerts, Jean-Marie", title="Assessment of the Barriers and Enablers of the Use of mHealth Systems in Sub-Saharan Africa According to the Perceptions of Patients, Physicians, and Health Care Executives in Ethiopia: Qualitative Study", journal="J Med Internet Res", year="2024", month="Mar", day="27", volume="26", pages="e50337", keywords="barriers", keywords="chronic disease", keywords="digital health", keywords="eHealth", keywords="enablers", keywords="health care", keywords="mHealth", keywords="mobile health", keywords="perspectives", keywords="Sub-Saharan Africa", abstract="Background: Digital technologies are increasingly being used to deliver health care services and promote public health. Mobile wireless technologies or mobile health (mHealth) technologies are particularly relevant owing to their ease of use, broad reach, and wide acceptance. Unlike developed countries, Sub-Saharan Africa experiences more challenges and obstacles when it comes to deploying, using, and expanding mHealth systems. In addition to barriers, there are enabling factors that could be exploited for the design, implementation, and scaling up of mHealth systems. Sub-Saharan Africa may require tailored solutions that address the specific challenges facing the region. Objective: The overall aim of this study was to identify the barriers and enablers for using mHealth systems in Sub-Saharan Africa from the perspectives of patients, physicians, and health care executives. Methods: Multi-level and multi-actor in-depth semistructured interviews were employed to qualitatively explore the barriers and enablers of the use of mHealth systems. Data were collected from patients, physicians, and health care executives. The interviews were audio recorded, transcribed verbatim, translated, and coded. Thematic analysis methodology was adopted, and NVivo software was used for the data analysis. Results: Through this rigorous study, a total of 137 determinants were identified. Of these determinants, 68 were identified as barriers and 69 were identified as enablers. Perceived barriers in patients included lack of awareness about mHealth systems and language barriers. Perceived enablers in patients included need for automated tools for health monitoring and an increasing literacy level of the society. According to physicians, barriers included lack of available digital health systems in the local context and concern about patients' mHealth capabilities, while enablers included the perceived usefulness in reducing workload and improving health care service quality, as well as the availability of mobile devices and the internet. As perceived by health care executives, barriers included competing priorities alongside digitalization in the health sector and lack of interoperability and complete digitalization of implemented digital health systems, while enablers included the perceived usefulness of digitalization for the survival of the highly overloaded health care system and the abundance of educated manpower specializing in technology. Conclusions: mHealth systems in Sub-Saharan Africa are hindered and facilitated by various factors. Common barriers and enablers were identified by patients, physicians, and health care executives. To promote uptake, all relevant stakeholders must actively mitigate the barriers. This study identified a promising outlook for mHealth in Sub-Saharan Africa, despite the present barriers. Opportunities exist for successful integration into health care systems, and a user-centered design is crucial for maximum uptake. ", doi="10.2196/50337", url="https://www.jmir.org/2024/1/e50337", url="http://www.ncbi.nlm.nih.gov/pubmed/38536231" } @Article{info:doi/10.2196/46971, author="Shaw, James and Glover, Wiljeana", title="The Political Economy of Digital Health Equity: Structural Analysis", journal="J Med Internet Res", year="2024", month="Mar", day="26", volume="26", pages="e46971", keywords="digital health equity", keywords="health equity", keywords="health policy", keywords="telemedicine", keywords="digital care", keywords="political economy", keywords="race", keywords="ethnicity", keywords="socioeconomic", keywords="policy", doi="10.2196/46971", url="https://www.jmir.org/2024/1/e46971", url="http://www.ncbi.nlm.nih.gov/pubmed/38530341" } @Article{info:doi/10.2196/47248, author="Moffatt, Colin and Leshin, Jonah", title="Best Practices in Evolving Privacy Frameworks for Patient Age Data: Census Data Study", journal="JMIR Form Res", year="2024", month="Mar", day="25", volume="8", pages="e47248", keywords="census", keywords="date of birth", keywords="deidentification", keywords="HIPAA", keywords="Health Insurance Portability and Accountability Act", keywords="k-anonymity", keywords="patient privacy", keywords="policy", keywords="reidentification risk", abstract="Background: Over the previous 4 decennial censuses, the population of the United States has grown older, with the proportion of individuals aged at least 90 years old in the 2010 census being more than 2 and a half times what it was in the 1980 census. This suggests that the threshold for constraining age introduced in the Safe Harbor method of the HIPAA (Health Insurance Portability and Accountability Act) in 1996 may be increased without exceeding the original levels of risk. This is desirable to maintain or even increase the utility of affected data sets without compromising privacy. Objective: In light of the upcoming release of 2020 census data, this study presents a straightforward recipe for updating age-constrained thresholds in the context of new census data and derives recommendations for new thresholds from the 2010 census. Methods: Using census data dating back to 1980, we used group size considerations to analyze the risk associated with various maximum age thresholds over time. We inferred the level of risk of the age cutoff of 90 years at the time of HIPAA's inception in 1996 and used this as a baseline from which to recommend updated cutoffs. Results: The maximum age threshold may be increased by at least 2 years without exceeding the levels of risk conferred in HIPAA's original recommendations. Moreover, in the presence of additional information that restricts the population in question to a known subgroup with increased longevity (for example, restricting to female patients), the threshold may be increased further. Conclusions: Increasing the maximum age threshold would enable the data user to gain more utility from the data without introducing risk beyond what was originally envisioned with the enactment of HIPAA. Going forward, a recurring update of such thresholds is advised, in line with the considerations detailed in the paper. ", doi="10.2196/47248", url="https://formative.jmir.org/2024/1/e47248", url="http://www.ncbi.nlm.nih.gov/pubmed/38526530" } @Article{info:doi/10.2196/53921, author="Chai, Yulin and Yuan, Xiaoping and Guo, Lin and Chen, Zhongming", title="The Impact of Broadband Infrastructure Construction on Medical Resource Mismatch: Quasi-Natural Experiment From the Broadband China Policy", journal="J Med Internet Res", year="2024", month="Mar", day="21", volume="26", pages="e53921", keywords="broadband", keywords="infrastructure", keywords="medical resources", keywords="resource mismatch", keywords="Broadband China Policy", abstract="Background: Whether the construction of broadband infrastructure can alleviate the problem of mismatched medical resources is crucial to the national information strategy, residents' well-being, and social equity. However, the academic community lacks a comprehensive theoretical analysis and rigorous empirical research on this issue. Objective: This study aims to construct a preliminary theoretical framework to scientifically assess the effects of broadband infrastructure development on the mitigation of health care resource mismatch from both theoretical and empirical perspectives, to explore the potential mechanisms of influence, and ultimately to develop several practical policy recommendations. Methods: We first used a theoretical analysis to propose testable theoretical hypotheses and establish a preliminary theoretical framework. Then, based on balanced panel data from 300 cities from 2010 to 2021, a 2-way fixed effects difference-in-differences model was used for empirical testing. Mechanism tests, robustness analyses, and heterogeneity analyses were further conducted. Results: The research findings demonstrate that the Broadband China Policy significantly reduces the degree of mismatch in medical resources by primarily using innovation effects and integration effects, resulting in a reduction of 13.2\%. In addition, the heterogeneity analysis reveals that the central and eastern regions, cities with large populations, and areas with a high proportion of young people benefit more significantly. Conclusions: This study fully confirms, both theoretically and empirically, that broadband infrastructure construction can effectively reduce the mismatch of medical resources not only by expanding the existing literature on the impact of broadband on public services but also by providing valuable opportunities for policy makers to optimize the allocation of medical resources. ", doi="10.2196/53921", url="https://www.jmir.org/2024/1/e53921", url="http://www.ncbi.nlm.nih.gov/pubmed/38512327" } @Article{info:doi/10.2196/49822, author="Baek, Jinyoung and Lawson, Jonathan and Rahimzadeh, Vasiliki", title="Investigating the Roles and Responsibilities of Institutional Signing Officials After Data Sharing Policy Reform for Federally Funded Research in the United States: National Survey", journal="JMIR Form Res", year="2024", month="Mar", day="20", volume="8", pages="e49822", keywords="biomedical research", keywords="survey", keywords="surveys", keywords="data sharing", keywords="data management", keywords="secondary use", keywords="National Institutes of Health", keywords="signing official", keywords="information sharing", keywords="exchange", keywords="access", keywords="data science", keywords="accessibility", keywords="policy", keywords="policies", abstract="Background: New federal policies along with rapid growth in data generation, storage, and analysis tools are together driving scientific data sharing in the United States. At the same, triangulating human research data from diverse sources can also create situations where data are used for future research in ways that individuals and communities may consider objectionable. Institutional gatekeepers, namely, signing officials (SOs), are therefore at the helm of compliant management and sharing of human data for research. Of those with data governance responsibilities, SOs most often serve as signatories for investigators who deposit, access, and share research data between institutions. Although SOs play important leadership roles in compliant data sharing, we know surprisingly little about their scope of work, roles, and oversight responsibilities. Objective: The purpose of this study was to describe existing institutional policies and practices of US SOs who manage human genomic data access, as well as how these may change in the wake of new Data Management and Sharing requirements for National Institutes of Health--funded research in the United States. Methods: We administered an anonymous survey to institutional SOs recruited from biomedical research institutions across the United States. Survey items probed where data generated from extramurally funded research are deposited, how researchers outside the institution access these data, and what happens to these data after extramural funding ends. Results: In total, 56 institutional SOs participated in the survey. We found that SOs frequently approve duplicate data deposits and impose stricter access controls when data use limitations are unclear or unspecified. In addition, 21\% (n=12) of SOs knew where data from federally funded projects are deposited after project funding sunsets. As a consequence, most investigators deposit their scientific data into ``a National Institutes of Health--funded repository'' to meet the Data Management and Sharing requirements but also within the ``institution's own repository'' or a third-party repository. Conclusions: Our findings inform 5 policy recommendations and best practices for US SOs to improve coordination and develop comprehensive and consistent data governance policies that balance the need for scientific progress with effective human data protections. ", doi="10.2196/49822", url="https://formative.jmir.org/2024/1/e49822", url="http://www.ncbi.nlm.nih.gov/pubmed/38506894" } @Article{info:doi/10.2196/53008, author="Chen, Yan and Esmaeilzadeh, Pouyan", title="Generative AI in Medical Practice: In-Depth Exploration of Privacy and Security Challenges", journal="J Med Internet Res", year="2024", month="Mar", day="8", volume="26", pages="e53008", keywords="artificial intelligence", keywords="AI", keywords="generative artificial intelligence", keywords="generative AI", keywords="medical practices", keywords="potential benefits", keywords="security and privacy threats", doi="10.2196/53008", url="https://www.jmir.org/2024/1/e53008", url="http://www.ncbi.nlm.nih.gov/pubmed/38457208" } @Article{info:doi/10.2196/51980, author="Sharma, Yashoda and Saha, Anindita and Goldsack, C. Jennifer", title="Defining the Dimensions of Diversity to Promote Inclusion in the Digital Era of Health Care: A Lexicon", journal="JMIR Public Health Surveill", year="2024", month="Feb", day="9", volume="10", pages="e51980", keywords="digital medicine", keywords="inclusion", keywords="digital health technology/product", keywords="digital health", keywords="digital technology", keywords="health care system", keywords="innovation", keywords="equity", keywords="quality", keywords="disparity", keywords="digital era", keywords="digital access", keywords="digital literacy", doi="10.2196/51980", url="https://publichealth.jmir.org/2024/1/e51980", url="http://www.ncbi.nlm.nih.gov/pubmed/38335013" } @Article{info:doi/10.2196/47197, author="Yu, Yang and Wang, Sufen and You, Lijue", title="Understanding the Integrated Health Management System Policy in China From Multiple Perspectives: Systematic Review and Content Analysis", journal="J Med Internet Res", year="2024", month="Jan", day="24", volume="26", pages="e47197", keywords="integrated health management system", keywords="medical association", keywords="medical consortium", keywords="policy tools", keywords="content analysis", keywords="PRISMA", keywords="Preferred Reporting Items for Systematic Reviews and Meta-Analyses", abstract="Background: The integrated health management system (IHMS), which unites all health care--related institutions under a health-centered organizational framework, is of great significance to China in promoting the hierarchical treatment system and improving the new health care reform. China's IHMS policy consists of multiple policies at different levels and at different times; however, there is a lack of comprehensive interpretation and analysis of these policies, which is not conducive to the further development of the IHMS in China. Objective: This study aims to comprehensively analyze and understand the characteristics, development, and evolution of China's IHMS policy to inform the design and improvement of the system. Methods: We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to collect 152 policy documents. With the perspective of policy tools and policy orientation as the core, a comprehensive 6D framework including policy level, policy nature, release time, policy tools, stakeholders, and policy orientation was established by combining the content of policy texts. These dimensions were then analyzed using content analysis. Results: First, we found that, regarding the coordination of policy tools and stakeholders, China's IHMS policy was more inclined to use environment-based policy tools (1089/1929, 56.45\%), which suggests a need for further balance in the internal structure of policy tools. Attention to different actors varied, and the participation of physicians and residents needs further improvement (65/2019, 3.22\% and 11/2019, 0.54\%, respectively). Second, in terms of level differences, Shanghai's IHMS policy used fewer demand-based policy tools (43/483, 8.9\%), whereas the national IHMS policy and those of other provinces and cities used fewer supply-based tools (61/357, 17.1\% and 248/357, 69.5\%, respectively). The national IHMS strategy placed more emphasis on the construction of smart health care (including digital health; 10/275, 3.6\%), whereas Shanghai was a leader in the development of healthy community and healthy China (9/158, 5.7\% and 4/158, 2.5\%, respectively). Third, in terms of time evolution, the various policy tools showed an increasing and then decreasing trend from 2014 to 2021, with relatively more use of environment-based policy tools and less use of demand-based policy tools in the last 3 years. The growth of China's IHMS policy can be divided into 3 stages: the disease-centered period (2014-2017), the e-health technology development period (2017-2019), and the health-centered period (2018-2021). Conclusions: Policy makers should make several adjustments, such as coordinating policy tools and the uneven relationships among stakeholders; grasping key policy priorities in the context of local characteristics; and focusing on horizontal, multidimensional integration of health resources starting from the community. This study expands the objects of policy research and improves the framework for policy analysis. The findings provide some possible lessons for future policy formulation and optimization. ", doi="10.2196/47197", url="https://www.jmir.org/2024/1/e47197", url="http://www.ncbi.nlm.nih.gov/pubmed/38265862" } @Article{info:doi/10.2196/48842, author="Zhou, Linyun and Jiang, Minghuan and Duan, Ran and Zuo, Feng and Li, Zongfang and Xu, Songhua", title="Barriers and Implications of 5G Technology Adoption for Hospitals in Western China: Integrated Interpretive Structural Modeling and Decision-Making Trial and Evaluation Laboratory Analysis", journal="JMIR Mhealth Uhealth", year="2024", month="Jan", day="23", volume="12", pages="e48842", keywords="5G health care", keywords="5G adoption barriers", keywords="5G adoption strategy", keywords="smart health care", keywords="Western China hospitals", abstract="Background: 5G technology is gaining traction in Chinese hospitals for its potential to enhance patient care and internal management. However, various barriers hinder its implementation in clinical settings, and studies on their relevance and importance are scarce. Objective: This study aimed to identify critical barriers hampering the effective implementation of 5G in hospitals in Western China, to identify interaction relationships and priorities of the above-identified barriers, and to assess the intensity of the relationships and cause-and-effect relations between the adoption barriers. Methods: This paper uses the Delphi expert consultation method to determine key barriers to 5G adoption in Western China hospitals, the interpretive structural modeling to uncover interaction relationships and priorities, and the decision-making trial and evaluation laboratory method to reveal cause-and-effect relationships and their intensity levels. Results: In total, 14 barriers were determined by literature review and the Delphi method. Among these, ``lack of policies on ethics, rights, and responsibilities in core health care scenarios'' emerged as the fundamental influencing factor in the entire system, as it was the only factor at the bottom level of the interpretive structural model. Overall, 8 barriers were classified as the ``cause group,'' and 6 as the ``effect group'' by the decision-making trial and evaluation laboratory method. ``High expense'' and ``organizational barriers within hospitals'' were determined as the most significant driving barrier (the highest R--C value of 1.361) and the most critical barrier (the highest R+C value of 4.317), respectively. Conclusions: Promoting the integration of 5G in hospitals in Western China faces multiple complex and interrelated barriers. The study provides valuable quantitative evidence and a comprehensive approach for regulatory authorities, hospitals, and telecom operators, helping them develop strategic pathways for promoting widespread 5G adoption in health care. It is suggested that the stakeholders cooperate to explore and solve the problems in the 5G medical care era, aiming to achieve the coverage of 5G medical care across the country. To our best knowledge, this study is the first academic exploration systematically analyzing factors resisting 5G integration in Chinese hospitals, and it may give subsequent researchers a solid foundation for further studying the application and development of 5G in health care. ", doi="10.2196/48842", url="https://mhealth.jmir.org/2024/1/e48842", url="http://www.ncbi.nlm.nih.gov/pubmed/38261368" } @Article{info:doi/10.2196/49986, author="Ulgu, Mahir Mustafa and Laleci Erturkmen, Banu Gokce and Yuksel, Mustafa and Namli, Tuncay and Postac?, ?enan and Gencturk, Mert and Kabak, Yildiray and Sinaci, Anil A. and Gonul, Suat and Dogac, Asuman and {\"O}zkan Altunay, Z{\"u}beyde and Ekinci, Banu and Aydin, Sahin and Birinci, Suayip", title="A Nationwide Chronic Disease Management Solution via Clinical Decision Support Services: Software Development and Real-Life Implementation Report", journal="JMIR Med Inform", year="2024", month="Jan", day="19", volume="12", pages="e49986", keywords="chronic disease management", keywords="clinical decision support services", keywords="integrated care", keywords="interoperability", keywords="evidence-based medicine", keywords="medicine", keywords="disease management", keywords="management", keywords="implementation", keywords="decision support", keywords="clinical decision", keywords="support", keywords="chronic disease", keywords="physician-centered", keywords="risk assessment", keywords="tracking", keywords="diagnosis", abstract="Background: The increasing population of older adults has led to a rise in the demand for health care services, with chronic diseases being a major burden. Person-centered integrated care is required to address these challenges; hence, the Turkish Ministry of Health has initiated strategies to implement an integrated health care model for chronic disease management. We aim to present the design, development, nationwide implementation, and initial performance results of the national Disease Management Platform (DMP). Objective: This paper's objective is to present the design decisions taken and technical solutions provided to ensure successful nationwide implementation by addressing several challenges, including interoperability with existing IT systems, integration with clinical workflow, enabling transition of care, ease of use by health care professionals, scalability, high performance, and adaptability. Methods: The DMP is implemented as an integrated care solution that heavily uses clinical decision support services to coordinate effective screening and management of chronic diseases in adherence to evidence-based clinical guidelines and, hence, to increase the quality of health care delivery. The DMP is designed and implemented to be easily integrated with the existing regional and national health IT systems via conformance to international health IT standards, such as Health Level Seven Fast Healthcare Interoperability Resources. A repeatable cocreation strategy has been used to design and develop new disease modules to ensure extensibility while ensuring ease of use and seamless integration into the regular clinical workflow during patient encounters. The DMP is horizontally scalable in case of high load to ensure high performance. Results: As of September 2023, the DMP has been used by 25,568 health professionals to perform 73,715,269 encounters for 16,058,904 unique citizens. It has been used to screen and monitor chronic diseases such as obesity, cardiovascular risk, diabetes, and hypertension, resulting in the diagnosis of 3,545,573 patients with obesity, 534,423 patients with high cardiovascular risk, 490,346 patients with diabetes, and 144,768 patients with hypertension. Conclusions: It has been demonstrated that the platform can scale horizontally and efficiently provides services to thousands of family medicine practitioners without performance problems. The system seamlessly interoperates with existing health IT solutions and runs as a part of the clinical workflow of physicians at the point of care. By automatically accessing and processing patient data from various sources to provide personalized care plan guidance, it maximizes the effect of evidence-based decision support services by seamless integration with point-of-care electronic health record systems. As the system is built on international code systems and standards, adaptation and deployment to additional regional and national settings become easily possible. The nationwide DMP as an integrated care solution has been operational since January 2020, coordinating effective screening and management of chronic diseases in adherence to evidence-based clinical guidelines. ", doi="10.2196/49986", url="https://medinform.jmir.org/2024/1/e49986", url="http://www.ncbi.nlm.nih.gov/pubmed/38241077" } @Article{info:doi/10.2196/48345, author="Schroeder, Tanja and Haug, Maximilian and Georgiou, Andrew and Seaman, Karla and Gewald, Heiko", title="Evidence of How Physicians and Their Patients Adopt mHealth Apps in Germany: Exploratory Qualitative Study", journal="JMIR Mhealth Uhealth", year="2024", month="Jan", day="17", volume="12", pages="e48345", keywords="mobile health apps", keywords="DiGA", keywords="adoption", keywords="prescription", keywords="mHealth", keywords="aging and individual differences", abstract="Background: The enactment of the ``Act to Improve Healthcare Provision through Digitalisation and Innovation '' (Digital Healthcare Act; Digitale-Versorgung-Gesetz [DVG]) in Germany has introduced a paradigm shift in medical practice, allowing physicians to prescribe mobile health (mHealth) apps alongside traditional medications. This transformation imposes a dual responsibility on physicians to acquaint themselves with qualifying apps and align them with patient diagnoses, while requiring patients to adhere to the prescribed app use, similar to pharmaceutical adherence. This transition, particularly challenging for older generations who are less skilled with technology, underscores a significant evolution in Germany's medical landscape. Objective: This study aims to investigate physicians' responses to this novel treatment option, their strategies for adapting to this form of prescription, and the willingness of patients to adhere to prescribed mHealth apps. Methods: Using an exploratory qualitative study design, we conducted semistructured interviews with 28 physicians and 30 potential patients aged 50 years and older from August 2020 to June 2021. Results: The findings reveal several factors influencing the adoption of mHealth apps, prompting a nuanced understanding of adoption research. Notably, both physicians and patients demonstrated a lack of information regarding mHealth apps and their positive health impacts, contributing to a deficiency in trust. Physicians' self-perceived digital competence and their evaluation of patients' digital proficiency emerge as pivotal factors influencing the prescription of mHealth apps. Conclusions: Our study provides comprehensive insights into the prescription process and the fundamental factors shaping the adoption of mHealth apps in Germany. The identified information gaps on both the physicians' and patients' sides contribute to a trust deficit and hindered digital competence. This research advances the understanding of adoption dynamics regarding digital health technologies and highlights crucial considerations for the successful integration of digital health apps into medical practice. ", doi="10.2196/48345", url="https://mhealth.jmir.org/2024/1/e48345", url="http://www.ncbi.nlm.nih.gov/pubmed/38231550" } @Article{info:doi/10.2196/45020, author="He, Xianying and Cui, Fangfang and Lyu, Minzhao and Sun, Dongxu and Zhang, Xu and Shi, Jinming and Zhang, Yinglan and Jiang, Shuai and Zhao, Jie", title="Key Factors Influencing the Operationalization and Effectiveness of Telemedicine Services in Henan Province, China: Cross-Sectional Analysis", journal="J Med Internet Res", year="2024", month="Jan", day="5", volume="26", pages="e45020", keywords="telemedicine", keywords="service statistics", keywords="efficiency", keywords="quality management", abstract="Background: Telemedicine has demonstrated its potential in alleviating the unbalanced distribution of medical resources across different regions. Henan, a province in China with a population of approximately 100 million, is especially affected by a health care divide. The province has taken a proactive step by establishing a regional collaborative platform for telemedicine services provided by top-tier provincial hospitals. Objective: We aim to identify the key factors that influence the current operationalization and effectiveness of telemedicine services in Henan province. The insights gained from this study will serve as valuable references for enhancing the efficient operation of telemedicine platforms in low- and middle-income regions. Methods: We analyzed service reports from the performance management system of telemedicine services in Henan province throughout 2020. Using descriptive statistics and graphical methods, we examined key influencing factors, such as management competency; device configuration; and hospital capability, capacity, and service efficacy, across hospitals at 2 different tiers. In addition, we used generalized linear models and multiple linear regression models to identify key operational factors that significantly affect the service volume and efficacy of 2 major telemedicine services, namely teleconsultation and tele-education. Results: Among the 89 tier 3 hospitals and 97 tier 2 hospitals connected to the collaborative telemedicine platform, 65 (73\%) and 55 (57\%), respectively, have established standardized management procedures for telemedicine services. As the primary delivery method for telemedicine services, 90\% (80/89) of the tier 3 hospitals and 94\% (91/97) of the tier 2 hospitals host videoconferencing consultations through professional hardware terminals rather than generic computers. Teleconsultation is the dominant service type, with an average annual service volume per institution of 173 (IQR 37-372) and 60 (IQR 14-271) teleconsultations for tier 3 and tier 2 hospitals, respectively. Key factors influencing the service volume at each hospital include available funding, management competency, the number of connected upper tiers, and the number of professional staff. After receiving teleconsultations from tier 3 (65/89, 73\%) and tier 2 (61/97, 63\%) hospitals, patients reported significant improvements in their medical conditions. In addition, we observed that service efficacy is positively influenced by management competency, financial incentives, the number of connected upper or lower tiers, and the involvement of participating medical professionals. Conclusions: Telemedicine has become increasingly popular in Henan province, with a notable focus on teleconsultation and tele-education services. Despite its popularity, many medical institutions, especially tier 2 hospitals, face challenges related to management competency. In addition to enhancing the effectiveness of existing telemedicine services, health care decision-makers in Henan province and other low- and middle-income regions should consider expanding the service categories, such as including remote emergency care and telesurgery, which have promise in addressing crucial health care needs in these regions. ", doi="10.2196/45020", url="https://www.jmir.org/2024/1/e45020", url="http://www.ncbi.nlm.nih.gov/pubmed/38180795" } @Article{info:doi/10.2196/48702, author="Pedrera-Jim{\'e}nez, Miguel and Garc{\'i}a-Barrio, Noelia and Frid, Santiago and Moner, David and Bosc{\'a}-Tom{\'a}s, Diego and Lozano-Rub{\'i}, Raimundo and Kalra, Dipak and Beale, Thomas and Mu{\~n}oz-Carrero, Adolfo and Serrano-Balazote, Pablo", title="Can OpenEHR, ISO 13606, and HL7 FHIR Work Together? An Agnostic Approach for the Selection and Application of Electronic Health Record Standards to the Next-Generation Health Data Spaces", journal="J Med Internet Res", year="2023", month="Dec", day="28", volume="25", pages="e48702", keywords="electronic health records", keywords="FAIR principles", keywords="health information standards", keywords="HL7 FHIR", keywords="ISO 13606", keywords="OpenEHR", keywords="semantics", doi="10.2196/48702", url="https://www.jmir.org/2023/1/e48702", url="http://www.ncbi.nlm.nih.gov/pubmed/38153779" } @Article{info:doi/10.2196/50903, author="Jacobs, Marie Sarah and Lundy, Nicole Neva and Issenberg, Barry Saul and Chandran, Latha", title="Reimagining Core Entrustable Professional Activities for Undergraduate Medical Education in the Era of Artificial Intelligence", journal="JMIR Med Educ", year="2023", month="Dec", day="19", volume="9", pages="e50903", keywords="artificial intelligence", keywords="entrustable professional activities", keywords="medical education", keywords="competency-based education", keywords="educational technology", keywords="machine learning", doi="10.2196/50903", url="https://mededu.jmir.org/2023/1/e50903", url="http://www.ncbi.nlm.nih.gov/pubmed/38052721" } @Article{info:doi/10.2196/49374, author="Khavandi, Sarah and Zaghloul, Fatema and Higham, Aisling and Lim, Ernest and de Pennington, Nick and Celi, Anthony Leo", title="Investigating the Impact of Automation on the Health Care Workforce Through Autonomous Telemedicine in the Cataract Pathway: Protocol for a Multicenter Study", journal="JMIR Res Protoc", year="2023", month="Dec", day="5", volume="12", pages="e49374", keywords="artificial intelligence", keywords="autonomous telemedicine", keywords="clinician burnout", keywords="clinician wellbeing", keywords="conversational agent", keywords="digital health", keywords="health communication", keywords="health information technology", keywords="health services", keywords="healthcare", keywords="medical informatics", keywords="socio-technical system approach", keywords="systems approach", keywords="technology acceptability", abstract="Background: While digital health innovations are increasingly being adopted by health care organizations, implementation is often carried out without considering the impacts on frontline staff who will be using the technology and who will be affected by its introduction. The enthusiasm surrounding the use of artificial intelligence (AI)--enabled digital solutions in health care is tempered by uncertainty around how it will change the working lives and practices of health care professionals. Digital enablement can be viewed as facilitating enhanced effectiveness and efficiency by improving services and automating cognitive labor, yet the implementation of such AI technology comes with challenges related to changes in work practices brought by automation. This research explores staff experiences before and after care pathway automation with an autonomous clinical conversational assistant, Dora (Ufonia Ltd), that is able to automate routine clinical conversations. Objective: The primary objective is to examine the impact of AI-enabled automation on clinicians, allied health professionals, and administrators who provide or facilitate health care to patients in high-volume, low-complexity care pathways. In the process of transforming care pathways through automation of routine tasks, staff will increasingly ``work at the top of their license.'' The impact of this fundamental change on the professional identity, well-being, and work practices of the individual is poorly understood at present. Methods: We will adopt a multiple case study approach, combining qualitative and quantitative data collection methods, over 2 distinct phases, namely phase A (preimplementation) and phase B (postimplementation). Results: The analysis is expected to reveal the interrelationship between Dora and those affected by its introduction. This will reveal how tasks and responsibilities have changed or shifted, current tensions and contradictions, ways of working, and challenges, benefits, and opportunities as perceived by those on the frontlines of the health care system. The findings will enable a better understanding of the resistance or susceptibility of different stakeholders within the health care workforce and encourage managerial awareness of differing needs, demands, and uncertainties. Conclusions: The implementation of AI in the health care sector, as well as the body of research on this topic, remain in their infancy. The project's key contribution will be to understand the impact of AI-enabled automation on the health care workforce and their work practices. International Registered Report Identifier (IRRID): PRR1-10.2196/49374 ", doi="10.2196/49374", url="https://www.researchprotocols.org/2023/1/e49374", url="http://www.ncbi.nlm.nih.gov/pubmed/38051569" } @Article{info:doi/10.2196/51884, author="Brommeyer, Mark and Liang, Zhanming and Whittaker, Maxine and Mackay, Mark", title="Developing Health Management Competency for Digital Health Transformation: Protocol for a Qualitative Study", journal="JMIR Res Protoc", year="2023", month="Nov", day="3", volume="12", pages="e51884", keywords="health care management", keywords="health service manager", keywords="digital health", keywords="health informatics", keywords="competency", keywords="workforce development", keywords="innovation", keywords="research protocol", keywords="informatics", keywords="manager", keywords="managers", keywords="service", keywords="services", keywords="delivery", keywords="organization", keywords="organizational", keywords="workforce", keywords="management", keywords="managerial", keywords="qualification", keywords="qualifications", keywords="focus group", keywords="focus groups", keywords="interview", keywords="interviews", keywords="scoping", keywords="review methods", keywords="review methodology", abstract="Background: Globally, the health care system is experiencing a period of rapid and radical change. In response, innovative service models have been adopted for the delivery of high-quality care that require a health workforce with skills to support transformation and new ways of working. Objective: The aim of this research protocol is to describe research that will contribute to developing the capability of health service managers in the digital health era and enabling digital transformation within the Australian health care environment. It also explains the process of preparing and finalizing the research design and methodologies by seeking answers to the following three research questions: (1) To what extent can the existing health service management and digital health competency frameworks guide the development of competence for health service managers in understanding and managing in the digital health space? (2) What are the competencies that are necessary for health service managers to acquire in order to effectively work with and manage in the digital health context? (3) What are the key factors that enable and inhibit health service managers to develop and demonstrate digital health competence in the workplace? Methods: The study has adopted a qualitative approach, guided by the empirically validated management competency identification process, using four steps: (1) health management and digital health competency mapping, (2) scoping review of literature and policy analysis, (3) focus group discussions with health service managers, and (4) semistructured interviews with digital health leaders. The first 2 steps were to confirm the need for updating the current health service management curriculum to address changing competency requirements of health service managers in the digital health context. Results: Two initial steps have been completed confirming the significance of the study and study design. Step 1, competency mapping, found that nearly half of the digital competencies were only partially or not addressed at all by the health management competency framework. The scoping review articulated the competencies health service managers need to effectively demonstrate digital health competence in the workplace. The findings effectively support the importance of the current research and also the appropriateness of the proposed steps 3 and 4 in answering the research questions and achieving the research aim. Conclusions: This study will provide insights into the health service management workforce performance and development needs for digital health and inform credentialing and professional development requirements. This will guide health service managers in leading and managing the adoption and implementation of digital health as a contemporary tool for health care delivery. The study will develop an in-depth understanding of Australian health service managers' experiences and views. This research process could be applied in other contexts, noting that the results need contextualization to individual country jurisdictions and environments. International Registered Report Identifier (IRRID): DERR1-10.2196/51884 ", doi="10.2196/51884", url="https://www.researchprotocols.org/2023/1/e51884", url="http://www.ncbi.nlm.nih.gov/pubmed/37921855" } @Article{info:doi/10.2196/44206, author="Keogh, Alison and Mc Ardle, R{\'i}ona and Diaconu, Gabriela Mara and Ammour, Nadir and Arnera, Valdo and Balzani, Federica and Brittain, Gavin and Buckley, Ellen and Buttery, Sara and Cantu, Alma and Corriol-Rohou, Solange and Delgado-Ortiz, Laura and Duysens, Jacques and Forman-Hardy, Tom and Gur-Arieh, Tova and Hamerlijnck, Dominique and Linnell, John and Leocani, Letizia and McQuillan, Tom and Neatrour, Isabel and Polhemus, Ashley and Remmele, Werner and Saraiva, Isabel and Scott, Kirsty and Sutton, Norman and van den Brande, Koen and Vereijken, Beatrix and Wohlrab, Martin and Rochester, Lynn and ", title="Mobilizing Patient and Public Involvement in the Development of Real-World Digital Technology Solutions: Tutorial", journal="J Med Internet Res", year="2023", month="Oct", day="27", volume="25", pages="e44206", keywords="patient involvement", keywords="patient engagement", keywords="public-private partnership", keywords="research consortium", keywords="digital mobility outcomes", keywords="real-world mobility", keywords="digital mobility measures", doi="10.2196/44206", url="https://www.jmir.org/2023/1/e44206", url="http://www.ncbi.nlm.nih.gov/pubmed/37889531" } @Article{info:doi/10.2196/47663, author="Castor, Charlotte and Lindkvist, Rose-Marie and Hallstr{\"o}m, Kristensson Inger and Holmberg, Robert", title="Health Care Professionals' Experiences and Views of eHealth in Pediatric Care: Qualitative Interview Study Applying a Theoretical Framework for Implementation", journal="JMIR Pediatr Parent", year="2023", month="Oct", day="18", volume="6", pages="e47663", keywords="communication", keywords="digital", keywords="experiences", keywords="eHealth", keywords="health care professionals", keywords="implementation", keywords="NASSS", keywords="pediatric care", abstract="Background: The development and evaluation of eHealth interventions in clinical care should be accompanied by a thorough assessment of their implementation. The NASSS (Non-adoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies) framework was designed to facilitate the implementation and scale-up of health technology programs, providing an option for analyzing the progression of these initiatives as they are implemented in real-time. Considering health care provider perspectives within the framework for implementation offers valuable insights into the early identification of barriers and facilitators in the implementation of potentially effective eHealth innovations. Nevertheless, there is a dearth of studies on eHealth interventions that encompass longer time frames and delve into the complexities of scaling up and sustaining such interventions within real-world health care environments. Objective: This study aims to investigate the perspectives and insights of health care professionals (HCPs) regarding the implementation of an eHealth intervention in pediatric health care while applying the NASSS framework to theorize and evaluate the conditions influencing the implementation of eHealth solutions. Methods: Semistructured interviews were performed with health care providers, including both staff and management personnel, within a university pediatric hospital (N=10). The data collection process occurred concurrently with a clinical trial focused on developing and assessing an eHealth app for self-management in pediatric care following hospital discharge. Using an abductive approach, the interviews were initially analyzed qualitatively and subsequently mapped onto the 7 domains of the NASSS framework to identify factors influencing implementation, encompassing facilitators, barriers, and varying levels of complexity. Results: In the realm of pediatric care, the family was identified as the primary unit of care, and patient heterogeneity was a prominent feature. The implementation of eHealth tools, while deemed usable and flexible, was also seen as a delicate balance between safety and adaptability, highlighting challenges related to health care integration. Child participation and secrecy, especially for adolescents, contributed to the complexity of using eHealth. HCPs had high eHealth literacy, and thus challenges concerning adoption were related to work adaptations and the risk of ``app overload.'' The readiness for implementation was experienced as induced through the research study and the pandemic situation. However, to move from research to implementation in clinical practice, organizational challenges identified a need to update the concept of care and ensure activity measurements. In a wider context, HCPs raised concerns related to regulatory requirements for documentation, public procurement, and data safety. Implementation became more complex due to a lack of overview in a large organization. Conclusions: Important perspectives for implementation were considerations of regulatory requirements, as well as the need for a shared vision of eHealth and the establishment of eHealth-related work as part of regular health care. Key contextual factors that support reach and impact are communication channels between different levels at the hospital and a need for paths and procedures compatible with legal, technological, and security concerns. Further research should focus on how eHealth interventions are perceived by children, adolescents, their parents, and other stakeholders. Trial Registration: ClinicalTrials.gov NCT04150120; https://clinicaltrials.gov/ct2/show/NCT04150120 ", doi="10.2196/47663", url="https://pediatrics.jmir.org/2023/1/e47663", url="http://www.ncbi.nlm.nih.gov/pubmed/37851500" } @Article{info:doi/10.2196/48097, author="Layer, Erica and Slim, Salim and Mussa, Issa and Al-Mafazy, Abdul-Wahid and Besana, R. Giulia V. and Msellem, Mwinyi and Fulcher, Isabel and Hornung, Heiko and Lampariello, Riccardo", title="The Journey of Zanzibar's Digitally Enabled Community Health Program to National Scale: Implementation Report", journal="JMIR Med Inform", year="2023", month="Oct", day="9", volume="11", pages="e48097", keywords="Zanzibar", keywords="digital health", keywords="community health", keywords="health systems strengthening", keywords="maternal health", keywords="child health", keywords="data for decision-making", keywords="implementation science", keywords="health systems", keywords="healthcare infrastructure", keywords="health care", keywords="implementation report", abstract="Background: While high-quality primary health care services can meet 80\%-90\% of health needs over a person's lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced, and managed community health worker programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation. Objective: In this implementation report, we describe the design and rollout of Zanzibar's national, digitally enabled community health program--Jamii ni Afya. Methods: Since 2010, D-tree International has partnered with the Ministry of Health Zanzibar to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community health workers use a mobile app that guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources, and continuous quality improvement. Results: The Zanzibar government has documented increases in the delivery of health facilities among pregnant women and reductions in stunting among children younger than 5 years since the community health program has scaled. Key success factors included starting with the health challenge and local context rather than the technology, usage of data for decision-making, and extensive collaboration with local and global partners and funders. Lessons learned include the significant time it takes to scale and institutionalize a digital health systems innovation due to the time to generate evidence, change opinions, and build capacity. Conclusions: Jamii ni Afya represents one of the world's first examples of a nationally scaled digitally enabled community health program. This implementation report outlines key successes and lessons learned, which may have applicability to other governments and partners working to sustainably strengthen primary health systems. ", doi="10.2196/48097", url="https://medinform.jmir.org/2023/1/e48097", url="http://www.ncbi.nlm.nih.gov/pubmed/37812488" } @Article{info:doi/10.2196/49003, author="van Kessel, Robin and Srivastava, Divya and Kyriopoulos, Ilias and Monti, Giovanni and Novillo-Ortiz, David and Milman, Ran and Zhang-Czabanowski, Wilhelm Wojciech and Nasi, Greta and Stern, Dora Ariel and Wharton, George and Mossialos, Elias", title="Digital Health Reimbursement Strategies of 8 European Countries and Israel: Scoping Review and Policy Mapping", journal="JMIR Mhealth Uhealth", year="2023", month="Sep", day="29", volume="11", pages="e49003", keywords="digital health", keywords="telehealth", keywords="telemedicine", keywords="reimbursement", keywords="policy", keywords="Europe", keywords="policy mapping", keywords="mapping", keywords="pricing", keywords="digital health app", keywords="application", keywords="health care ecosystem", keywords="framework", keywords="integration", abstract="Background: The adoption of digital health care within health systems is determined by various factors, including pricing and reimbursement. The reimbursement landscape for digital health in Europe remains underresearched. Although various emergency reimbursement decisions were made during the COVID-19 pandemic to enable health care delivery through videoconferencing and asynchronous care (eg, digital apps), research so far has primarily focused on the policy innovations that facilitated this outside of Europe. Objective: This study examines the digital health reimbursement strategies in 8 European countries (Belgium, France, Germany, Italy, the Netherlands, Poland, Sweden, and the United Kingdom) and Israel. Methods: We mapped available digital health reimbursement strategies using a scoping review and policy mapping framework. We reviewed the literature on the MEDLINE, Embase, Global Health, and Web of Science databases. Supplementary records were identified through Google Scholar and country experts. Results: Our search strategy yielded a total of 1559 records, of which 40 (2.57\%) were ultimately included in this study. As of August 2023, digital health solutions are reimbursable to some extent in all studied countries except Poland, although the mechanism of reimbursement differs significantly across countries. At the time of writing, the pricing of digital health solutions was mostly determined through discussions between national or regional committees and the manufacturers of digital health solutions in the absence of value-based assessment mechanisms. Financing digital health solutions outside traditional reimbursement schemes was possible in all studied countries except Poland and typically occurs via health innovation or digital health--specific funding schemes. European countries have value-based pricing frameworks that range from nonexistent to embryonic. Conclusions: Studied countries show divergent approaches to the reimbursement of digital health solutions. These differences may complicate the ability of patients to seek cross-country health care in another country, even if a digital health app is available in both countries. Furthermore, the fragmented environment will present challenges for developers of such solutions, as they look to expand their impact across countries and health systems. An increased emphasis on developing a clear conceptualization of digital health, as well as value-based pricing and reimbursement mechanisms, is needed for the sustainable integration of digital health. This study can therein serve as a basis for further, more detailed research as the field of digital health reimbursement evolves. ", doi="10.2196/49003", url="https://mhealth.jmir.org/2023/1/e49003", url="http://www.ncbi.nlm.nih.gov/pubmed/37773610" } @Article{info:doi/10.2196/40959, author="Li, Zhong and Merrell, A. Melinda and Eberth, M. Jan and Wu, Dezhi and Hung, Peiyin", title="Successes and Barriers of Health Information Exchange Participation Across Hospitals in South Carolina From 2014 to 2020: Longitudinal Observational Study", journal="JMIR Med Inform", year="2023", month="Sep", day="28", volume="11", pages="e40959", keywords="health information exchange", keywords="electronic health records", keywords="interoperability", keywords="meaningful use", keywords="hospital", abstract="Background: The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation. Objective: This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals. Methods: This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated. Results: Hospitals in SC have been increasingly participating in HIE, improving from 43\% (24/56) in 2014 to 82\% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95\% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95\% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95\% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95\% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68\%), difficulty in finding patient health information (27/40, 68\%), adapting different vendor platforms (26/40, 65\%), difficulty matching or identifying same patients between systems (23/40, 58\%), and providers that do not typically exchange patient data (23/40, 58\%). Conclusions: HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information. ", doi="10.2196/40959", url="https://medinform.jmir.org/2023/1/e40959", url="http://www.ncbi.nlm.nih.gov/pubmed/37768730" } @Article{info:doi/10.2196/49303, author="Lammons, William and Silkens, Milou and Hunter, Jamie and Shah, Sudhir and Stavropoulou, Charitini", title="Centering Public Perceptions on Translating AI Into Clinical Practice: Patient and Public Involvement and Engagement Consultation Focus Group Study", journal="J Med Internet Res", year="2023", month="Sep", day="26", volume="25", pages="e49303", keywords="acceptance", keywords="AI in health care", keywords="AI", keywords="artificial intelligence", keywords="health care research", keywords="health care", keywords="patient and public engagement and involvement", keywords="patient engagement", keywords="public engagement", keywords="transition", abstract="Background: Artificial intelligence (AI) is widely considered to be the new technical advancement capable of a large-scale modernization of health care. Considering AI's potential impact on the clinician-patient relationship, health care provision, and health care systems more widely, patients and the wider public should be a part of the development, implementation, and embedding of AI applications in health care. Failing to establish patient and public engagement and involvement (PPIE) can limit AI's impact. Objective: This study aims to (1) understand patients' and the public's perceived benefits and challenges for AI and (2) clarify how to best conduct PPIE in projects on translating AI into clinical practice, given public perceptions of AI. Methods: We conducted this qualitative PPIE focus-group consultation in the United Kingdom. A total of 17 public collaborators representing 7 National Institute of Health and Care Research Applied Research Collaborations across England participated in 1 of 3 web-based semistructured focus group discussions. We explored public collaborators' understandings, experiences, and perceptions of AI applications in health care. Transcripts were coanalyzed iteratively with 2 public coauthors using thematic analysis. Results: We identified 3 primary deductive themes with 7 corresponding inductive subthemes. Primary theme 1, advantages of implementing AI in health care, had 2 subthemes: system improvements and improve quality of patient care and shared decision-making. Primary theme 2, challenges of implementing AI in health care, had 3 subthemes: challenges with security, bias, and access; public misunderstanding of AI; and lack of human touch in care and decision-making. Primary theme 3, recommendations on PPIE for AI in health care, had 2 subthemes: experience, empowerment, and raising awareness; and acknowledging and supporting diversity in PPIE. Conclusions: Patients and the public can bring unique perspectives on the development, implementation, and embedding of AI in health care. Early PPIE is therefore crucial not only to safeguard patients but also to increase the chances of acceptance of AI by the public and the impact AI can make in terms of outcomes. ", doi="10.2196/49303", url="https://www.jmir.org/2023/1/e49303", url="http://www.ncbi.nlm.nih.gov/pubmed/37751234" } @Article{info:doi/10.2196/45224, author="O'Brien, Niki and Li, Edmond and Chaibva, N. Cynthia and Gomez Bravo, Raquel and Kovacevic, Lana and Kwame Ayisi-Boateng, Nana and Lounsbury, Olivia and Nwabufo, F. Ngnedjou Francoise and Senkyire, Kumi Ephraim and Serafini, Alice and Surafel Abay, Eleleta and van de Vijver, Steven and Wanjala, Mercy and Wangari, Marie-Claire and Moosa, Shabir and Neves, Luisa Ana", title="Strengths, Weaknesses, Opportunities, and Threats Analysis of the Use of Digital Health Technologies in Primary Health Care in the Sub-Saharan African Region: Qualitative Study", journal="J Med Internet Res", year="2023", month="Sep", day="7", volume="25", pages="e45224", keywords="digital health", keywords="digital health technology", keywords="telemedicine", keywords="remote care", keywords="primary care", keywords="primary health carel PHC", keywords="COVID-19", keywords="global health", keywords="sub-Saharan Africa", keywords="eHealth", abstract="Background: Digital health technologies (DHTs) have become increasingly commonplace as a means of delivering primary care. While DHTs have been postulated to reduce inequalities, increase access, and strengthen health systems, how the implementation of DHTs has been realized in the sub-Saharan Africa (SSA) health care environment remains inadequately explored. Objective: This study aims to capture the multidisciplinary experiences of primary care professionals using DHTs to explore the strengths and weaknesses, as well as opportunities and threats, regarding the implementation and use of DHTs in SSA primary care settings. Methods: A combination of qualitative approaches was adopted (ie, focus groups and semistructured interviews). Participants were recruited through the African Forum for Primary Care and researchers' contact networks using convenience sampling and included if having experience with digital technologies in primary health care in SSA. Focus and interviews were conducted, respectively, in November 2021 and January-March 2022. Topic guides were used to cover relevant topics in the interviews, using the strengths, weaknesses, opportunities, and threats framework. Transcripts were compiled verbatim and systematically reviewed by 2 independent reviewers using framework analysis to identify emerging themes. The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was used to ensure the study met the recommended standards of qualitative data reporting. Results: A total of 33 participants participated in the study (n=13 and n=23 in the interviews and in focus groups, respectively; n=3 participants participated in both). The strengths of using DHTs ranged from improving access to care, supporting the continuity of care, and increasing care satisfaction and trust to greater collaboration, enabling safer decision-making, and hastening progress toward universal health coverage. Weaknesses included poor digital literacy, health inequalities, lack of human resources, inadequate training, lack of basic infrastructure and equipment, and poor coordination when implementing DHTs. DHTs were perceived as an opportunity to improve patient digital literacy, increase equity, promote more patient-centric design in upcoming DHTs, streamline expenditure, and provide a means to learn international best practices. Threats identified include the lack of buy-in from both patients and providers, insufficient human resources and local capacity, inadequate governmental support, overly restrictive regulations, and a lack of focus on cybersecurity and data protection. Conclusions: The research highlights the complex challenges of implementing DHTs in the SSA context as a fast-moving health delivery modality, as well as the need for multistakeholder involvement. Future research should explore the nuances of these findings across different technologies and settings in the SSA region and implications on health and health care equity, capitalizing on mixed-methods research, including the use of real-world quantitative data to understand patient health needs. The promise of digital health will only be realized when informed by studies that incorporate patient perspective at every stage of the research cycle. ", doi="10.2196/45224", url="https://www.jmir.org/2023/1/e45224", url="http://www.ncbi.nlm.nih.gov/pubmed/37676721" } @Article{info:doi/10.2196/48496, author="Lehoux, Pascale and Rocha de Oliveira, Robson and Rivard, Lysanne and Silva, Pacifico Hudson and Alami, Hassane and M{\"o}rch, Maria Carl and Malas, Kathy", title="A Comprehensive, Valid, and Reliable Tool to Assess the Degree of Responsibility of Digital Health Solutions That Operate With or Without Artificial Intelligence: 3-Phase Mixed Methods Study", journal="J Med Internet Res", year="2023", month="Aug", day="28", volume="25", pages="e48496", keywords="Responsible Innovation in Health", keywords="digital health policy", keywords="artificial intelligence ethics", keywords="responsible research and innovation", keywords="mixed methods", keywords="e-Delphi", keywords="interrater agreement", keywords="mobile phone", abstract="Background: Clinicians' scope of responsibilities is being steadily transformed by digital health solutions that operate with or without artificial intelligence (DAI solutions). Most tools developed to foster ethical practices lack rigor and do not concurrently capture the health, social, economic, and environmental issues that such solutions raise. Objective: To support clinical leadership in this field, we aimed to develop a comprehensive, valid, and reliable tool that measures the responsibility of DAI solutions by adapting the multidimensional and already validated Responsible Innovation in Health Tool. Methods: We conducted a 3-phase mixed methods study. Relying on a scoping review of available tools, phase 1 (concept mapping) led to a preliminary version of the Responsible DAI solutions Assessment Tool. In phase 2, an international 2-round e-Delphi expert panel rated on a 5-level scale the importance, clarity, and appropriateness of the tool's components. In phase 3, a total of 2 raters independently applied the revised tool to a sample of DAI solutions (n=25), interrater reliability was measured, and final minor changes were made to the tool. Results: The mapping process identified a comprehensive set of responsibility premises, screening criteria, and assessment attributes specific to DAI solutions. e-Delphi experts critically assessed these new components and provided comments to increase content validity (n=293), and after round 2, consensus was reached on 85\% (22/26) of the items surveyed. Interrater agreement was substantial for a subcriterion and almost perfect for all other criteria and assessment attributes. Conclusions: The Responsible DAI solutions Assessment Tool offers a comprehensive, valid, and reliable means of assessing the degree of responsibility of DAI solutions in health. As regulation remains limited, this forward-looking tool has the potential to change practice toward more equitable as well as economically and environmentally sustainable digital health care. ", doi="10.2196/48496", url="https://www.jmir.org/2023/1/e48496", url="http://www.ncbi.nlm.nih.gov/pubmed/37639297" } @Article{info:doi/10.2196/48824, author="van Kessel, Robin and Haig, Madeleine and Mossialos, Elias", title="Strengthening Cybersecurity for Patient Data Protection in Europe", journal="J Med Internet Res", year="2023", month="Aug", day="24", volume="25", pages="e48824", keywords="cybersecurity", keywords="Europe", keywords="European Health Data Space", keywords="digital health", keywords="mHealth", keywords="medical informatics", keywords="data privacy", keywords="patient safety", keywords="privacy", keywords="health service", doi="10.2196/48824", url="https://www.jmir.org/2023/1/e48824", url="http://www.ncbi.nlm.nih.gov/pubmed/37616048" } @Article{info:doi/10.2196/48009, author="Wang, Changyu and Liu, Siru and Yang, Hao and Guo, Jiulin and Wu, Yuxuan and Liu, Jialin", title="Ethical Considerations of Using ChatGPT in Health Care", journal="J Med Internet Res", year="2023", month="Aug", day="11", volume="25", pages="e48009", keywords="ethics", keywords="ChatGPT", keywords="artificial intelligence", keywords="AI", keywords="large language models", keywords="health care", keywords="artificial intelligence development", keywords="development", keywords="algorithm", keywords="patient safety", keywords="patient privacy", keywords="safety", keywords="privacy", doi="10.2196/48009", url="https://www.jmir.org/2023/1/e48009", url="http://www.ncbi.nlm.nih.gov/pubmed/37566454" } @Article{info:doi/10.2196/47547, author="El-Khatib, Ziad and Richter, Lukas and Reich, Andreas and Benka, Bernhard and Assadian, Ojan", title="Implementation of a Surveillance System for Severe Acute Respiratory Infections at a Tertiary Care Hospital in Austria: Protocol for a Retrospective Longitudinal Feasibility Study", journal="JMIR Res Protoc", year="2023", month="Aug", day="3", volume="12", pages="e47547", keywords="severe acute respiratory infection", keywords="SARI", keywords="Austria", keywords="influenza", keywords="European Union", keywords="COVID-19", keywords="respiratory", keywords="data retrieval", keywords="information retrieval", keywords="electronic health record", keywords="EHR", keywords="health records", keywords="health record", keywords="surveillance", keywords="risk", keywords="database structure", keywords="incidence", keywords="data collection", abstract="Background: The risk of a large number of severe acute respiratory infection (SARI) cases emerging is a global concern. SARI can overwhelm the health care capacity and cause several deaths. Therefore, the Austrian Agency for Health and Food Safety will explore the feasibility of implementing an automatic electronically based SARI surveillance system at a tertiary care hospital in Austria as part of the hospital network, initiated by the European Centre for Disease Prevention and Control. Objective: We aim to investigate the availability of routinely collected health record data pertaining to respiratory infections and the optimal approach to use such available data for systematic surveillance of SARI in a real-world setting, describe the characteristics of patients with SARI before and after the beginning of the COVID-19 pandemic, and investigate the feasibility of identifying the risk factors for a severe outcome (intensive care unit admission or death) in patients with SARI. Methods: We will test the feasibility of a surveillance system, as part of a large European network, at a tertiary care hospital in the province of Lower Austria (called Regional Hospital Wiener Neustadt). It will be a cross-sectional study for the inventory of the electronic data records and implementation of automatic data retrieval for the period of January 2019 through the end of December 2022. The analysis will include an exploration of the database structure, descriptive analysis of the general characteristics of the patients with SARI, estimation of the SARI incidence rate, and assessment of the risk factors and different levels of severity of patients with SARI using logistic regression analysis. Results: This will be the first study to assess the feasibility of SARI surveillance at a large 800-bed tertiary care hospital in Austria. It will provide a general overview of the potential for establishing a hospital-based surveillance system for SARI. In addition, if successful, the electronic surveillance will be able to improve the response to early warning signs of new SARI, which will better inform policy makers in strengthening the surveillance system. Conclusions: The findings will support the expansion of the SARI hospital-based surveillance system to other hospitals in Austria. This network will be of use to Austria in preparing for future pandemics. International Registered Report Identifier (IRRID): PRR1-10.2196/47547 ", doi="10.2196/47547", url="https://www.researchprotocols.org/2023/1/e47547", url="http://www.ncbi.nlm.nih.gov/pubmed/37535414" } @Article{info:doi/10.2196/46873, author="Pham, Quynh and Wong, David and Pfisterer, J. Kaylen and Aleman, Dionne and Bansback, Nick and Cafazzo, A. Joseph and Casson, J. Alexander and Chan, Brian and Dixon, William and Kakaroumpas, Gerasimos and Lindner, Claudia and Peek, Niels and Potts, WW Henry and Ribeiro, Barbara and Seto, Emily and Stockton-Powdrell, Charlotte and Thompson, Alexander and van der Veer, Sabine", title="The Complexity of Transferring Remote Monitoring and Virtual Care Technology Between Countries: Lessons From an International Workshop", journal="J Med Internet Res", year="2023", month="Aug", day="1", volume="25", pages="e46873", keywords="digital health innovation", keywords="digital health intervention", keywords="digital health landscape", keywords="digital health solution", keywords="health care system", keywords="regulatory pathway", keywords="remote monitoring", keywords="technology transfer", keywords="virtual care", doi="10.2196/46873", url="https://www.jmir.org/2023/1/e46873", url="http://www.ncbi.nlm.nih.gov/pubmed/37526964" } @Article{info:doi/10.2196/39154, author="AlHamawi, Rana and Saad, K. Randa and Abdul Rahim, F. Hanan and Mir Islam Saeed, Khwaja and Husseini, Abdullatif and Khader, Yousef and Al Nsour, Mohannad", title="Supporting Public Health Research Capacity, Quality, and Productivity in a Diverse Region", journal="Interact J Med Res", year="2023", month="Jul", day="31", volume="12", pages="e39154", keywords="health research", keywords="Public health", keywords="Eastern Mediterranean region", keywords="Research capacity", keywords="Research Quality", doi="10.2196/39154", url="https://www.i-jmr.org/2023/1/e39154", url="http://www.ncbi.nlm.nih.gov/pubmed/37523227" } @Article{info:doi/10.2196/46542, author="Pujolar-D{\'i}az, Georgina and Vidal-Alaball, Josep and Forcada, Anna and Descals-Singla, Elisabet and Basora, Josep and ", title="Creation of a Laboratory for Statistics and Analysis of Dependence and Chronic Conditions: Protocol for the Bages Territorial Specialization and Competitiveness Project (PECT BAGESS)", journal="JMIR Res Protoc", year="2023", month="Jul", day="26", volume="12", pages="e46542", keywords="chronic disease", keywords="multiple chronic conditions", keywords="primary health care", keywords="diffusion of innovation", keywords="health data", keywords="data sharing", abstract="Background: With the increasing prevalence of chronic diseases, partly due to the increase in life expectancy and the aging of the population, the complexity of the approach faced by the structures, dynamics, and actors that are part of the current care and attention systems is evident. The territory of Bages (Catalonia, Spain) presents characteristics of a highly complex ecosystem where there is a need to develop new, more dynamic structures for the various actors in the health and social systems, aimed at incorporating new actors in the technological and business field that would allow innovation in the management of this context. Within the framework of the Bages Territorial Specialization and Competitiveness Project (PECT BAGESS), the aim is to address these challenges through various entities that will develop 7 interrelated operations. Of these, the operation of the IDIAP Jordi Gol-Catalan Health Institute focuses on the creation of a Laboratory for Statistics and Analysis of Dependence and Chronic Conditions in the Bages region, in the form of a database that will collect the most relevant information from the different environments that affect the management of chronic conditions and dependence: health, social, economic, and environment. Objective: This study aims to create a laboratory for statistical, dependence, and chronic condition analysis in the Bages region, to determine the chronic conditions and conditions that generate dependence in the Bages area, in order to propose products and services that respond to the needs of people in these situations. Methods: PECT BAGESS originated from the Shared Agenda initiative, which was established in the Bages region with the goal of enhancing the quality of life and fostering social inclusion for individuals with chronic diseases. This study presents part of this broader project, consisting of the creation of a database. Data from chronic conditions and dependence service providers will be combined, using a unique identifier for the different sources of information. A thorough legal analysis was conducted to establish a secure data sharing mechanism among the entities participating in the project. Results: The laboratory will be a key piece in the structure generated in the environment of the PECT BAGESS, which will allow relevant information to be passed on from the different sectors involved to respond to the needs of people with chronic conditions and dependence, as well as to generate opportunities for products and services. Conclusions: The emerging organizational dynamics and structures are expected to demonstrate a health and social management model that may have a remarkable impact on these sectors. Products and services developed may be very useful for generating synergies and facilitating the living conditions of people who can benefit from all these services. However, secure data sharing circuits must be considered. International Registered Report Identifier (IRRID): PRR1-10.2196/46542 ", doi="10.2196/46542", url="https://www.researchprotocols.org/2023/1/e46542", url="http://www.ncbi.nlm.nih.gov/pubmed/37494102" } @Article{info:doi/10.2196/42187, author="de Batlle, Jordi and Ben{\'i}tez, D. Ivan and Moncus{\'i}-Moix, Anna and Androutsos, Odysseas and Angles Barbastro, Rosana and Antonini, Alessio and Arana, Eunate and Cabrera-Umpierrez, Fernanda Maria and Cea, Gloria and Dafoulas, $\Epsilon$ George and Folkvord, Frans and Fullaondo, Ane and Giuliani, Francesco and Huang, Hsiao-Ling and Innominato, F. Pasquale and Kardas, Przemyslaw and Lou, Q. Vivian W. and Manios, Yannis and Matsangidou, Maria and Mercalli, Franco and Mokhtari, Mounir and Pagliara, Silvio and Schellong, Julia and Stieler, Lisa and Votis, Konstantinos and Curr{\'a}s, Paula and Arredondo, Teresa Maria and Posada, Jorge and Guill{\'e}n, Sergio and Pecchia, Leandro and Barb{\'e}, Ferran and Torres, Gerard and Fico, Giuseppe and ", title="GATEKEEPER's Strategy for the Multinational Large-Scale Piloting of an eHealth Platform: Tutorial on How to Identify Relevant Settings and Use Cases", journal="J Med Internet Res", year="2023", month="Jun", day="28", volume="25", pages="e42187", keywords="big data", keywords="chronic diseases", keywords="eHealth", keywords="healthy aging", keywords="integrated care", keywords="large-scale pilots", abstract="Background: The World Health Organization's strategy toward healthy aging fosters person-centered integrated care sustained by eHealth systems. However, there is a need for standardized frameworks or platforms accommodating and interconnecting multiple of these systems while ensuring secure, relevant, fair, trust-based data sharing and use. The H2020 project GATEKEEPER aims to implement and test an open-source, European, standard-based, interoperable, and secure framework serving broad populations of aging citizens with heterogeneous health needs. Objective: We aim to describe the rationale for the selection of an optimal group of settings for the multinational large-scale piloting of the GATEKEEPER platform. Methods: The selection of implementation sites and reference use cases (RUCs) was based on the adoption of a double stratification pyramid reflecting the overall health of target populations and the intensity of proposed interventions; the identification of a principles guiding implementation site selection; and the elaboration of guidelines for RUC selection, ensuring clinical relevance and scientific excellence while covering the whole spectrum of citizen complexities and intervention intensities. Results: Seven European countries were selected, covering Europe's geographical and socioeconomic heterogeneity: Cyprus, Germany, Greece, Italy, Poland, Spain, and the United Kingdom. These were complemented by the following 3 Asian pilots: Hong Kong, Singapore, and Taiwan. Implementation sites consisted of local ecosystems, including health care organizations and partners from industry, civil society, academia, and government, prioritizing the highly rated European Innovation Partnership on Active and Healthy Aging reference sites. RUCs covered the whole spectrum of chronic diseases, citizen complexities, and intervention intensities while privileging clinical relevance and scientific rigor. These included lifestyle-related early detection and interventions, using artificial intelligence--based digital coaches to promote healthy lifestyle and delay the onset or worsening of chronic diseases in healthy citizens; chronic obstructive pulmonary disease and heart failure decompensations management, proposing integrated care management based on advanced wearable monitoring and machine learning (ML) to predict decompensations; management of glycemic status in diabetes mellitus, based on beat to beat monitoring and short-term ML-based prediction of glycemic dynamics; treatment decision support systems for Parkinson disease, continuously monitoring motor and nonmotor complications to trigger enhanced treatment strategies; primary and secondary stroke prevention, using a coaching app and educational simulations with virtual and augmented reality; management of multimorbid older patients or patients with cancer, exploring novel chronic care models based on digital coaching, and advanced monitoring and ML; high blood pressure management, with ML-based predictions based on different intensities of monitoring through self-managed apps; and COVID-19 management, with integrated management tools limiting physical contact among actors. Conclusions: This paper provides a methodology for selecting adequate settings for the large-scale piloting of eHealth frameworks and exemplifies with the decisions taken in GATEKEEPER the current views of the WHO and European Commission while moving forward toward a European Data Space. ", doi="10.2196/42187", url="https://www.jmir.org/2023/1/e42187", url="http://www.ncbi.nlm.nih.gov/pubmed/37379060" } @Article{info:doi/10.2196/44688, author="Brantnell, Anders and Temiz, Serdar and Baraldi, Enrico and Woodford, Joanne and von Essen, Louise", title="Barriers to and Facilitators of the Implementation of Digital Mental Health Interventions as Perceived by Primary Care Decision Makers: Content Analysis of Structured Open-Ended Survey Data", journal="JMIR Hum Factors", year="2023", month="Jun", day="26", volume="10", pages="e44688", keywords="digital mental health", keywords="implementation", keywords="barriers", keywords="facilitators", keywords="internet-based cognitive behavioral therapy", keywords="survey", keywords="decision makers", abstract="Background: Digital mental health represents a way to increase access to evidence-based psychological support. However, the implementation of digital mental health in routine health care practice is limited, with few studies focusing on implementation. Accordingly, there is a need to better understand the barriers to and facilitators of implementing digital mental health. Existing studies have mainly focused on the viewpoints of patients and health professionals. Currently, there are few studies about barriers and facilitators from the perspective of primary care decision makers, that is, the persons responsible for deciding whether a given digital mental health intervention should be implemented in a primary care organization. Objective: The objectives were to identify and describe barriers to and facilitators of the implementation of digital mental health as perceived by primary care decision makers, evaluate the relative importance of different barriers and facilitators, and compare barriers and facilitators reported by primary care decision makers who have versus have not implemented digital mental health interventions. Methods: A web-based self-report survey was conducted with primary care decision makers responsible for the implementation of digital mental health in primary care organizations in Sweden. Answers to 2 open-ended questions about barriers and facilitators were analyzed through summative and deductive content analysis. Results: The survey was completed by 284 primary care decision makers---59 (20.8\%) decision makers representing implementers (ie, organizations that offered digital mental health interventions) and 225 (79.2\%) respondents representing nonimplementers (ie, organizations that did not offer digital mental health interventions). Overall, 90\% (53/59) of the implementers and 98.7\% (222/225) of the nonimplementers identified barriers, and 97\% (57/59) of the implementers and 93.3\% (210/225) of the nonimplementers identified facilitators. Altogether, 29 barriers and 20 facilitators of implementation were identified related to guidelines; patients; health professionals; incentives and resources; capacity for organizational change; and social, political, and legal factors. The most prevalent barriers were related to incentives and resources, whereas the most prevalent facilitators were related to the capacity for organizational change. Conclusions: A number of barriers and facilitators were identified that could influence the implementation of digital mental health from the perspective of primary care decision makers. Implementers and nonimplementers identified many common barriers and facilitators, but they differ in terms of certain barriers and facilitators. Common and differing barriers and facilitators identified by implementers and nonimplementers may be important to address when planning for the implementation of digital mental health interventions. For instance, financial incentives and disincentives (eg, increased costs) are the most frequently mentioned barrier and facilitator, respectively, by nonimplementers, but not by implementers. One way to facilitate implementation could be to provide more information to nonimplementers about the actual costs related to the implementation of digital mental health. ", doi="10.2196/44688", url="https://humanfactors.jmir.org/2023/1/e44688", url="http://www.ncbi.nlm.nih.gov/pubmed/37358902" } @Article{info:doi/10.2196/43333, author="Malerbi, Korn Fernando and Nakayama, Filipe Luis and Gayle Dychiao, Robyn and Zago Ribeiro, Lucas and Villanueva, Cleva and Celi, Anthony Leo and Regatieri, Vinicius Caio", title="Digital Education for the Deployment of Artificial Intelligence in Health Care", journal="J Med Internet Res", year="2023", month="Jun", day="22", volume="25", pages="e43333", keywords="artificial intelligence", keywords="digital health", keywords="health education", keywords="machine learning", keywords="digital education", keywords="digital", keywords="education", keywords="transformation", keywords="neural", keywords="network", keywords="evaluation", keywords="dataset", keywords="data", keywords="set", keywords="clinical", doi="10.2196/43333", url="https://www.jmir.org/2023/1/e43333", url="http://www.ncbi.nlm.nih.gov/pubmed/37347537" } @Article{info:doi/10.2196/37863, author="Cresswell, Kathrin and Hinder, Susan and Sheikh, Aziz and Pontefract, Sarah and Watson, W. Neil and Price, David and Heed, Andrew and Coleman, Jamie and Ennis, Holly and Beggs, Jillian and Chuter, Antony and Williams, Robin", title="ePrescribing-Based Antimicrobial Stewardship Practices in an English National Health Service Hospital: Qualitative Interview Study Among Medical Prescribers and Pharmacists", journal="JMIR Form Res", year="2023", month="Jun", day="6", volume="7", pages="e37863", keywords="antimicrobial resistance", keywords="antimicrobial stewardship", keywords="electronic prescribing", keywords="hospitals", abstract="Background: Antimicrobial resistance, the ability of microorganisms to survive antimicrobial drugs, is a public health emergency. Although electronic prescribing (ePrescribing)--based interventions designed to reduce unnecessary antimicrobial usage exist, these often do not integrate effectively with existing workflows. As a result, ePrescribing-based interventions may have limited impact in addressing antimicrobial resistance. Objective: We sought to understand the existing ePrescribing-based antimicrobial stewardship (AMS) practices in an English hospital preceding the implementation of functionality designed to improve AMS. Methods: We conducted 18 semistructured interviews with medical prescribers and pharmacists with varying levels of seniority exploring current AMS practices and investigating potential areas for improvement. Participants were recruited with the help of local gatekeepers. Topic guides sought to explore both formal and informal practices surrounding AMS, and challenges and opportunities for ePrescribing-based intervention. We coded audio-recorded and transcribed data with the help of the Technology, People, Organizations, and Macroenvironmental factors framework, allowing emerging themes to be added inductively. We used NVivo 12 (QSR International) to facilitate coding. Results: Antimicrobial prescribing and review processes were characterized by competing priorities and uncertainty of prescribers and reviewers around prescribing decisions. For example, medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and the rationale for prescribing decisions was not always clear. Prescribing involved a complex set of activities carried out by various health care practitioners who each only had a partial and temporary view of the whole process, and whose relationships were characterized by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, newly qualified doctors and pharmacists were hesitant to change a consultant's prescribing decision when reviewing prescriptions. Multidisciplinary communication, collaboration, and coordination promoted good AMS practices by reducing uncertainty. Conclusions: Design of ePrescribing-based interventions to improve AMS needs to take into account the multitude of actors and organizational complexities involved in the prescribing and review processes. Interventions that help reduce prescriber or reviewer uncertainty and improve multidisciplinary collaboration surrounding initial antimicrobial prescribing and subsequent prescription review are most likely to be effective. Without such attention, interventions are unlikely to fulfill their goal of improving patient outcomes and combatting antimicrobial resistance. ", doi="10.2196/37863", url="https://formative.jmir.org/2023/1/e37863", url="http://www.ncbi.nlm.nih.gov/pubmed/37279044" } @Article{info:doi/10.2196/47283, author="Benjamens, Stan and Dhunnoo, Pranavsingh and G{\"o}r{\"o}g, M{\'a}rton and Mesko, Bertalan", title="Forecasting Artificial Intelligence Trends in Health Care: Systematic International Patent Analysis", journal="JMIR AI", year="2023", month="May", day="26", volume="2", pages="e47283", keywords="artificial intelligence", keywords="patent", keywords="healthcare", keywords="health care", keywords="medical", keywords="forecasting", keywords="future", keywords="AI", keywords="machine learning", keywords="medical device", keywords="open-access", keywords="AI technology", abstract="Background: Artificial intelligence (AI)-- and machine learning (ML)--based medical devices and algorithms are rapidly changing the medical field. To provide an insight into the trends in AI and ML in health care, we conducted an international patent analysis. Objective: It is pivotal to obtain a clear overview on upcoming AI and MLtrends in health care to provide regulators with a better position to foresee what technologies they will have to create regulations for, which are not yet available on the market. Therefore, in this study, we provide insights and forecasts into the trends in AI and ML in health care by conducting an international patent analysis. Methods: A systematic patent analysis, focusing on AI- and ML-based patents in health care, was performed using the Espacenet database (from January 2012 until July 2022). This database includes patents from the China National Intellectual Property Administration, European Patent Office, Japan Patent Office, Korean Intellectual Property Office, and the United States Patent and Trademark Office. Results: We identified 10,967 patents: 7332 (66.9\%) from the China National Intellectual Property Administration, 191 (1.7\%) from the European Patent Office, 163 (1.5\%) from the Japan Patent Office, 513 (4.7\%) from the Korean Intellectual Property Office, and 2768 (25.2\%) from the United States Patent and Trademark Office. The number of published patents showed a yearly doubling from 2015 until 2021. Five international companies that had the greatest impact on this increase were Ping An Medical and Healthcare Management Co Ltd with 568 (5.2\%) patents, Siemens Healthineers with 273 (2.5\%) patents, IBM Corp with 226 (2.1\%) patents, Philips Healthcare with 150 (1.4\%) patents, and Shanghai United Imaging Healthcare Co Ltd with 144 (1.3\%) patents. Conclusions: This international patent analysis showed a linear increase in patents published by the 5 largest patent offices. An open access database with interactive search options was launched for AI- and ML-based patents in health care. ", doi="10.2196/47283", url="https://ai.jmir.org/2023/1/e47283", url="http://www.ncbi.nlm.nih.gov/pubmed/10449890" } @Article{info:doi/10.2196/40669, author="Alaqra, Sarah Ala and Khumalo, C. Akhona", title="Handling Public Well-being During the COVID-19 Crisis: Empirical Study With Representatives From Municipalities in Sweden", journal="JMIR Form Res", year="2023", month="May", day="12", volume="7", pages="e40669", keywords="COVID-19", keywords="Sweden", keywords="government", keywords="well-being", keywords="public health", keywords="information and communications technology", keywords="recreational activities", abstract="Background: COVID-19 has had a significant impact on the public's health and well-being due to infections and restrictions imposed during the crisis. Recreational activities are important for the public's well-being; however, the public's safety from the COVID-19 virus is the top priority. Sweden, a country with a decentralized public health and welfare system, relied on less stringent approaches for handling the crisis. The limited restrictions in Sweden allowed recreational activities to take place despite the pandemic, which could be attributed to considerations for the public's well-being. Objective: The objective of this study was to investigate municipal approaches for handling and supporting recreational activities during the COVID-19 crisis. Methods: We conducted an empirical study (qualitative and quantitative), using an online survey for data collection, with 23 participants. They were representatives holding mostly managerial roles in 18 distinct municipalities (18 counties). A thematic analysis was conducted to analyze open-ended responses, and descriptive statistics were used to summarize the closed-ended responses. Results: In this study, we report on the status of municipalities during the COVID-19 pandemic. The highlighted results showed a significant impact on the municipalities as a result of COVID-19, where 78\% (18/23) of participants stated significant changes due to the pandemic. Moreover, 91\% (21/23) indicated efforts and approaches for supporting recreational activities during COVID-19. Following national guidelines for the public's health and safety was indicated by 78\% (18/23) of participants. Information and communications technology (ICT) was considered significant for dealing with COVID-19 according to 87\% (20/23) of participants. Our qualitative results further showed details of the public's health and safety considerations, the efforts to support recreational activities particularly for youth, and the role and requirements of ICT. Challenges relating to the usability of ICT were also highlighted. Conclusions: Despite the critique of Sweden's lenient strategy for handling the COVID-19 crisis, our results showed significant considerations for the public's safety and well-being by the municipalities (regional and local levels) in this study. The Swedish approach to handling the crisis involved trusting the public with safety guidelines in addition to efforts for the public's safety, supporting the public's well-being with approaches for maintaining recreational activities, and giving special care to the youth. Despite having technological solutions in place, challenges in using digital solutions and requirements for future development were noted. ", doi="10.2196/40669", url="https://formative.jmir.org/2023/1/e40669", url="http://www.ncbi.nlm.nih.gov/pubmed/37053098" } @Article{info:doi/10.2196/44823, author="Pickard Strange, Martha and Booth, Amy and Akiki, Melissa and Wieringa, Sietse and Shaw, E. Sara", title="The Role of Virtual Consulting in Developing Environmentally Sustainable Health Care: Systematic Literature Review", journal="J Med Internet Res", year="2023", month="May", day="3", volume="25", pages="e44823", keywords="virtual consulting", keywords="environmental sustainability", keywords="systematic review", keywords="carbon footprinting", keywords="net zero", keywords="mobile phone", abstract="Background: Health systems globally need to rapidly set and achieve targets for reaching net zero carbon emissions. Virtual consulting (including video- and telephone-based consulting) is regarded as one means by which this might be achieved, largely through reduced patient travel. Little is currently known about the ways in which forms of virtual consulting might contribute to the net zero agenda or how countries may develop and implement programs at scale that can support increased environmental sustainability. Objective: In this paper, we asked, What is the impact of virtual consulting on environmental sustainability in health care? and What can we learn from current evaluations that can inform future reductions in carbon emissions? Methods: We conducted a systematic review of published literature according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. We searched the MEDLINE, PubMed, and Scopus databases using key terms relating to ``carbon footprint,'' ``environmental impact,'' ``telemedicine,'' and ``remote consulting,'' using citation tracking to identify additional articles. The articles were screened, and full texts that met the inclusion criteria were obtained. Data on the approach to carbon footprinting reported reductions in emissions, and the opportunities and challenges associated with the environmental sustainability of virtual consultations were extracted into a spreadsheet, analyzed thematically, and theorized using the Planning and Evaluating Remote Consultation Services framework to consider the various interacting influences, including environmental sustainability, that shape the adoption of virtual consulting services. Results: A total of 1672 papers were identified. After removing duplicates and screening for eligibility, 23 papers that focused on a range of virtual consulting equipment and platforms across different clinical conditions and services were included. The focus on the environmental sustainability potential of virtual consulting was unanimously reported through carbon savings achieved by a reduction in travel related to face-to-face appointments. The shortlisted papers used a range of methods and assumptions to determine carbon savings, reporting these using different units and across varied sample sizes. This limited the potential for comparison. Despite methodological inconsistencies, all papers concluded that virtual consulting significantly reduced carbon emissions. However, there was limited consideration of wider factors (eg, patient suitability, clinical indication, and organizational infrastructure) influencing the adoption, use, and spread of virtual consultations and the carbon footprint of the entire clinical pathway in which the virtual consultation was provided (eg, risk of missed diagnoses from virtual consultations that result in the need for subsequent in-person consultations or admissions). Conclusions: There is overwhelming evidence that virtual consulting can reduce health care carbon emissions, largely through reducing travel related to in-person appointments. However, the current evidence fails to look at system factors associated with implementing virtual health care delivery and wider research into carbon emissions across the entire clinical pathway. ", doi="10.2196/44823", url="https://www.jmir.org/2023/1/e44823", url="http://www.ncbi.nlm.nih.gov/pubmed/37133914" } @Article{info:doi/10.2196/32962, author="Olaye, M. Iredia and Seixas, A. Azizi", title="The Gap Between AI and Bedside: Participatory Workshop on the Barriers to the Integration, Translation, and Adoption of Digital Health Care and AI Startup Technology Into Clinical Practice", journal="J Med Internet Res", year="2023", month="May", day="2", volume="25", pages="e32962", keywords="digital health", keywords="startups", keywords="venture capital", keywords="artificial intelligence", keywords="AI translation", keywords="clinical practice", keywords="early-stage", keywords="funding", keywords="bedside", keywords="machine learning", keywords="technology", keywords="tech", keywords="qualitative", keywords="workshop", keywords="entrepreneurs", abstract="Background: Artificial intelligence (AI) and digital health technological innovations from startup companies used in clinical practice can yield better health outcomes, reduce health care costs, and improve patients' experience. However, the integration, translation, and adoption of these technologies into clinical practice are plagued with many challenges and are lagging. Furthermore, explanations of the impediments to clinical translation are largely unknown and have not been systematically studied from the perspective of AI and digital health care startup founders and executives. Objective: The aim of this paper is to describe the barriers to integrating early-stage technologies in clinical practice and health care systems from the perspectives of digital health and health care AI founders and executives. Methods: A stakeholder focus group workshop was conducted with a sample of 10 early-stage digital health and health care AI founders and executives. Digital health, health care AI, digital health--focused venture capitalists, and physician executives were represented. Using an inductive thematic analysis approach, transcripts were organized, queried, and analyzed for thematic convergence. Results: We identified the following four categories of barriers in the integration of early-stage digital health innovations into clinical practice and health care systems: (1) lack of knowledge of health system technology procurement protocols and best practices, (2) demanding regulatory and validation requirements, (3) challenges within the health system technology procurement process, and (4) disadvantages of early-stage digital health companies compared to large technology conglomerates. Recommendations from the study participants were also synthesized to create a road map to mitigate the barriers to integrating early-stage or novel digital health technologies in clinical practice. Conclusions: Early-stage digital health and health care AI entrepreneurs identified numerous barriers to integrating digital health solutions into clinical practice. Mitigation initiatives should create opportunities for early-stage digital health technology companies and health care providers to interact, develop relationships, and use evidence-based research and best practices during health care technology procurement and evaluation processes. ", doi="10.2196/32962", url="https://www.jmir.org/2023/1/e32962", url="http://www.ncbi.nlm.nih.gov/pubmed/37129947" } @Article{info:doi/10.2196/44357, author="Couture, Vincent and Roy, Marie-Christine and Dez, Emma and Laperle, Samuel and B{\'e}lisle-Pipon, Jean-Christophe", title="Ethical Implications of Artificial Intelligence in Population Health and the Public's Role in Its Governance: Perspectives From a Citizen and Expert Panel", journal="J Med Internet Res", year="2023", month="Apr", day="27", volume="25", pages="e44357", keywords="artificial intelligence", keywords="population health", keywords="citizen engagement", keywords="ethics", keywords="bioethics", keywords="digital app", abstract="Background: Artificial intelligence (AI) systems are widely used in the health care sector. Mainly applied for individualized care, AI is increasingly aimed at population health. This raises important ethical considerations but also calls for responsible governance, considering that this will affect the population. However, the literature points to a lack of citizen participation in the governance of AI in health. Therefore, it is necessary to investigate the governance of the ethical and societal implications of AI in population health. Objective: This study aimed to explore the perspectives and attitudes of citizens and experts regarding the ethics of AI in population health, the engagement of citizens in AI governance, and the potential of a digital app to foster citizen engagement. Methods: We recruited a panel of 21 citizens and experts. Using a web-based survey, we explored their perspectives and attitudes on the ethical issues of AI in population health, the relative role of citizens and other actors in AI governance, and the ways in which citizens can be supported to participate in AI governance through a digital app. The responses of the participants were analyzed quantitatively and qualitatively. Results: According to the participants, AI is perceived to be already present in population health and its benefits are regarded positively, but there is a consensus that AI has substantial societal implications. The participants also showed a high level of agreement toward involving citizens into AI governance. They highlighted the aspects to be considered in the creation of a digital app to foster this involvement. They recognized the importance of creating an app that is both accessible and transparent. Conclusions: These results offer avenues for the development of a digital app to raise awareness, to survey, and to support citizens' decision-making regarding the ethical, legal, and social issues of AI in population health. ", doi="10.2196/44357", url="https://www.jmir.org/2023/1/e44357", url="http://www.ncbi.nlm.nih.gov/pubmed/37104026" } @Article{info:doi/10.2196/42453, author="J{\~o}gi, Reelika and Timonen, Johanna and Saastamoinen, Leena and Laius, Ott and Volmer, Daisy", title="Implementation of European Cross-border Electronic Prescription and Electronic Dispensing Service: Cross-sectional Survey", journal="J Med Internet Res", year="2023", month="Apr", day="4", volume="25", pages="e42453", keywords="electronic prescription", keywords="ePrescription", keywords="cross-border ePrescription", keywords="electronic dispensing", keywords="eDispensing", keywords="eHealth", keywords="digital health", keywords="implementation", keywords="European Union", abstract="Background: The European cross-border electronic prescription (CBeP) and cross-border electronic dispensing system was first implemented in January 2019 when it became possible to purchase medications from community pharmacies in Estonia using a Finnish ePrescription. In 2020, Estonian ePrescriptions became available to be dispensed in Finnish pharmacies. The CBeP is an important milestone in increasing access to medicines across the European Union, and it has been unstudied to date. Objective: This study aimed to investigate Estonian and Finnish pharmacists' experiences of factors influencing access to, and dispensing of, CBePs. Methods: A web-based survey was conducted among Estonian and Finnish pharmacists between April and May 2021. The survey was distributed to all 664 community pharmacies (n=289, 43.5\% in Estonia and n=375, 56.5\% in Finland) where CBePs had been dispensed in 2020. The data were analyzed using frequencies and a chi-square test. Answers to open-ended questions were categorized using content analysis and then analyzed by frequency. Results: In total, 66.7\% (84/126) of the responses from Estonia and 76.6\% (154/201) of the responses from Finland were included in the study. The majority of Estonian (74/84, 88\%) and Finnish (126/154, 81.8\%) respondents agreed that CBePs have improved patients' access to medications. Problems with the availability of medications when dispensing CBePs were reported by 76\% (64/84) of the Estonian respondents and 35.1\% (54/154) of the Finnish respondents. In Estonia, the most commonly reported availability problem concerned the same active ingredient (49/84, 58\%) of the medication not being available in the market, whereas in Finland, the most common issue was the unavailability of equivalent package size in the market (30/154, 19.5\%). Encountering ambiguities or errors in the CBePs was reported by 61\% (51/84) of the Estonian respondents and 42.8\% (66/154) of the Finnish respondents. Mostly, the availability issues and ambiguities or errors were encountered rarely. The most commonly encountered ambiguities or errors were incorrect pharmaceutical form (23/84, 27\%) in Estonia and incorrect total amount of medication (21/154, 13.6\%) in Finland. Technical problems with using the CBeP system were reported by 57\% (48/84) of the Estonian respondents and 40.2\% (62/154) of the Finnish respondents. Most of the Estonian and Finnish respondents (53/84, 63\%, and 133/154, 86.4\%, respectively) had access to guidelines for dispensing CBePs. More than half of the Estonian (52/84, 62\%) and Finnish (95/154, 61.7\%) respondents felt that they had received sufficient training on dispensing CBePs. Conclusions: Pharmacists in both Estonia and Finland agreed that CBePs improve access to medications. However, interfering factors, such as ambiguities or errors in CBePs and technical problems in the CBeP system, can reduce access to medications. The respondents had received sufficient training and were informed of the guidelines; however, they felt that the content of the guidelines could be improved. ", doi="10.2196/42453", url="https://www.jmir.org/2023/1/e42453", url="http://www.ncbi.nlm.nih.gov/pubmed/37014689" } @Article{info:doi/10.2196/41588, author="Brauneck, Alissa and Schmalhorst, Louisa and Kazemi Majdabadi, Mahdi Mohammad and Bakhtiari, Mohammad and V{\"o}lker, Uwe and Baumbach, Jan and Baumbach, Linda and Buchholtz, Gabriele", title="Federated Machine Learning, Privacy-Enhancing Technologies, and Data Protection Laws in Medical Research: Scoping Review", journal="J Med Internet Res", year="2023", month="Mar", day="30", volume="25", pages="e41588", keywords="federated learning", keywords="data protection regulation", keywords="data protection by design", keywords="privacy protection", keywords="General Data Protection Regulation compliance", keywords="GDPR compliance", keywords="privacy-preserving technologies", keywords="differential privacy", keywords="secure multiparty computation", abstract="Background: The collection, storage, and analysis of large data sets are relevant in many sectors. Especially in the medical field, the processing of patient data promises great progress in personalized health care. However, it is strictly regulated, such as by the General Data Protection Regulation (GDPR). These regulations mandate strict data security and data protection and, thus, create major challenges for collecting and using large data sets. Technologies such as federated learning (FL), especially paired with differential privacy (DP) and secure multiparty computation (SMPC), aim to solve these challenges. Objective: This scoping review aimed to summarize the current discussion on the legal questions and concerns related to FL systems in medical research. We were particularly interested in whether and to what extent FL applications and training processes are compliant with the GDPR data protection law and whether the use of the aforementioned privacy-enhancing technologies (DP and SMPC) affects this legal compliance. We placed special emphasis on the consequences for medical research and development. Methods: We performed a scoping review according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). We reviewed articles on Beck-Online, SSRN, ScienceDirect, arXiv, and Google Scholar published in German or English between 2016 and 2022. We examined 4 questions: whether local and global models are ``personal data'' as per the GDPR; what the ``roles'' as defined by the GDPR of various parties in FL are; who controls the data at various stages of the training process; and how, if at all, the use of privacy-enhancing technologies affects these findings. Results: We identified and summarized the findings of 56 relevant publications on FL. Local and likely also global models constitute personal data according to the GDPR. FL strengthens data protection but is still vulnerable to a number of attacks and the possibility of data leakage. These concerns can be successfully addressed through the privacy-enhancing technologies SMPC and DP. Conclusions: Combining FL with SMPC and DP is necessary to fulfill the legal data protection requirements (GDPR) in medical research dealing with personal data. Even though some technical and legal challenges remain, for example, the possibility of successful attacks on the system, combining FL with SMPC and DP creates enough security to satisfy the legal requirements of the GDPR. This combination thereby provides an attractive technical solution for health institutions willing to collaborate without exposing their data to risk. From a legal perspective, the combination provides enough built-in security measures to satisfy data protection requirements, and from a technical perspective, the combination provides secure systems with comparable performance with centralized machine learning applications. ", doi="10.2196/41588", url="https://www.jmir.org/2023/1/e41588", url="http://www.ncbi.nlm.nih.gov/pubmed/36995759" } @Article{info:doi/10.2196/46700, author="Tewari, Ambuj", title="mHealth Systems Need a Privacy-by-Design Approach: Commentary on ``Federated Machine Learning, Privacy-Enhancing Technologies, and Data Protection Laws in Medical Research: Scoping Review''", journal="J Med Internet Res", year="2023", month="Mar", day="30", volume="25", pages="e46700", keywords="mHealth", keywords="differential privacy", keywords="private synthetic data", keywords="federated learning", keywords="data protection regulation", keywords="data protection by design", keywords="privacy protection", keywords="General Data Protection Regulation", keywords="GDPR compliance", keywords="privacy-preserving technologies", keywords="secure multiparty computation", keywords="multiparty computation", keywords="machine learning", keywords="privacy", doi="10.2196/46700", url="https://www.jmir.org/2023/1/e46700", url="http://www.ncbi.nlm.nih.gov/pubmed/36995757" } @Article{info:doi/10.2196/41408, author="Ndlovu, Kagiso and Mauco, Leonard Kabelo and Chibemba, Star and Wanyee, Steven and Oluoch, Tom", title="Assessment of Stakeholder Perceptions and Attitudes Toward Health Data Governance Principles in Botswana: Web-Based Survey", journal="JMIR Form Res", year="2023", month="Mar", day="13", volume="7", pages="e41408", keywords="health data", keywords="governance", keywords="Botswana", keywords="digital health", keywords="decision-making", keywords="health care stakeholders", keywords="perceptions", keywords="health policy", keywords="data governance", keywords="data policy", keywords="implementation", abstract="Background: The use of information and communication technologies for health---eHealth---is described as having potential to improve the quality of health care service delivery. Consequently, there is an increased global trend toward?adoption of eHealth interventions by health care systems worldwide. Despite the proliferation of eHealth solutions, many health care institutions especially in transitioning countries are struggling to attain effective data governance approaches.?The Ministry of Health in?Botswana is an exemplar institution continually seeking better approaches to strengthen health data governance (HDG) approaches following the adoption of eHealth solutions. Recognizing the need for a global HDG framework, the Transform Health coalition conceptualized HDG principles that are structured around 3 interconnected objectives: protecting people, promoting the value of health, and prioritizing equity. Objective: The aim of the study is to solicit and evaluate perceptions and attitudes of health sector workers in Botswana toward the HDG principles by Transform Health and derive any future guidance. Methods: Purposive sampling was used to select participants. A total of 23 participants from various health care organizations in Botswana completed a web-based survey and 10 participated in a follow-up remote round-table discussion. The aim of the round-table discussion was to gain further insight into participants' responses from the web-based survey. Participants were from the following health care cadres: nurses, doctors, information technology professionals, and health informaticians. Both validity and reliability testing were performed for the survey tool before sharing it with study participants. An analysis of participants' close-ended responses from the survey?was performed using descriptive statistics. Thematic analysis of open-ended responses from the questionnaire?and the?round-table discussion was achieved using the Delve software and the widely accepted principles of thematic analysis. Results: Although some participants highlighted having measures in place similar to the HDG principles, there were some who either did not know or disagreed that their organizations already had in place mechanisms similar to the proposed HDG principles. Participants further expressed relevance and importance of the HDG principles in the context of Botswana.?However, some modifications to the principles were also suggested. Conclusions: This study highlights the necessity of data governance in health care particularly toward meeting the requirements for Universal Health Coverage. The existence of other health data governance frameworks calls for a critical analysis to assess the most appropriate and applicable framework in the context of Botswana and similar transitioning countries. An organization-centered approach may be most appropriate, as well as strengthening of existing organizations' HDG practices with the Transform Health principles. ", doi="10.2196/41408", url="https://formative.jmir.org/2023/1/e41408", url="http://www.ncbi.nlm.nih.gov/pubmed/36912870" } @Article{info:doi/10.2196/41528, author="Tian, Shenghu and Chen, Yu", title="Vertical Integration of Electronic Health Records in Medical Consortiums: Dynamic Modeling Approach Based on the Evolutionary Game Theory", journal="JMIR Serious Games", year="2023", month="Mar", day="6", volume="11", pages="e41528", keywords="medical consortium", keywords="EHRs", keywords="evolutionary game", keywords="system dynamics", keywords="medical information resources", abstract="Background: China has continuously issued policies to speed up the interconnection, mutual recognition, sharing of medical information systems, and data integration management across regions and institutions. However, the vertical integration of electronic health records (EHRs) within the medical consortium is hampered by ``poor mechanism and insufficient motivation'' and the phenomenon of ``free riding'' among participating medical institutions, which makes the integration less effective. Objective: We hope to clarify the game mechanism of stakeholders in the vertical integration of EHRs, and put forward targeted policy suggestions for improvement. Methods: We constructed the ``government-hospital-patient'' tripartite evolutionary game model based on the detailed analysis of the research problems and their assumptions. We then simulated the game strategies and outcomes of each participant using the system dynamics approach to reveal the long-term strategy evolution mechanism of the core participants in the vertical integration of EHRs in the medical consortium, as well as the influencing factors and action mechanisms of each party's strategy evolution to provide references for improving relevant policies. Results: The evolutionary game system could eventually reach an optimal equilibrium, but in areas where the government was required to be in a dominant position, patient supervision was necessary to have a positive role, while a reasonable reward and punishment mechanism can promote active participation of hospitals. Conclusions: The effective way to achieve the goal of vertical integration of EHRs in the medical consortium is to build a multiagent coordination mechanism under the guidance of the government. Meanwhile, it is necessary to establish a scientific integration performance evaluation mechanism, a reward and punishment mechanism, and a benefit distribution mechanism to promote the healthy development of vertical integration of EHRs in medical consortiums. ", doi="10.2196/41528", url="https://games.jmir.org/2023/1/e41528", url="http://www.ncbi.nlm.nih.gov/pubmed/36877574" } @Article{info:doi/10.2196/43966, author="Joseph, L. Amanda and Monkman, Helen and Kushniruk, Andre and Quintana, Yuri", title="Exploring Patient Journey Mapping and the Learning Health System: Scoping Review", journal="JMIR Hum Factors", year="2023", month="Feb", day="27", volume="10", pages="e43966", keywords="patient journey map", keywords="journey map", keywords="patient health information", keywords="learning health system", keywords="learning health care system", keywords="delivery of health care", keywords="service delivery", keywords="scoping review", keywords="health informatics", keywords="user experience", keywords="data integration", abstract="Background: Journey maps are visualization tools that can facilitate the diagrammatical representation of stakeholder groups by interest or function for comparative visual analysis. Therefore, journey maps can illustrate intersections and relationships between organizations and consumers using products or services. We propose that some synergies may exist between journey maps and the concept of a learning health system (LHS). The overarching goal of an LHS is to use health care data to inform clinical practice and improve service delivery processes and patient outcomes. Objective: The purpose of this review was to assess the literature and establish a relationship between journey mapping techniques and LHSs. Specifically, in this study, we explored the current state of the literature to answer the following research questions: (1) Is there a relationship between journey mapping techniques and an LHS in the literature? (2) Is there a way to integrate the data from journey mapping activities into an LHS? (3) How can the data gleaned from journey map activities be used to inform an LHS? Methods: A scoping review was conducted by querying the following electronic databases: Cochrane Database of Systematic Reviews (Ovid), IEEE Xplore, PubMed, Web of Science, Academic Search Complete (EBSCOhost), APA PsycInfo (EBSCOhost), CINAHL (EBSCOhost), and MEDLINE (EBSCOhost). Two researchers applied the inclusion criteria and assessed all articles by title and abstract in the first screen, using Covidence. Following this, a full-text review of included articles was done, with relevant data extracted, tabulated, and assessed thematically. Results: The initial search yielded 694 studies. Of those, 179 duplicates were removed. Following this, 515 articles were assessed during the first screening phase, and 412 were excluded, as they did not meet the inclusion criteria. Next, 103 articles were read in full, and 95 were excluded, resulting in a final sample of 8 articles that satisfied the inclusion criteria. The article sample can be subsumed into 2 overarching themes: (1) the need to evolve service delivery models in health care, and (2) the potential value of using patient journey data in an LHS. Conclusions: This scoping review demonstrated the gap in knowledge regarding integrating the data from journey mapping activities into an LHS. Our findings highlighted the importance of using the data from patient experiences to enrich an LHS and provide holistic care. To satisfy this gap, the authors intend to continue this investigation to establish the relationship between journey mapping and the concept of LHSs. This scoping review will serve as phase 1 of an investigative series. Phase 2 will entail the creation of a holistic framework to guide and streamline data integration from journey mapping activities into an LHS. Lastly, phase 3 will provide a proof of concept to demonstrate how patient journey mapping activities could be integrated into an LHS. ", doi="10.2196/43966", url="https://humanfactors.jmir.org/2023/1/e43966", url="http://www.ncbi.nlm.nih.gov/pubmed/36848189" } @Article{info:doi/10.2196/40976, author="Baltaxe, Erik and Hsieh, Wen Hsin and Roca, Josep and Cano, Isaac", title="The Assessment of Medical Device Software Supporting Health Care Services for Chronic Patients in a Tertiary Hospital: Overarching Study", journal="J Med Internet Res", year="2023", month="Jan", day="4", volume="25", pages="e40976", keywords="chronic patients", keywords="digital health", keywords="health technology assessment", keywords="implementation research", keywords="integrated care", abstract="Background: Innovative digital health tools are increasingly being evaluated and, in some instances, integrated at scale into health systems. However, the applicability of assessment methodologies in real-life scenarios to demonstrate value generation and consequently foster sustainable adoption of digitally enabled health interventions has some bottlenecks. Objective: We aimed to build on the process of premarket assessment of 4 digital health interventions piloted at the Hospital Clinic de Barcelona (HCB), as well as on the analysis of current medical device software regulations and postmarket surveillance in the European Union and United States in order to generate recommendations and lessons learnt for the sustainable adoption of digitally enabled health interventions. Methods: Four digital health interventions involving prototypes were piloted at the HCB (studies 1-4). Cocreation and quality improvement methodologies were used to consolidate a pragmatic evaluation method to assess the perceived usability and satisfaction of end users (both patients and health care professionals) by means of the System Usability Scale and the Net Promoter Score, including general questions about satisfaction. Analyses of both medical software device regulations and postmarket surveillance in the European Union and United States (2017-2021) were performed. Finally, an overarching analysis on lessons learnt was conducted considering 4 domains (technical, clinical, usability, and cost), as well as differentiating among 3 different eHealth strategies (telehealth, integrated care, and digital therapeutics). Results: Among the participant stakeholders, the System Usability Scale score was consistently higher in patients (studies 1, 2, 3, and 4: 78, 67, 56, and 76, respectively) than in health professionals (studies 2, 3, and 4: 52, 43, and 54, respectively). In general, use of the supporting digital health tools was recommended more by patients (studies 1, 2, 3, and 4: Net Promoter Scores of ?3\%, 31\%, ?21\%, and 31\%, respectively) than by professionals (studies 2, 3, and 4: Net Promoter Scores of ?67\%, 1\%, and ?80\%, respectively). The overarching analysis resulted in pragmatic recommendations for the digital health evaluation domains and the eHealth strategies considered. Conclusions: Lessons learnt on the digitalization of health resulted in practical recommendations that could contribute to future deployment experiences. ", doi="10.2196/40976", url="https://www.jmir.org/2023/1/e40976", url="http://www.ncbi.nlm.nih.gov/pubmed/36598817" } @Article{info:doi/10.2196/36929, author="Dong, Xuejie and Ding, Fang and Zhou, Shuduo and Ma, Junxiong and Li, Na and Maimaitiming, Mailikezhati and Xu, Yawei and Guo, Zhigang and Jia, Shaobin and Li, Chunjie and Luo, Suxin and Bian, Huiping and Luobu, Gesang and Yuan, Zuyi and Shi, Hong and Zheng, Zhi-jie and Jin, Yinzi and Huo, Yong", title="Optimizing an Emergency Medical Dispatch System to Improve Prehospital Diagnosis and Treatment of Acute Coronary Syndrome: Nationwide Retrospective Study in China", journal="J Med Internet Res", year="2022", month="Nov", day="23", volume="24", number="11", pages="e36929", keywords="medical priority dispatch system", keywords="acute coronary syndrome", keywords="prehospital care", keywords="emergency medical service", keywords="health service", keywords="healthcare", keywords="health care", keywords="coronary", keywords="cardiology", keywords="cardiovascular", abstract="Background: Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care. Objective: This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China. Methods: This retrospective analysis was based on an integrated database of China's MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score--matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes. Results: A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen $\kappa$=0.918, P<.001) was higher than that of the before MPDS group (Cohen $\kappa$=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: --1.67, 95\% CI --2.33 to --1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: --3.81, 95\% CI --4.63 to --2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes. Conclusions: The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis. ", doi="10.2196/36929", url="https://www.jmir.org/2022/11/e36929", url="http://www.ncbi.nlm.nih.gov/pubmed/36416876" } @Article{info:doi/10.2196/32679, author="Faruki, A. Adeel and Zane, D. Richard and Wiler, L. Jennifer", title="The Role of Academic Health Systems in Leading the ``Third Wave'' of Digital Health Innovation", journal="JMIR Med Educ", year="2022", month="Nov", day="9", volume="8", number="4", pages="e32679", keywords="innovation", keywords="academic hospitals", keywords="academic health systems", keywords="health technology", keywords="entrepreneur", keywords="disruption", keywords="digital health", keywords="research programs", keywords="cost", keywords="investment", keywords="intrapreneur", doi="10.2196/32679", url="https://mededu.jmir.org/2022/4/e32679", url="http://www.ncbi.nlm.nih.gov/pubmed/36350700" } @Article{info:doi/10.2196/37236, author="Moln{\'a}r-G{\'a}bor, Fruzsina and Beauvais, S. Michael J. and Bernier, Alexander and Jimenez, Nicolas Maria Pilar and Recuero, Mikel and Knoppers, Maria Bartha", title="Bridging the European Data Sharing Divide in Genomic Science", journal="J Med Internet Res", year="2022", month="Oct", day="19", volume="24", number="10", pages="e37236", keywords="international data transfer", keywords="scientific research", keywords="genomics", keywords="safe data spaces", keywords="data protection", doi="10.2196/37236", url="https://www.jmir.org/2022/10/e37236", url="http://www.ncbi.nlm.nih.gov/pubmed/36260387" } @Article{info:doi/10.2196/37793, author="Raj, Minakshi and Ryan, Kerry and Nong, Paige and Calhoun, Karen and Trinidad, Grace M. and De Vries, Raymond and Creary, Melissa and Spector-Bagdady, Kayte and Kardia, R. Sharon L. and Platt, Jodyn", title="Public Deliberation Process on Patient Perspectives on Health Information Sharing: Evaluative Descriptive Study", journal="JMIR Cancer", year="2022", month="Sep", day="16", volume="8", number="3", pages="e37793", keywords="public deliberation", keywords="data sharing", keywords="health information exchange", keywords="patient engagement", keywords="health information", keywords="sharing", keywords="cancer", keywords="oncology", keywords="precision oncology", keywords="information", keywords="policy", keywords="personalized medicine", keywords="public preference", abstract="Background: Precision oncology is one of the fastest-developing domains of personalized medicine and is one of many data-intensive fields. Policy for health information sharing that is informed by patient perspectives can help organizations align practice with patient preferences and expectations, but many patients are largely unaware of the complexities of how and why clinical health information is shared. Objective: This paper evaluates the process of public deliberation as an approach to understanding the values and preferences of current and former patients with cancer regarding the use and sharing of health information collected in the context of precision oncology. Methods: We conducted public deliberations with patients who had a current or former cancer diagnosis. A total of 61 participants attended 1 of 2 deliberative sessions (session 1, n=28; session 2, n=33). Study team experts led two educational plenary sessions, and trained study team members then facilitated discussions with small groups of participants. Participants completed pre- and postdeliberation surveys measuring knowledge, attitudes, and beliefs about precision oncology and data sharing. Following informational sessions, participants discussed, ranked, and deliberated two policy-related scenarios in small groups and in a plenary session. In the analysis, we evaluate our process of developing the deliberative sessions, the knowledge gained by participants during the process, and the extent to which participants reasoned with complex information to identify policy preferences. Results: The deliberation process was rated highly by participants. Participants felt they were listened to by their group facilitator, that their opinions were respected by their group, and that the process that led to the group's decision was fair. Participants demonstrated improved knowledge of health data sharing policies between pre- and postdeliberation surveys, especially regarding the roles of physicians and health departments in health information sharing. Qualitative analysis of reasoning revealed that participants recognized complexity, made compromises, and engaged with trade-offs, considering both individual and societal perspectives related to health data sharing. Conclusions: The deliberative approach can be valuable for soliciting the input of informed patients on complex issues such as health information sharing policy. Participants in our two public deliberations demonstrated that giving patients information about a complex topic like health data sharing and the opportunity to reason with others and discuss the information can help garner important insights into policy preferences and concerns. Data on public preferences, along with the rationale for information sharing, can help inform policy-making processes. Increasing transparency and patient engagement is critical to ensuring that data-driven health care respects patient autonomy and honors patient values and expectations. ", doi="10.2196/37793", url="https://cancer.jmir.org/2022/3/e37793", url="http://www.ncbi.nlm.nih.gov/pubmed/36112409" } @Article{info:doi/10.2196/34905, author="Nguyen, Hoang Long and Nguyen, Khanh Lien Thi and Nguyen, Thi Tham and Trong Dam, Anh Vu and Vu, Thi Thuc Minh and Nguyen, Si Hao Anh and Vu, Thu Giang and Latkin, A. Carl and Ho, M. Roger C. and Ho, H. Cyrus S.", title="Practices, Perceived Benefits, and Barriers Among Medical Students and Health Care Professionals Regarding the Adoption of eHealth in Clinical Settings: Cross-sectional Survey Study", journal="JMIR Med Educ", year="2022", month="Sep", day="13", volume="8", number="3", pages="e34905", keywords="eHealth", keywords="literacy", keywords="perception", keywords="practices", keywords="health care professional", abstract="Background: eHealth is increasingly becoming an indispensable part of health practice and policy-making strategies. However, the use of eHealth tools in clinical practice and the perceptions of eHealth among medical students and health care professionals in Vietnam are not well understood. Objective: This study aims to investigate perceptions and practices regarding eHealth and their associated factors among medical students and health care professionals. Methods: A web-based cross-sectional study was conducted on 523 medical students and health care professionals. Information about the practices for, perceived barriers to, and benefits of eHealth application in clinical practices was collected. Multivariate Tobit and logistic regression models were used to determine factors associated with perceptions and practices. Results: In total, 61.6\% (322/523) of participants used eHealth tools in clinical practices, with moderate levels of eHealth literacy. The score for the perceived benefits of eHealth tools was low. The most common barrier for eHealth utilization was human resources for IT (240/523, 45.9\%), followed by security and risk control capacity (226/523, 43.2\%) and no training in eHealth application (223/523, 42.6\%). Age, eHealth literacy, and the use of the internet for updating medical knowledge were positively associated with using eHealth tools in clinical practices. Conclusions: eHealth tools were moderately used in clinical practices, and the benefits of eHealth were underestimated among health care professionals and medical students in Vietnam. Renovating the current medical education curriculum to integrate eHealth principles should be required to equip health care professionals and medical students with essential skills for rapid digital transformation. ", doi="10.2196/34905", url="https://mededu.jmir.org/2022/3/e34905", url="http://www.ncbi.nlm.nih.gov/pubmed/36098992" } @Article{info:doi/10.2196/37887, author="Weiss, Samuel Paul and Waller, Allyn Lance", title="The Impact of Nonrandom Missingness in Surveillance Data for Population-Level Summaries: Simulation Study", journal="JMIR Public Health Surveill", year="2022", month="Sep", day="9", volume="8", number="9", pages="e37887", keywords="surveillance", keywords="estimation", keywords="missing data", keywords="population-level estimates", keywords="health policy", keywords="public health policy", keywords="estimates", keywords="data", keywords="policy decision", keywords="bias", keywords="response rate", abstract="Background: Surveillance data are essential public health resources for guiding policy and allocation of human and capital resources. These data often consist of large collections of information based on nonrandom sample designs. Population estimates based on such data may be impacted by the underlying sample distribution compared to the true population of interest. In this study, we simulate a population of interest and allow response rates to vary in nonrandom ways to illustrate and measure the effect this has on population-based estimates of an important public health policy outcome. Objective: The aim of this study was to illustrate the effect of nonrandom missingness on population-based survey sample estimation. Methods: We simulated a population of respondents answering a survey question about their satisfaction with their community's policy regarding vaccination mandates for government personnel. We allowed response rates to differ between the generally satisfied and dissatisfied and considered the effect of common efforts to control for potential bias such as sampling weights, sample size inflation, and hypothesis tests for determining missingness at random. We compared these conditions via mean squared errors and sampling variability to characterize the bias in estimation arising under these different approaches. Results: Sample estimates present clear and quantifiable bias, even in the most favorable response profile. On a 5-point Likert scale, nonrandom missingness resulted in errors averaging to almost a full point away from the truth. Efforts to mitigate bias through sample size inflation and sampling weights have negligible effects on the overall results. Additionally, hypothesis testing for departures from random missingness rarely detect the nonrandom missingness across the widest range of response profiles considered. Conclusions: Our results suggest that assuming surveillance data are missing at random during analysis could provide estimates that are widely different from what we might see in the whole population. Policy decisions based on such potentially biased estimates could be devastating in terms of community disengagement and health disparities. Alternative approaches to analysis that move away from broad generalization of a mismeasured population at risk are necessary to identify the marginalized groups, where overall response may be very different from those observed in measured respondents. ", doi="10.2196/37887", url="https://publichealth.jmir.org/2022/9/e37887", url="http://www.ncbi.nlm.nih.gov/pubmed/36083618" } @Article{info:doi/10.2196/37665, author="K{\"o}ngeter, Anja and Schickhardt, Christoph and Jungkunz, Martin and Bergbold, Susanne and Mehlis, Katja and Winkler, C. Eva", title="Patients' Willingness to Provide Their Clinical Data for Research Purposes and Acceptance of Different Consent Models: Findings From a Representative Survey of Patients With Cancer", journal="J Med Internet Res", year="2022", month="Aug", day="25", volume="24", number="8", pages="e37665", keywords="secondary use", keywords="consent", keywords="data sharing", keywords="data access", keywords="research benefit and control of data", keywords="health data", keywords="clinical data", keywords="private sector", keywords="international data sharing", keywords="patient perspective", abstract="Background: Secondary use of clinical data for biomedical research purposes holds great potential for various types of noninterventional, data-driven studies. Patients' willingness to support research with their clinical data is a crucial prerequisite for research progress. Objective: The aim of the study was to learn about patients' attitudes and expectations regarding secondary use of their clinical data. In a next step, our results can inform the development of an appropriate governance framework for secondary use of clinical data for research purposes. Methods: A questionnaire was developed to assess the willingness of patients with cancer to provide their clinical data for biomedical research purposes, considering different conditions of data sharing and consent models. The Cancer Registry of the German federal state of Baden-W{\"u}rttemberg recruited a proportionally stratified random sample of patients with cancer and survivors of cancer based on a full census. Results: In total, 838 participants completed the survey. Approximately all participants (810/838, 96.7\%) showed general willingness to make clinical data available for biomedical research purposes; however, they expected certain requirements to be met, such as comparable data protection standards for data use abroad and the possibility to renew consent at regular time intervals. Most participants (620/838, 73.9\%) supported data use also by researchers in commercial companies. More than half of the participants (503/838, 60\%) were willing to give up control over clinical data in favor of research benefits. Most participants expressed acceptance of the broad consent model (494/838, 58.9\%), followed by data use by default (with the option to opt out at any time; 419/838, 50\%); specific consent for every study showed the lowest acceptance rate (327/838, 39\%). Patients expected physicians to share their data (763/838, 91.1\%) and their fellow patients to support secondary use with their clinical data (679/838, 81\%). Conclusions: Although patients' general willingness to make their clinical data available for biomedical research purposes is very high, the willingness of a substantial proportion of patients depends on additional requirements. Taking these perspectives into account is essential for designing trustworthy governance of clinical data reuse and sharing. The willingness to accept the loss of control over clinical data to enhance the benefits of research should be given special consideration. ", doi="10.2196/37665", url="https://www.jmir.org/2022/8/e37665", url="http://www.ncbi.nlm.nih.gov/pubmed/36006690" } @Article{info:doi/10.2196/28013, author="Fortmann, Jonas and Lutz, Marlene and Spreckelsen, Cord", title="System for Context-Specific Visualization of Clinical Practice Guidelines (GuLiNav): Concept and Software Implementation", journal="JMIR Form Res", year="2022", month="Jun", day="22", volume="6", number="6", pages="e28013", keywords="clinical practice guideline", keywords="clinical decision support system", keywords="decision support techniques", keywords="computer-assisted decision making", keywords="guideline representation", keywords="workflow control patterns", keywords="workflow", keywords="clinical", keywords="decision making", keywords="support systems", keywords="software", keywords="eHealth", keywords="electronic health", abstract="Background: Clinical decision support systems often adopt and operationalize existing clinical practice guidelines leading to higher guideline availability, increased guideline adherence, and data integration. Most of these systems use an internal state-based model of a clinical practice guideline to derive recommendations but do not provide the user with comprehensive insight into the model. Objective: Here we present a novel approach based on dynamic guideline visualization that incorporates the individual patient's current treatment context. Methods: We derived multiple requirements to be fulfilled by such an enhanced guideline visualization. Using business process and model notation as the representation format for computer-interpretable guidelines, a combination of graph-based representation and logical inferences is adopted for guideline processing. A context-specific guideline visualization is inferred using a business rules engine. Results: We implemented and piloted an algorithmic approach for guideline interpretation and processing. As a result of this interpretation, a context-specific guideline is derived and visualized. Our implementation can be used as a software library but also provides a representational state transfer interface. Spring, Camunda, and Drools served as the main frameworks for implementation. A formative usability evaluation of a demonstrator tool that uses the visualization yielded high acceptance among clinicians. Conclusions: The novel guideline processing and visualization concept proved to be technically feasible. The approach addresses known problems of guideline-based clinical decision support systems. Further research is necessary to evaluate the applicability of the approach in specific medical use cases. ", doi="10.2196/28013", url="https://formative.jmir.org/2022/6/e28013", url="http://www.ncbi.nlm.nih.gov/pubmed/35731571" } @Article{info:doi/10.2196/35380, author="Silva, Vieira C{\'i}cera Renata Diniz and Lopes, Hor{\'a}cio Rayssa and de Goes Bay Jr, Osvaldo and Martiniano, Santos Claudia and Fuentealba-Torres, Miguel and Arc{\^e}ncio, Alexandre Ricardo and Lap{\~a}o, Velez Lu{\'i}s and Dias, Sonia and Uchoa, Costa Severina Alice da", title="Digital Health Opportunities to Improve Primary Health Care in the Context of COVID-19: Scoping Review", journal="JMIR Hum Factors", year="2022", month="May", day="31", volume="9", number="2", pages="e35380", keywords="digital health", keywords="telehealth", keywords="telemedicine", keywords="primary health care", keywords="quality of care", keywords="COVID-19", keywords="pandemic", keywords="science database", keywords="gray literature", abstract="Background: The COVID-19 pandemic brought social, economic, and health impacts, requiring fast adaptation of health systems. Although information and communication technologies were essential for achieving this objective, the extent to which health systems incorporated this technology is unknown. Objective: The aim of this study was to map the use of digital health strategies in primary health care worldwide and their impact on quality of care during the COVID-19 pandemic. Methods: We performed a scoping review based on the Joanna Briggs Institute manual and guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) Extension for Scoping Reviews. A systematic and comprehensive three-step search was performed in June and July 2021 in multidisciplinary health science databases and the gray literature. Data extraction and eligibility were performed by two authors independently and interpreted using thematic analysis. Results: A total of 44 studies were included and six thematic groups were identified: characterization and geographic distribution of studies; nomenclatures of digital strategies adopted; types of information and communication technologies; characteristics of digital strategies in primary health care; impacts on quality of care; and benefits, limitations, and challenges of digital strategies in primary health care. The impacts on organization of quality of care were investigated by the majority of studies, demonstrating the strengthening of (1) continuity of care; (2) economic, social, geographical, time, and cultural accessibility; (3) coordination of care; (4) access; (5) integrality of care; (6) optimization of appointment time; (7) and efficiency. Negative impacts were also observed in the same dimensions, such as reduced access to services and increased inequity and unequal use of services offered, digital exclusion of part of the population, lack of planning for defining the role of professionals, disarticulation of actions with real needs of the population, fragile articulation between remote and face-to-face modalities, and unpreparedness of professionals to meet demands using digital technologies. Conclusions: The results showed the positive and negative impacts of remote strategies on quality of care in primary care and the inability to take advantage of the potential of technologies. This may demonstrate differences in the organization of fast and urgent implementation of digital strategies in primary health care worldwide. Primary health care must strengthen its response capacity, expand the use of information and communication technologies, and manage challenges using scientific evidence since digital health is important and must be integrated into public service. ", doi="10.2196/35380", url="https://humanfactors.jmir.org/2022/2/e35380", url="http://www.ncbi.nlm.nih.gov/pubmed/35319466" } @Article{info:doi/10.2196/33742, author="Zhu, Xiao and Tao, Youyou and Zhu, Ruilin and Wu, Dezhi and Ming, Wai-kit", title="Impact of Hospital Characteristics and Governance Structure on the Adoption of Tracking Technologies for Clinical and Supply Chain Use: Longitudinal Study of US Hospitals", journal="J Med Internet Res", year="2022", month="May", day="26", volume="24", number="5", pages="e33742", keywords="radio frequency identification", keywords="bar coding", keywords="tracking technology adoption", keywords="smart hospital", keywords="hospital affiliation", keywords="governance structure", keywords="location", keywords="clinical use", keywords="supply chain use", abstract="Background: Despite the increasing adoption rate of tracking technologies in hospitals in the United States, few empirical studies have examined the factors involved in such adoption within different use contexts (eg, clinical and supply chain use contexts). To date, no study has systematically examined how governance structures impact technology adoption in different use contexts in hospitals. Given that the hospital governance structure fundamentally governs health care workflows and operations, understanding its critical role provides a solid foundation from which to explore factors involved in the adoption of tracking technologies in hospitals. Objective: This study aims to compare critical factors associated with the adoption of tracking technologies for clinical and supply chain uses and examine how governance structure types affect the adoption of tracking technologies in hospitals. Methods: This study was conducted based on a comprehensive and longitudinal national census data set comprising 3623 unique hospitals across 50 states in the United States from 2012 to 2015. Using mixed effects population logistic regression models to account for the effects within and between hospitals, we captured and examined the effects of hospital characteristics, locations, and governance structure on adjustments to the innate development of tracking technology over time. Results: From 2012 to 2015, we discovered that the proportion of hospitals in which tracking technologies were fully implemented for clinical use increased from 36.34\% (782/2152) to 54.63\% (1316/2409), and that for supply chain use increased from 28.58\% (615/2152) to 41.3\% (995/2409). We also discovered that adoption factors impact the clinical and supply chain use contexts differently. In the clinical use context, compared with hospitals located in urban areas, hospitals in rural areas (odds ratio [OR] 0.68, 95\% CI 0.56-0.80) are less likely to fully adopt tracking technologies. In the context of supply chain use, the type of governance structure influences tracking technology adoption. Compared with hospitals not affiliated with a health system, implementation rates increased as hospitals affiliated with a more centralized health system---1.9-fold increase (OR 1.87, 95\% CI 1.60-2.13) for decentralized or independent hospitals, 2.4-fold increase (OR 2.40, 95\% CI 2.07-2.80) for moderately centralized health systems, and 3.1-fold increase for centralized health systems (OR 3.07, 95\% CI 2.67-3.53). Conclusions: As the first of such type of studies, we provided a longitudinal overview of how hospital characteristics and governance structure jointly affect adoption rates of tracking technology in both clinical and supply chain use contexts, which is essential for developing intelligent infrastructure for smart hospital systems. This study informs researchers, health care providers, and policy makers that hospital characteristics, locations, and governance structures have different impacts on the adoption of tracking technologies for clinical and supply chain use and on health resource disparities among hospitals of different sizes, locations, and governance structures. ", doi="10.2196/33742", url="https://www.jmir.org/2022/5/e33742", url="http://www.ncbi.nlm.nih.gov/pubmed/35617002" } @Article{info:doi/10.2196/30050, author="Yeng, Kandabongee Prosper and Fauzi, Ali Muhammad and Sun, Luyi and Yang, Bian", title="Assessing the Legal Aspects of Information Security Requirements for Health Care in 3 Countries: Scoping Review and Framework Development", journal="JMIR Hum Factors", year="2022", month="May", day="25", volume="9", number="2", pages="e30050", keywords="legal requirement", keywords="information security", keywords="healthcare", keywords="security practice", abstract="Background: The loss of human lives from cyberattacks in health care is no longer a probabilistic quantification but a reality that has begun. In addition, the threat scope is also expanding to involve a threat of national security, among others, resulting in surging data breaches within the health care sector. For that matter, there have been provisions of various legislation, regulations, and information security governance tools such as policies, standards, and directives toward enhancing health care information security--conscious care behavior among users. Meanwhile, in a research scenario, there are no comprehensive required security practices to serve as a yardstick in assessing security practices in health care. Moreover, an analysis of the holistic view of the requirements that need more concentration of management, end users, or both has not been comprehensively developed. Thus, there is a possibility that security practice research will leave out vital requirements. Objective: The objective of this study was to systematically identify, assess, and analyze the state-of-the-art information security requirements in health care. These requirements can be used to develop a framework to serve as a yardstick for measuring the future real security practices of health care staff. Methods: A scoping review was, as a result, adopted to identify, assess, and analyze the information security requirement sources within health care in Norway, Indonesia, and Ghana. Results: Of 188 security and privacy requirement sources that were initially identified, 130 (69.1\%) were fully read by the authors. Subsequently, of these 188 requirement documents, 82 (43.6\%) fully met the inclusion criteria and were accessed and analyzed. In total, 253 security and privacy requirements were identified in this work. The findings were then used to develop a framework to serve as a benchmark for modeling and analyzing health care security practices. Conclusions: On the basis of these findings, a framework for modeling, analyzing, and developing effective security countermeasures, including incentivization measures, was developed. Following this framework, research results of health care security practices would be more reliable and effective than relying on incomprehensive security requirements. ", doi="10.2196/30050", url="https://humanfactors.jmir.org/2022/2/e30050", url="http://www.ncbi.nlm.nih.gov/pubmed/35612891" } @Article{info:doi/10.2196/32411, author="Lee, An Hsiu and Wu, Wei-Chen and Kung, Hsin-Hua and Udayasankaran, Ganesh Jai and Wei, Yu-Chih and Kijsanayotin, Boonchai and Marcelo, B. Alvin and Hsu, Chien-Yeh", title="Design of a Vaccine Passport Validation System Using Blockchain-based Architecture: Development Study", journal="JMIR Public Health Surveill", year="2022", month="Apr", day="26", volume="8", number="4", pages="e32411", keywords="COVID-19", keywords="vaccine passport", keywords="global border control", keywords="health policy", keywords="international infectious disease strategy", keywords="vaccine", keywords="policy", keywords="strategy", keywords="blockchain", keywords="privacy", keywords="security", keywords="testing", keywords="verification", keywords="certification", keywords="Fast Healthcare Interoperability Resource", abstract="Background: COVID-19 is an ongoing global pandemic caused by SARS-CoV-2. As of June 2021, 5 emergency vaccines were available for COVID-19 prevention, and with the improvement of vaccination rates and the resumption of activities in each country, verification of vaccination has become an important issue. Currently, in most areas, vaccination and reverse transcription polymerase chain reaction (RT-PCR) test results are certified and validated on paper. This leads to the problem of counterfeit documents. Therefore, a global vaccination record is needed. Objective: The main objective of this study is to design a vaccine passport (VP) validation system based on a general blockchain architecture for international use in a simulated environment. With decentralized characteristics, the system is expected to have the advantages of low cost, high interoperability, effectiveness, security, and verifiability through blockchain architecture. Methods: The blockchain decentralized mechanism was used to build an open and anticounterfeiting information platform for VPs. The contents of a vaccination card are recorded according to international Fast Healthcare Interoperability Resource (FHIR) standards, and blockchain smart contracts (SCs) are used for authorization and authentication to achieve hierarchical management of various international hospitals and people receiving injections. The blockchain stores an encrypted vaccination path managed by the user who manages the private key. The blockchain uses the proof-of-authority (PoA) public chain and can access all information through the specified chain. This will achieve the goal of keeping development costs low and streamlining vaccine transit management so that countries in different economies can use them. Results: The openness of the blockchain helps to create transparency and data accuracy. This blockchain architecture contains a total of 3 entities. All approvals are published on Open Ledger. Smart certificates enable authorization and authentication, and encryption and decryption mechanisms guarantee data protection. This proof of concept demonstrates the design of blockchain architecture, which can achieve accurate global VP verification at an affordable price. In this study, an actual VP case was established and demonstrated. An open blockchain, an individually approved certification mechanism, and an international standard vaccination record were introduced. Conclusions: Blockchain architecture can be used to build a viable international VP authentication process with the advantages of low cost, high interoperability, effectiveness, security, and verifiability. ", doi="10.2196/32411", url="https://publichealth.jmir.org/2022/4/e32411", url="http://www.ncbi.nlm.nih.gov/pubmed/35377316" } @Article{info:doi/10.2196/32776, author="Yuan, Junyi and Wang, Sufen and Pan, Changqing", title="Mechanism of Impact of Big Data Resources on Medical Collaborative Networks From the Perspective of Transaction Efficiency of Medical Services: Survey Study", journal="J Med Internet Res", year="2022", month="Apr", day="21", volume="24", number="4", pages="e32776", keywords="medical collaborative networks", keywords="big data resources", keywords="transaction efficiency", abstract="Background: The application of big data resources and the development of medical collaborative networks (MCNs) boost each other. However, MCNs are often assumed to be exogenous. How big data resources affect the emergence, development, and evolution of endogenous MCNs has not been well explained. Objective: This study aimed to explore and understand the influence of the mechanism of a wide range of shared and private big data resources on the transaction efficiency of medical services to reveal the impact of big data resources on the emergence and development of endogenous MCNs. Methods: This study was conducted by administering a survey questionnaire to information technology staff and medical staff from 132 medical institutions in China. Data from information technology staff and medical staff were integrated. Structural equation modeling was used to test the direct impact of big data resources on transaction efficiency of medical services. For those big data resources that had no direct impact, we analyzed their indirect impact. Results: Sharing of diagnosis and treatment data ($\beta$=.222; P=.03) and sharing of medical research data ($\beta$=.289; P=.04) at the network level (as big data itself) positively directly affected the transaction efficiency of medical services. Network protection of the external link systems ($\beta$=.271; P=.008) at the level of medical institutions (as big data technology) positively directly affected the transaction efficiency of medical services. Encryption security of web-based data (as big data technology) at the level of medical institutions, medical service capacity available for external use, real-time data of diagnosis and treatment services (as big data itself) at the level of medical institutions, and policies and regulations at the network level indirectly affected the transaction efficiency through network protection of the external link systems at the level of medical institutions. Conclusions: This study found that big data technology, big data itself, and policy at the network and organizational levels interact with, and influence, each other to form the transaction efficiency of medical services. On the basis of the theory of neoclassical economics, the study highlighted the implications of big data resources for the emergence and development of endogenous MCNs. ", doi="10.2196/32776", url="https://www.jmir.org/2022/4/e32776", url="http://www.ncbi.nlm.nih.gov/pubmed/35318187" } @Article{info:doi/10.2196/30986, author="Shen, Nelson and Kassam, Iman and Zhao, Haoyu and Chen, Sheng and Wang, Wei and Wickham, Sarah and Strudwick, Gillian and Carter-Langford, Abigail", title="Foundations for Meaningful Consent in Canada's Digital Health Ecosystem: Retrospective Study", journal="JMIR Med Inform", year="2022", month="Mar", day="31", volume="10", number="3", pages="e30986", keywords="consent", keywords="eConsent", keywords="privacy", keywords="trust", keywords="digital health", keywords="health information exchange", keywords="patient perspective", keywords="health informatics", keywords="Canada", abstract="Background: Canadians are increasingly gaining web-based access to digital health services, and they expect to access their data from these services through a central patient access channel. Implementing data sharing between these services will require patient trust that is fostered through meaningful consent and consent management. Understanding user consent requirements and information needs is necessary for developing a trustworthy and transparent consent management system. Objective: The objective of this study is to explore consent management preferences and information needs to support meaningful consent. Methods: A secondary analysis of a national survey was conducted using a retrospective descriptive study design. The 2019 cross-sectional survey used a series of vignettes and consent scenarios to explore Canadians' privacy perspectives and preferences regarding consent management. Nonparametric tests and logistic regression analyses were conducted to identify the differences and associations between various factors. Results: Of the 1017 total responses, 716 (70.4\%) participants self-identified as potential users. Of the potential users, almost all (672/716, 93.8\%) felt that the ability to control their data was important, whereas some (385/716, 53.8\%) believed that an all or none control at the data source level was adequate. Most potential users preferred new data sources to be accessible by health care providers (546/716, 76.3\%) and delegated parties (389/716, 54.3\%) by default. Prior digital health use was associated with greater odds of granting default access when compared with no prior use, with the greatest odds of granting default access to digital health service providers (odds ratio 2.17, 95\% CI 1.36-3.46). From a list of 9 information elements found in consent forms, potential users selected an average of 5.64 (SD 2.68) and 5.54 (SD 2.85) items to feel informed in consenting to data access by care partners and commercial digital health service providers, respectively. There was no significant difference in the number of items selected between the 2 scenarios (P>.05); however, there were significant differences (P<.05) in information types that were selected between the scenarios. Conclusions: A majority of survey participants reported that they would register and use a patient access channel and believed that the ability to control data access was important, especially as it pertains to access by those outside their care. These findings suggest that a broad all or none approach based on data source may be accepted; however, approximately one-fifth of potential users were unable to decide. Although vignettes were used to introduce the questions, this study showed that more context is required for potential users to make informed consent decisions. Understanding their information needs will be critical, as these needs vary with the use case, highlighting the importance of prioritizing and tailoring information to enable meaningful consent. ", doi="10.2196/30986", url="https://medinform.jmir.org/2022/3/e30986", url="http://www.ncbi.nlm.nih.gov/pubmed/35357318" } @Article{info:doi/10.2196/29108, author="?Lee, Sejong and Kim, Jaehyeon and Kwon, Yongseok and Kim, Teasung and Cho, Sunghyun", title="Privacy Preservation in Patient Information Exchange Systems Based on Blockchain: System Design Study", journal="J Med Internet Res", year="2022", month="Mar", day="22", volume="24", number="3", pages="e29108", keywords="electronic medical records", keywords="consortium blockchain", keywords="data security", keywords="medical data management", keywords="privacy preservation", keywords="smart contract", keywords="proxy re-encryption", keywords="patient-centered medical system", keywords="InterPlanetary File System", abstract="Background: With the increasing sophistication of the medical industry, various advanced medical services such as medical artificial intelligence, telemedicine, and personalized health care services have emerged. The demand for medical data is also rapidly increasing today because advanced medical services use medical data such as user data and electronic medical records (EMRs) to provide services. As a result, health care institutions and medical practitioners are researching various mechanisms and tools to feed medical data into their systems seamlessly. However, medical data contain sensitive personal information of patients. Therefore, ensuring security while meeting the demand for medical data is a very important problem in the information age for which a solution is required. Objective: Our goal is to design a blockchain-based decentralized patient information exchange (PIE) system that can safely and efficiently share EMRs. The proposed system preserves patients' privacy in the EMRs through a medical information exchange process that includes data encryption and access control. Methods: We propose a blockchain-based EMR-sharing system that allows patients to manage their EMRs scattered across multiple hospitals and share them with other users. Our PIE system protects the patient's EMR from security threats such as counterfeiting and privacy attacks during data sharing. In addition, it provides scalability by using distributed data-sharing methods to quickly share an EMR, regardless of its size or type. We implemented simulation models using Hyperledger Fabric, an open source blockchain framework. Results: We performed a simulation of the EMR-sharing process and compared it with previous works on blockchain-based medical systems to check the proposed system's performance. During the simulation, we found that it takes an average of 0.01014 (SD 0.0028) seconds to download 1 MB of EMR in our proposed PIE system. Moreover, it has been confirmed that data can be freely shared with other users regardless of the size or format of the data to be transmitted through the distributed data-sharing technique using the InterPlanetary File System. We conducted a security analysis to check whether the proposed security mechanism can effectively protect users of the EMR-sharing system from security threats such as data forgery or unauthorized access, and we found that the distributed ledger structure and re-encryption--based data encryption method can effectively protect users' EMRs from forgery and privacy leak threats and provide data integrity. Conclusions: Blockchain is a distributed ledger technology that provides data integrity to enable patient-centered health information exchange and access control. PIE systems integrate and manage fragmented patient EMRs through blockchain and protect users from security threats during the data exchange process among users. To increase safety and efficiency in the EMR-sharing process, we used access control using security levels, data encryption based on re-encryption, and a distributed data-sharing scheme. ", doi="10.2196/29108", url="https://www.jmir.org/2022/3/e29108", url="http://www.ncbi.nlm.nih.gov/pubmed/35315778" } @Article{info:doi/10.2196/33819, author="van Kessel, Robin and Hrzic, Rok and O'Nuallain, Ella and Weir, Elizabeth and Wong, Han Brian Li and Anderson, Michael and Baron-Cohen, Simon and Mossialos, Elias", title="Digital Health Paradox: International Policy Perspectives to Address Increased Health Inequalities for People Living With Disabilities", journal="J Med Internet Res", year="2022", month="Feb", day="22", volume="24", number="2", pages="e33819", keywords="digital health", keywords="eHealth", keywords="health policy", keywords="health systems", keywords="disability", keywords="inclusion", keywords="digital technologies", keywords="people living with disabilities", doi="10.2196/33819", url="https://www.jmir.org/2022/2/e33819", url="http://www.ncbi.nlm.nih.gov/pubmed/35191848" } @Article{info:doi/10.2196/32392, author="Tran, Minh Duc and Thwaites, Louise C. and Van Nuil, Ilo Jennifer and McKnight, Jacob and Luu, Phuoc An and Paton, Chris and ", title="Digital Health Policy and Programs for Hospital Care in Vietnam: Scoping Review", journal="J Med Internet Res", year="2022", month="Feb", day="9", volume="24", number="2", pages="e32392", keywords="digital health", keywords="eHealth", keywords="policy", keywords="Vietnam", keywords="hospital care", keywords="data", keywords="health", keywords="electronic medical records", keywords="standards", keywords="compulsory", keywords="patient ID", keywords="administrative information", keywords="health insurance ID", keywords="mobile phone", abstract="Background: There are a host of emergent technologies with the potential to improve hospital care in low- and middle-income countries such as Vietnam. Wearable monitors and artificial intelligence--based decision support systems could be integrated with hospital-based digital health systems such as electronic health records (EHRs) to provide higher level care at a relatively low cost. However, the appropriate and sustainable application of these innovations in low- and middle-income countries requires an understanding of the local government's requirements and regulations such as technology specifications, cybersecurity, data-sharing protocols, and interoperability. Objective: This scoping review aims to explore the current state of digital health research and the policies that govern the adoption of digital health systems in Vietnamese hospitals. Methods: We conducted a scoping review using a modification of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. PubMed and Web of Science were searched for academic publications, and Th? Vi?n Ph{\'a}p Lu?t, a proprietary database of Vietnamese government documents, and the Vietnam Electronic Health Administration website were searched for government documents. Google Scholar and Google Search were used for snowballing searches. The sources were assessed against predefined eligibility criteria through title, abstract, and full-text screening. Relevant information from the included sources was charted and summarized. The review process was primarily undertaken by one researcher and reviewed by another researcher during each step. Results: In total, 11 academic publications and 20 government documents were included in this review. Among the academic studies, 5 reported engineering solutions for information systems in hospitals, 2 assessed readiness for EHR implementation, 1 tested physicians' performance before and after using clinical decision support software, 1 reported a national laboratory information management system, and 2 reviewed the health system's capability to implement eHealth and artificial intelligence. Of the 20 government documents, 19 were promulgated from 2013 to 2020. These regulations and guidance cover a wide range of digital health domains, including hospital information management systems, general and interoperability standards, cybersecurity in health organizations, conditions for the provision of health information technology (HIT), electronic health insurance claims, laboratory information systems, HIT maturity, digital health strategies, electronic medical records, EHRs, and eHealth architectural frameworks. Conclusions: Research about hospital-based digital health systems in Vietnam is very limited, particularly implementation studies. Government regulations and guidance for HIT in health care organizations have been released with increasing frequency since 2013, targeting a variety of information systems such as electronic medical records, EHRs, and laboratory information systems. In general, these policies were focused on the basic specifications and standards that digital health systems need to meet. More research is needed in the future to guide the implementation of digital health care systems in the Vietnam hospital setting. ", doi="10.2196/32392", url="https://www.jmir.org/2022/2/e32392", url="http://www.ncbi.nlm.nih.gov/pubmed/35138264" } @Article{info:doi/10.2196/31623, author="Morley, Jessica and Murphy, Lisa and Mishra, Abhishek and Joshi, Indra and Karpathakis, Kassandra", title="Governing Data and Artificial Intelligence for Health Care: Developing an International Understanding", journal="JMIR Form Res", year="2022", month="Jan", day="31", volume="6", number="1", pages="e31623", keywords="digital health", keywords="artificial intelligence", keywords="health policy", abstract="Background: Although advanced analytical techniques falling under the umbrella heading of artificial intelligence (AI) may improve health care, the use of AI in health raises safety and ethical concerns. There are currently no internationally recognized governance mechanisms (policies, ethical standards, evaluation, and regulation) for developing and using AI technologies in health care. A lack of international consensus creates technical and social barriers to the use of health AI while potentially hampering market competition. Objective: The aim of this study is to review current health data and AI governance mechanisms being developed or used by Global Digital Health Partnership (GDHP) member countries that commissioned this research, identify commonalities and gaps in approaches, identify examples of best practices, and understand the rationale for policies. Methods: Data were collected through a scoping review of academic literature and a thematic analysis of policy documents published by selected GDHP member countries. The findings from this data collection and the literature were used to inform semistructured interviews with key senior policy makers from GDHP member countries exploring their countries' experience of AI-driven technologies in health care and associated governance and inform a focus group with professionals working in international health and technology to discuss the themes and proposed policy recommendations. Policy recommendations were developed based on the aggregated research findings. Results: As this is an empirical research paper, we primarily focused on reporting the results of the interviews and the focus group. Semistructured interviews (n=10) and a focus group (n=6) revealed 4 core areas for international collaborations: leadership and oversight, a whole systems approach covering the entire AI pipeline from data collection to model deployment and use, standards and regulatory processes, and engagement with stakeholders and the public. There was a broad range of maturity in health AI activity among the participants, with varying data infrastructure, application of standards across the AI life cycle, and strategic approaches to both development and deployment. A demand for further consistency at the international level and policies was identified to support a robust innovation pipeline. In total, 13 policy recommendations were developed to support GDHP member countries in overcoming core AI governance barriers and establishing common ground for international collaboration. Conclusions: AI-driven technology research and development for health care outpaces the creation of supporting AI governance globally. International collaboration and coordination on AI governance for health care is needed to ensure coherent solutions and allow countries to support and benefit from each other's work. International bodies and initiatives have a leading role to play in the international conversation, including the production of tools and sharing of practical approaches to the use of AI-driven technologies for health care. ", doi="10.2196/31623", url="https://formative.jmir.org/2022/1/e31623", url="http://www.ncbi.nlm.nih.gov/pubmed/35099403" } @Article{info:doi/10.2196/28870, author="Neher, Margit and Nyg{\aa}rdh, Annette and Brostr{\"o}m, Anders and Lundgren, Johan and Johansson, Peter", title="Perspectives of Policy Makers and Service Users Concerning the Implementation of eHealth in Sweden: Interview Study", journal="J Med Internet Res", year="2022", month="Jan", day="28", volume="24", number="1", pages="e28870", keywords="clients", keywords="computer-assisted therapy", keywords="consultation telehealth", keywords="decision-makers", keywords="implementation", keywords="patients", keywords="politicians", keywords="qualitative methods", keywords="remote", keywords="mobile phone", abstract="Background: Increasing life spans of populations and a growing demand for more advanced care make effective and cost-efficient provision of health care necessary. eHealth technology is often proposed, although research on barriers to and facilitators of the implementation of eHealth technology is still scarce and fragmented. Objective: The aim of this study is to explore the perceptions concerning barriers to and facilitators of the implementation of eHealth among policy makers and service users and explore the ways in which their perceptions converge and differ. Methods: This study used interview data from policy makers at different levels of health care (n=7) and service users enrolled in eHealth interventions (n=25). The analysis included separate qualitative content analyses for the 2 groups and then a second qualitative content analysis to explore differences and commonalities. Results: Implementation barriers perceived by policy makers were that not all service users benefit from eHealth and that there is uncertainty about the impact of eHealth on the work of health care professionals. Policy makers also perceived political decision-making as complex; this included problems related to provision of technical infrastructure and lack of extra resources for health care digitalization. Facilitators were policy makers' conviction that eHealth is what citizens want, their belief in eHealth solutions as beneficial for health care practice, and their belief in the importance of health care digitalization. Barriers for service users comprised capability limitations and varied preferences of service users and a mismatch of technology with user needs, lack of data protection, and their perception of eHealth as being more time consuming. Facilitators for service users were eHealth technology design and match with their skill set, personal feedback and staff support, a sense of privacy, a credible sender, and flexible use of time.There were several commonalities between the 2 stakeholder groups. Facilitators for both groups were the strong impetus toward technology adoption in society and expectations of time flexibility. Both groups perceived barriers in the difficulties of tailoring eHealth, and both groups expressed uncertainty about the care burden distribution. There were also differences: policy makers perceived that their decision-making was very complex and that resources for implementation were limited. Service users highlighted their need to feel that their digital data were protected and that they needed to trust the eHealth sender. Conclusions: Perceptions about barriers to and facilitators of eHealth implementation varied among stakeholders in different parts of the health care system. The study points to the need to reach an enhanced mutual understanding of priorities and overcome challenges at both the micro and macro levels of the health care system. More well-balanced decisions at the policy-maker level may lead to more effective and sustainable development and future implementation of eHealth. ", doi="10.2196/28870", url="https://www.jmir.org/2022/1/e28870", url="http://www.ncbi.nlm.nih.gov/pubmed/35089139" } @Article{info:doi/10.2196/34038, author="Carolan, Elizabeth Jane and McGonigle, John and Dennis, Andrea and Lorgelly, Paula and Banerjee, Amitava", title="Technology-Enabled, Evidence-Driven, and Patient-Centered: The Way Forward for Regulating Software as a Medical Device", journal="JMIR Med Inform", year="2022", month="Jan", day="27", volume="10", number="1", pages="e34038", keywords="Artificial intelligence", keywords="machine learning", keywords="algorithm", keywords="software", keywords="risk assessment", keywords="informatics", doi="10.2196/34038", url="https://medinform.jmir.org/2022/1/e34038", url="http://www.ncbi.nlm.nih.gov/pubmed/35084352" } @Article{info:doi/10.2196/32455, author="Secor, M. Andrew and Mtenga, Hassan and Richard, John and Bulula, Ngwegwe and Ferriss, Ellen and Rathod, Mansi and Ryman, K. Tove and Werner, Laurie and Carnahan, Emily", title="Added Value of Electronic Immunization Registries in Low- and Middle-Income Countries: Observational Case Study in Tanzania", journal="JMIR Public Health Surveill", year="2022", month="Jan", day="21", volume="8", number="1", pages="e32455", keywords="immunization", keywords="immunization information system", keywords="electronic immunization registry", keywords="digital health", keywords="eHealth", abstract="Background: There is growing interest and investment in electronic immunization registries (EIRs) in low- and middle-income countries. EIRs provide ready access to patient- and aggregate-level service delivery data that can be used to improve patient care, identify spatiotemporal trends in vaccination coverage and dropout, inform resource allocation and program operations, and target quality improvement measures. The Government of Tanzania introduced the Tanzania Immunization Registry (TImR) in 2017, and the system has since been rolled out in 3736 facilities in 15 regions. Objective: The aims of this study are to conceptualize the additional ways in which EIRs can add value to immunization programs (beyond measuring vaccine coverage) and assess the potential value-add using EIR data from Tanzania as a case study. Methods: This study comprised 2 sequential phases. First, a comprehensive list of ways EIRs can potentially add value to immunization programs was developed through stakeholder interviews. Second, the added value was evaluated using descriptive and regression analyses of TImR data for a prioritized subset of program needs. Results: The analysis areas prioritized through stakeholder interviews were population movement, missed opportunities for vaccination (MOVs), continuum of care, and continuous quality improvement. The included TImR data comprised 958,870 visits for 559,542 patients from 2359 health facilities. Our analyses revealed that few patients sought care outside their assigned facility (44,733/810,568, 5.52\% of applicable visits); however, this varied by region; facility urbanicity, type, ownership, patient volume, and duration of TImR system use; density of facilities in the immediate area; and patient age. Analyses further showed that MOVs were highest among children aged <12 months (215,576/831,018, 25.94\% of visits included an MOV and were applicable visits); however, there were few significant differences based on other individual or facility characteristics. Nearly half (133,337/294,464, 45.28\%) of the children aged 12 to 35 months were fully vaccinated or had received all doses except measles-containing vaccine--1 of the 14-dose under-12-month schedule (ie, through measles-containing vaccine--1), and facility and patient characteristics associated with dropout varied by vaccine. The continuous quality improvement analysis showed that most quality issues (eg, MOVs) were concentrated in <10\% of facilities, indicating the potential for EIRs to target quality improvement efforts. Conclusions: EIRs have the potential to add value to immunization stakeholders at all levels of the health system. Individual-level electronic data can enable new analyses to understand service delivery or care-seeking patterns, potential risk factors for underimmunization, and where challenges occur. However, to achieve this potential, country programs need to leverage and strengthen the capacity to collect, analyze, interpret, and act on the data. As EIRs are introduced and scaled in low- and middle-income countries, implementers and researchers should continue to share real-world examples and build an evidence base for how EIRs can add value to immunization programs, particularly for innovative uses. ", doi="10.2196/32455", url="https://publichealth.jmir.org/2022/1/e32455", url="http://www.ncbi.nlm.nih.gov/pubmed/35060919" } @Article{info:doi/10.2196/17278, author="Elangovan, Deepa and Long, Soon Chiau and Bakrin, Safina Faizah and Tan, Siang Ching and Goh, Wen Khang and Yeoh, Fei Siang and Loy, Jun Mei and Hussain, Zahid and Lee, Seng Kah and Idris, Che Azam and Ming, Chiau Long", title="The Use of Blockchain Technology in the Health Care Sector: Systematic Review", journal="JMIR Med Inform", year="2022", month="Jan", day="20", volume="10", number="1", pages="e17278", keywords="blockchain", keywords="health care", keywords="hospital information system", keywords="data integrity", keywords="access control", keywords="data logging", keywords="health informatics", abstract="Background: Blockchain technology is a part of Industry 4.0's new Internet of Things applications: decentralized systems, distributed ledgers, and immutable and cryptographically secure technology. This technology entails a series of transaction lists with identical copies shared and retained by different groups or parties. One field where blockchain technology has tremendous potential is health care, due to the more patient-centric approach to the health care system as well as blockchain's ability to connect disparate systems and increase the accuracy of electronic health records. Objective: The aim of this study was to systematically review studies on the use of blockchain technology in health care and to analyze the characteristics of the studies that have implemented blockchain technology. Methods: This study used a systematic review methodology to find literature related to the implementation aspect of blockchain technology in health care. Relevant papers were searched for using PubMed, SpringerLink, IEEE Xplore, Embase, Scopus, and EBSCOhost. A quality assessment of literature was performed on the 22 selected papers by assessing their trustworthiness and relevance. Results: After full screening, 22 papers were included. A table of evidence was constructed, and the results of the selected papers were interpreted. The results of scoring for measuring the quality of the publications were obtained and interpreted. Out of 22 papers, a total of 3 (14\%) high-quality papers, 9 (41\%) moderate-quality papers, and 10 (45\%) low-quality papers were identified. Conclusions: Blockchain technology was found to be useful in real health care environments, including for the management of electronic medical records, biomedical research and education, remote patient monitoring, pharmaceutical supply chains, health insurance claims, health data analytics, and other potential areas. The main reasons for the implementation of blockchain technology in the health care sector were identified as data integrity, access control, data logging, data versioning, and nonrepudiation. The findings could help the scientific community to understand the implementation aspect of blockchain technology. The results from this study help in recognizing the accessibility and use of blockchain technology in the health care sector. ", doi="10.2196/17278", url="https://medinform.jmir.org/2022/1/e17278", url="http://www.ncbi.nlm.nih.gov/pubmed/35049516" } @Article{info:doi/10.2196/32220, author="B{\o}nes, Erlend and Granja, Concei{\c{c}}{\~a}o and Solvoll, Terje", title="Implementation of the Flexible Assertive Community Treatment (FACT) Model in Norway: eHealth Assessment Study", journal="J Med Internet Res", year="2022", month="Jan", day="10", volume="24", number="1", pages="e32220", keywords="mental health", keywords="FACT", keywords="electronic health records", keywords="eHealth", keywords="FACT implementation", keywords="EHR", keywords="implementation", keywords="assessment", keywords="model", keywords="community", keywords="treatment", keywords="policy", keywords="regulation", keywords="infrastructure", keywords="literature", keywords="challenge", keywords="intervention", abstract="Background: Flexible Assertive Community Treatment (FACT) is a model for treatment of long-term severe mental disorders. This method has become more widespread in Norway. Objective: The objective of our study was to examine how the implementation of FACT teams in Norway has been affected by eHealth policy, infrastructure, and regulations. Another objective was to examine existing literature on eHealth interventions and challenges within FACT teams. Methods: We have examined Norwegian policy regulating mental health services, laws and regulations, eHealth infrastructure, relevant literature on FACT teams, and current implementation of FACT in Norway. Results: FACT teams are a wanted part of the Norwegian service system, but the current eHealth infrastructure makes sharing of data within teams and levels of health care challenging, even if eHealth regulations allow such sharing. This has been shown to be an issue in the current implementation of FACT teams in Norway. There is little or no existing research on the eHealth challenges facing FACT teams. Conclusions: Weaknesses in the Norwegian eHealth infrastructure have been a barrier for an easy implementation of FACT teams in Norway. It is difficult to share information between the different levels of health care. We need systems that allow for easy, secure sharing of health information to and between the FACT team members and other involved health care workers. ", doi="10.2196/32220", url="https://www.jmir.org/2022/1/e32220", url="http://www.ncbi.nlm.nih.gov/pubmed/35006087" } @Article{info:doi/10.2196/31066, author="Eum, Ji Nam and Kim, Hyun Seung", title="The Role of Information and Communications Technology Policies and Infrastructure in Curbing the Spread of the Novel Coronavirus: Cross-country Comparative Study", journal="JMIR Public Health Surveill", year="2022", month="Jan", day="7", volume="8", number="1", pages="e31066", keywords="health policy", keywords="telehealth", keywords="physical distancing", keywords="disease transmission", keywords="COVID-19", abstract="Background: Despite worldwide efforts, control of COVID-19 transmission and its after effects is lagging. As seen from the cases of SARS-CoV-2 and influenza, worldwide crises associated with infections and their side effects are likely to recur in the future because of extensive international interactions. Consequently, there is an urgent need to identify the factors that can mitigate disease spread. We observed that the transmission speed and severity of consequences of COVID-19 varied substantially across countries, signaling the need for a country-level investigation. Objective: We aimed to investigate how distancing-enabling information and communications technology (ICT) infrastructure and medical ICT infrastructure, and related policies have affected the cumulative number of confirmed cases, fatality rate, and initial speed of transmission across different countries. Methods: We analyzed the determinants of COVID-19 transmission during the relatively early days of the pandemic by conducting regression analysis based on our data for country-level characteristics, including demographics, culture, ICT infrastructure, policies, economic status, and transmission of COVID-19. To gain further insights, we conducted a subsample analysis for countries with low population density. Results: Our full sample analysis showed that implied telehealth policy, which refers to the lack of a specific telehealth-related policy but presence of a general eHealth policy, was associated with lower fatality rates when controlled for cultural characteristics (P=.004). In particular, the fatality rate for countries with an implied telehealth policy was lower than that for others by 2.7\%. Interestingly, stated telehealth policy, which refers to the existence of a specified telehealth policy, was found to not be associated with lower fatality rates (P=.30). Furthermore, countries with a government-run health website had 36\% fewer confirmed cases than those without it, when controlled for cultural characteristics (P=.03). Our analysis further revealed that the interaction between implied telehealth policy and training ICT health was significant (P=.01), suggesting that implied telehealth policy may be more effective when in-service training on ICT is provided to health professionals. In addition, credit card ownership, as an enabler of convenient e-commerce transactions and distancing, showed a negative association with fatality rates in the full sample analysis (P=.04), but not in the subsample analysis (P=.76), highlighting that distancing-enabling ICT is more useful in densely populated countries. Conclusions: Our findings demonstrate important relationships between national traits and COVID-19 infections, suggesting guidelines for policymakers to minimize the negative consequences of pandemics. The findings suggest physicians' autonomous use of medical ICT and strategic allocation of distancing-enabling ICT infrastructure in countries with high population density to maximize efficiency. This study also encourages further research to investigate the role of health policies in combatting COVID-19 and other pandemics. ", doi="10.2196/31066", url="https://publichealth.jmir.org/2022/1/e31066", url="http://www.ncbi.nlm.nih.gov/pubmed/34817392" } @Article{info:doi/10.2196/34567, author="Santonen, Teemu and Petsani, Despoina and Julin, Mikko and Garschall, Markus and Kropf, Johannes and Van der Auwera, Vicky and Bernaerts, Sylvie and Losada, Raquel and Almeida, Rosa and Garatea, Jokin and Mu{\~n}oz, Idoia and Nagy, Eniko and Kehayia, Eva and de Guise, Elaine and Nadeau, Sylvie and Azevedo, Nancy and Segkouli, Sofia and Lazarou, Ioulietta and Petronikolou, Vasileia and Bamidis, Panagiotis and Konstantinidis, Evdokimos", title="Cocreating a Harmonized Living Lab for Big Data--Driven Hybrid Persona Development: Protocol for Cocreating, Testing, and Seeking Consensus", journal="JMIR Res Protoc", year="2022", month="Jan", day="6", volume="11", number="1", pages="e34567", keywords="Living Lab", keywords="everyday living", keywords="technology", keywords="big data", keywords="harmonization", keywords="personas", keywords="small-scale real-life testing", keywords="mobile phone", abstract="Background: Living Labs are user-centered, open innovation ecosystems based on a systematic user cocreation approach, which integrates research and innovation processes in real-life communities and settings. The Horizon 2020 Project VITALISE (Virtual Health and Wellbeing Living Lab Infrastructure) unites 19 partners across 11 countries. The project aims to harmonize Living Lab procedures and enable effective and convenient transnational and virtual access to key European health and well-being research infrastructures, which are governed by Living Labs. The VITALISE consortium will conduct joint research activities in the fields included in the care pathway of patients: rehabilitation, transitional care, and everyday living environments for older adults. This protocol focuses on health and well-being research in everyday living environments. Objective: The main aim of this study is to cocreate and test a harmonized research protocol for developing big data--driven hybrid persona, which are hypothetical user archetypes created to represent a user community. In addition, the use and applicability of innovative technologies will be investigated in the context of various everyday living and Living Lab environments. Methods: In phase 1, surveys and structured interviews will be used to identify the most suitable Living Lab methods, tools, and instruments for health-related research among VITALISE project Living Labs (N=10). A series of web-based cocreation workshops and iterative cowriting processes will be applied to define the initial protocols. In phase 2, five small-scale case studies will be conducted to test the cocreated research protocols in various real-life everyday living settings and Living Lab infrastructures. In phase 3, a cross-case analysis grounded on semistructured interviews will be conducted to identify the challenges and benefits of using the proposed research protocols. Furthermore, a series of cocreation workshops and the consensus seeking Delphi study process will be conducted in parallel to cocreate and validate the acceptance of the defined harmonized research protocols among wider Living Lab communities. Results: As of September 30, 2021, project deliverables Ethics and safety manual and Living lab standard version 1 have been submitted to the European Commission review process. The study will be finished by March 2024. Conclusions: The outcome of this research will lead to harmonized procedures and protocols in the context of big data--driven hybrid persona development among health and well-being Living Labs in Europe and beyond. Harmonized protocols enable Living Labs to exploit similar research protocols, devices, hardware, and software for interventions and complex data collection purposes. Economies of scale and improved use of resources will speed up and improve research quality and offer novel possibilities for open data sharing, multidisciplinary research, and comparative studies beyond current practices. Case studies will also provide novel insights for implementing innovative technologies in the context of everyday Living Lab research. International Registered Report Identifier (IRRID): DERR1-10.2196/34567 ", doi="10.2196/34567", url="https://www.researchprotocols.org/2022/1/e34567", url="http://www.ncbi.nlm.nih.gov/pubmed/34989697" } @Article{info:doi/10.2196/29288, author="Kang-Yi, D. Christina and Page, Amy", title="Purpose Formulation, Coalition Building, and Evidence Use in Public--Academic Partnerships: Web-Based Survey Study", journal="JMIR Hum Factors", year="2022", month="Jan", day="5", volume="9", number="1", pages="e29288", keywords="use of research evidence", keywords="public care policy", keywords="public--academic partnership", keywords="partnership purpose formulation", keywords="partnership coalition building", keywords="youth mental health and well-being", abstract="Background: Partnerships between academic institutions and public care agencies (public--academic partnerships [PAPs]) can promote effective policy making and care delivery. Public care agencies are often engaged in PAPs for evidence-informed policy making in health care. Previous research has reported essential partnership contextual factors and mechanisms that promote evidence-based policy making and practice in health care. However, the studies have not yet informed whether public care agency leaders' and academic researchers' perceptions of partnership purpose formulation and coalition building evolve through the PAP life cycle and whether public care agency leaders' use of research evidence differs through life cycle stages. Objective: This exploratory study aims to focus on PAPs designed to improve youth mental health and well-being outcomes. This study also aims to identify public care agency leaders' and academic researchers' perceptions of PAP purpose formulation (structure, goals, primary function, and agenda-setting process) and coalition building (mutual benefits, trust, convener's role, member role clarity, and conflict management) by PAP life cycle stage and examine whether public care agency leaders' use of research evidence differs according to the perception of PAP purpose formulation and coalition building through the PAP life cycle. Methods: A web-based survey of PAP experience was conducted by recruiting academic researchers (n=40) and public care agency leaders (n=26) who were engaged in PAPs for the past 10 years. Public care agency leaders additionally participated in the survey of the Structured Interview for Evidence Use scale (n=48). Results: Most public care agency leaders and academic researchers in PAPs formed, matured, and sustained perceived their PAP as having purpose formulation context well aligned with their organizational purpose formulation context, pursuing mutual benefits, having leadership representation and role clarity, having a higher level of trust, and knowing how to handle conflicts. Most PAPs across all life cycle stages crystallized another issue to focus, but not all PAPs with issue crystallization had purpose reformulation. Public care agency leaders who trusted academic researchers in their PAP had greater use of research evidence. Public care agency leaders in PAPs that had gone through new issue crystallization also showed greater use of research evidence compared with those that had not. Conclusions: To promote public care agency leaders' use of research evidence, focusing on developing trusting partnerships and continuously crystallizing PAP issues are important. International Registered Report Identifier (IRRID): RR2-10.2196/14382 ", doi="10.2196/29288", url="https://humanfactors.jmir.org/2022/1/e29288", url="http://www.ncbi.nlm.nih.gov/pubmed/34989678" } @Article{info:doi/10.2196/20466, author="Silva, Patr{\'i}cia and Delerue Matos, Alice and Martinez-Pecino, Roberto", title="The Contribution of the Internet to Reducing Social Isolation in Individuals Aged 50 Years and Older: Quantitative Study of Data From the Survey of Health, Ageing and Retirement in Europe", journal="J Med Internet Res", year="2022", month="Jan", day="3", volume="24", number="1", pages="e20466", keywords="social isolation", keywords="internet", keywords="50+ individuals", keywords="e-inclusion", keywords="SHARE", abstract="Background: Social isolation has a negative impact on the quality of life of older people; therefore, studies have focused on identifying its sociodemographic, economic, and health determinants. In view of the growing importance of the internet as a means of communication, it is essential to assess whether internet use interferes with social isolation. Objective: This study specifically aims to clarify the relationship between internet use and social isolation of individuals aged ?50 years, for which other surveys present contradictory results. Methods: We performed logistic regression analysis with social isolation as the dependent variable, internet use as the interest variable, and several other sociodemographic, economic, and health characteristics of the individuals as control variables. The sample size was 67,173 individuals aged 50 years and older from 17 European countries (Portugal, Greece, Italy, Spain, Denmark, Sweden, Austria, Belgium, France, Germany, Switzerland, Luxemburg, Poland, Czech Republic, Slovenia, Estonia, and Croatia) plus Israel, who were interviewed in the Survey of Health, Ageing and Retirement in Europe (SHARE), wave 6. Results: The results show that countries differ in the level of social isolation and rate of internet use by individuals aged 50 years and older. They also evidence that in most of the countries analyzed, social isolation of internet users was lower compared to that of nonusers after controlling for a set of sociodemographic, economic, and health characteristics of the individuals that have been previously described in the literature as determinants of social isolation. Indeed, on average, although 31.4\% of individuals in the nonuser group experienced high social isolation, only 12.9\% of individuals who used the internet experienced this condition. Conclusions: Internet users show lower social isolation. This result underlines the importance of promoting e-inclusion in Europe as a way to counter social isolation of individuals aged 50 years and older. ", doi="10.2196/20466", url="https://www.jmir.org/2022/1/e20466", url="http://www.ncbi.nlm.nih.gov/pubmed/34982040" } @Article{info:doi/10.2196/31702, author="Grout, Leah and Telfer, Kendra and Wilson, Nick and Cleghorn, Christine and Mizdrak, Anja", title="Prescribing Smartphone Apps for Physical Activity Promotion in Primary Care: Modeling Study of Health Gain and Cost Savings", journal="J Med Internet Res", year="2021", month="Dec", day="20", volume="23", number="12", pages="e31702", keywords="physical activity", keywords="smartphone apps", keywords="mobile health", keywords="mHealth", keywords="modeling", keywords="primary care", keywords="mobile phone", abstract="Background: Inadequate physical activity is a substantial cause of health loss worldwide, and this loss is attributable to diseases such as coronary heart disease, diabetes, stroke, and certain forms of cancer. Objective: This study aims to assess the potential impact of the prescription of smartphone apps in primary care settings on physical activity levels, health gains (in quality-adjusted life years [QALYs]), and health system costs in New Zealand (NZ). Methods: A proportional multistate lifetable model was used to estimate the change in physical activity levels and predict the resultant health gains in QALYs and health system costs over the remaining life span of the NZ population alive in 2011 at a 3\% discount rate. Results: The modeled intervention resulted in an estimated 430 QALYs gained (95\% uncertainty interval 320-550), with net cost savings of 2011 NZ \$2.2 million (2011 US \$1.5 million) over the remaining life span of the 2011 NZ population. On a per capita basis, QALY gains were generally larger in women than in men and larger in M?ori than in non-M?ori. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions on intervention uptake and decay. For example, the scenario analysis with the largest benefits, which assumed a 5-year maintenance of additional physical activity levels, delivered 1750 QALYs and 2011 NZ \$22.5 million (2011 US \$15.1 million) in cost savings. Conclusions: The prescription of smartphone apps for promoting physical activity in primary care settings is likely to generate modest health gains and cost savings at the population level in this high-income country. Such gains may increase with ongoing improvements in app design and increased health worker promotion of the apps to patients. ", doi="10.2196/31702", url="https://www.jmir.org/2021/12/e31702", url="http://www.ncbi.nlm.nih.gov/pubmed/34931993" } @Article{info:doi/10.2196/24109, author="Yeung, Karen", title="The Health Care Sector's Experience of Blockchain: A Cross-disciplinary Investigation of Its Real Transformative Potential", journal="J Med Internet Res", year="2021", month="Dec", day="20", volume="23", number="12", pages="e24109", keywords="blockchain", keywords="health information management", keywords="health information systems", keywords="electronic health record", keywords="data sharing", keywords="health services administration", keywords="privacy of patient data", keywords="computer security", keywords="mobile phone", abstract="Background: Academic literature highlights blockchain's potential to transform health care, particularly by seamlessly and securely integrating existing data silos while enabling patients to exercise automated, fine-grained control over access to their electronic health records. However, no serious scholarly attempt has been made to assess how these technologies have in fact been applied to real-world health care contexts. Objective: The primary aim of this paper is to assess whether blockchain's theoretical potential to deliver transformative benefits to health care is likely to become a reality by undertaking a critical investigation of the health care sector's actual experience of blockchain technologies to date. Methods: This mixed methods study entailed a series of iterative, in-depth, theoretically oriented, desk-based investigations and 2 focus group investigations. It builds on the findings of a companion research study documenting real-world engagement with blockchain technologies in health care. Data were sourced from academic and gray literature from multiple disciplinary perspectives concerned with the configuration, design, and functionality of blockchain technologies. The analysis proceeded in 3 stages. First, it undertook a qualitative investigation of observed patterns of blockchain for health care engagement to identify the application domains, data-sharing problems, and the challenges encountered to date. Second, it critically compared these experiences with claims about blockchain's potential benefits in health care. Third, it developed a theoretical account of challenges that arise in implementing blockchain in health care contexts, thus providing a firmer foundation for appraising its future prospects in health care. Results: Health care organizations have actively experimented with blockchain technologies since 2016 and have demonstrated proof of concept for several applications (use cases) primarily concerned with administrative data and to facilitate medical research by enabling algorithmic models to be trained on multiple disparately located sets of patient data in a secure, privacy-preserving manner. However, blockchain technology is yet to be implemented at scale in health care, remaining largely in its infancy. These early experiences have demonstrated blockchain's potential to generate meaningful value to health care by facilitating data sharing between organizations in circumstances where computational trust can overcome a lack of social trust that might otherwise prevent valuable cooperation. Although there are genuine prospects of using blockchain to bring about positive transformations in health care, the successful development of blockchain for health care applications faces a number of very significant, multidimensional, and highly complex challenges. Early experience suggests that blockchain is unlikely to rapidly and radically revolutionize health care. Conclusions: The successful development of blockchain for health care applications faces numerous significant, multidimensional, and complex challenges that will not be easily overcome, suggesting that blockchain technologies are unlikely to revolutionize health care in the near future. ", doi="10.2196/24109", url="https://www.jmir.org/2021/12/e24109", url="http://www.ncbi.nlm.nih.gov/pubmed/34932009" } @Article{info:doi/10.2196/26611, author="Ploug, Thomas and Sundby, Anna and Moeslund, B. Thomas and Holm, S{\o}ren", title="Population Preferences for Performance and Explainability of Artificial Intelligence in Health Care: Choice-Based Conjoint Survey", journal="J Med Internet Res", year="2021", month="Dec", day="13", volume="23", number="12", pages="e26611", keywords="artificial Intelligence", keywords="performance", keywords="transparency", keywords="explainability", keywords="population preferences", keywords="public policy", abstract="Background: Certain types of artificial intelligence (AI), that is, deep learning models, can outperform health care professionals in particular domains. Such models hold considerable promise for improved diagnostics, treatment, and prevention, as well as more cost-efficient health care. They are, however, opaque in the sense that their exact reasoning cannot be fully explicated. Different stakeholders have emphasized the importance of the transparency/explainability of AI decision making. Transparency/explainability may come at the cost of performance. There is need for a public policy regulating the use of AI in health care that balances the societal interests in high performance as well as in transparency/explainability. A public policy should consider the wider public's interests in such features of AI. Objective: This study elicited the public's preferences for the performance and explainability of AI decision making in health care and determined whether these preferences depend on respondent characteristics, including trust in health and technology and fears and hopes regarding AI. Methods: We conducted a choice-based conjoint survey of public preferences for attributes of AI decision making in health care in a representative sample of the adult Danish population. Initial focus group interviews yielded 6 attributes playing a role in the respondents' views on the use of AI decision support in health care: (1) type of AI decision, (2) level of explanation, (3) performance/accuracy, (4) responsibility for the final decision, (5) possibility of discrimination, and (6) severity of the disease to which the AI is applied. In total, 100 unique choice sets were developed using fractional factorial design. In a 12-task survey, respondents were asked about their preference for AI system use in hospitals in relation to 3 different scenarios. Results: Of the 1678 potential respondents, 1027 (61.2\%) participated. The respondents consider the physician having the final responsibility for treatment decisions the most important attribute, with 46.8\% of the total weight of attributes, followed by explainability of the decision (27.3\%) and whether the system has been tested for discrimination (14.8\%). Other factors, such as gender, age, level of education, whether respondents live rurally or in towns, respondents' trust in health and technology, and respondents' fears and hopes regarding AI, do not play a significant role in the majority of cases. Conclusions: The 3 factors that are most important to the public are, in descending order of importance, (1) that physicians are ultimately responsible for diagnostics and treatment planning, (2) that the AI decision support is explainable, and (3) that the AI system has been tested for discrimination. Public policy on AI system use in health care should give priority to such AI system use and ensure that patients are provided with information. ", doi="10.2196/26611", url="https://www.jmir.org/2021/12/e26611", url="http://www.ncbi.nlm.nih.gov/pubmed/34898454" } @Article{info:doi/10.2196/25833, author="Espinoza, Juan and Sikder, Taher Abu and Dickhoner, James and Lee, Thomas", title="Assessing Health Data Security Risks in Global Health Partnerships: Development of a Conceptual Framework", journal="JMIR Form Res", year="2021", month="Dec", day="8", volume="5", number="12", pages="e25833", keywords="health information technology", keywords="low- and middle-income countries", keywords="low income", keywords="conceptual framework analysis", keywords="framework method", keywords="data security", keywords="decision-making", keywords="database", keywords="information use", keywords="misuse", keywords="global health", keywords="security", abstract="Background: Health care databases contain a wealth of information that can be used to develop programs and mature health care systems. There is concern that the sensitive nature of health data (eg, ethnicity, reproductive health, sexually transmitted infections, and lifestyle information) can have significant impact on individuals if misused, particularly among vulnerable and marginalized populations. As academic institutions, nongovernmental organizations, and international agencies begin to collaborate with low- and middle-income countries to develop and deploy health information technology (HIT), it is important to understand the technical and practical security implications of these initiatives. Objective: Our aim is to develop a conceptual framework for risk stratification of global health data partnerships and HIT projects. In addition to identifying key conceptual domains, we map each domain to a variety of publicly available indices that could be used to inform a quantitative model. Methods: We conducted an overview of the literature to identify relevant publications, position statements, white papers, and reports. The research team reviewed all sources and used the framework method and conceptual framework analysis to name and categorize key concepts, integrate them into domains, and synthesize them into an overarching conceptual framework. Once key domains were identified, public international data sources were searched for relevant structured indices to generate quantitative counterparts. Results: We identified 5 key domains to inform our conceptual framework: State of HIT, Economics of Health Care, Demographics and Equity, Societal Freedom and Safety, and Partnership and Trust. Each of these domains was mapped to a number of structured indices. Conclusions: There is a complex relationship among the legal, economic, and social domains of health care, which affects the state of HIT in low- and middle-income countries and associated data security risks. The strength of partnership and trust among collaborating organizations is an important moderating factor. Additional work is needed to formalize the assessment of partnership and trust and to develop a quantitative model of the conceptual framework that can help support organizational decision-making. ", doi="10.2196/25833", url="https://formative.jmir.org/2021/12/e25833", url="http://www.ncbi.nlm.nih.gov/pubmed/34889752" } @Article{info:doi/10.2196/28503, author="Bailey, E. James and Gurgol, Cathy and Pan, Eric and Njie, Shirilyn and Emmett, Susan and Gatwood, Justin and Gauthier, Lynne and Rosas, G. Lisa and Kearney, M. Shannon and Robler, Kleindienst Samantha and Lawrence, H. Raymona and Margolis, L. Karen and Osunkwo, Ifeyinwa and Wilfley, Denise and Shah, O. Vallabh", title="Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review", journal="J Med Internet Res", year="2021", month="Dec", day="7", volume="23", number="12", pages="e28503", keywords="telehealth", keywords="scoping review", keywords="disparities", keywords="implementation science", abstract="Background: Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US \$386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities. Objective: This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities. Methods: A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study. Results: PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71\%), web-based interventions (30/41, 73\%), real-time videoconferencing (15/41, 37\%), remote patient monitoring (8/41, 20\%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10\%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41\%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information. Conclusions: Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information. ", doi="10.2196/28503", url="https://www.jmir.org/2021/12/e28503", url="http://www.ncbi.nlm.nih.gov/pubmed/34878986" } @Article{info:doi/10.2196/26123, author="Javidan, Pedram Arshia and Brand, Allan and Cameron, Andrew and D'Ovidio, Tommaso and Persaud, Martin and Lewis, Kirsten and O'Connor, Chris", title="Examination of a Canada-Wide Collaboration Platform for Order Sets: Retrospective Analysis", journal="J Med Internet Res", year="2021", month="Nov", day="29", volume="23", number="11", pages="e26123", keywords="evidence-based medicine", keywords="health informatics", keywords="knowledge translation", keywords="order sets", keywords="Web 2.0", abstract="Background: Knowledge translation and dissemination are some of the main challenges that affect evidence-based medicine. Web 2.0 platforms promote the sharing and collaborative development of content. Executable knowledge tools, such as order sets, are a knowledge translation tool whose localization is critical to its effectiveness but a challenge for organizations to develop independently. Objective: This paper describes a Web 2.0 resource, referred to as the collaborative network (TCN), for order set development designed to share executable knowledge (order sets). This paper also analyzes the scope of its use, describes its use through network analysis, and examines the provision and use of order sets in the platform by organizational size. Methods: Data were collected from Think Research's TxConnect platform. We measured interorganization sharing across Canadian hospitals using descriptive statistics. A weighted chi-square analysis was used to evaluate institutional size to share volumes based on institution size, with post hoc Cramer V score to measure the strength of association. Results: TCN consisted of 12,495 order sets across 683 diagnoses or processes. Between January 2010 and March 2015, a total of 131 health care organizations representing 360 hospitals in Canada downloaded order sets 105,496 times. Order sets related to acute coronary syndrome, analgesia, and venous thromboembolism were most commonly shared. COVID-19 order sets were among the most actively shared, adjusting for order set lifetime. A weighted chi-square analysis showed nonrandom downloading behavior (P<.001), with medium-sized institutions downloading content from larger institutions acting as the most significant driver of this variance (chi-gram=124.70). Conclusions: In this paper, we have described and analyzed a Web 2.0 platform for the sharing of order set content with significant network activity. The robust use of TCN to access customized order sets reflects its value as a resource for health care organizations when they develop or update their own order sets. ", doi="10.2196/26123", url="https://www.jmir.org/2021/11/e26123", url="http://www.ncbi.nlm.nih.gov/pubmed/34847055" } @Article{info:doi/10.2196/25170, author="Rauwerdink, Anneloek and Kasteleyn, J. Marise and Chavannes, H. Niels and Schijven, P. Marlies", title="Successes of and Lessons From the First Joint eHealth Program of the Dutch University Hospitals: Evaluation Study", journal="J Med Internet Res", year="2021", month="Nov", day="25", volume="23", number="11", pages="e25170", keywords="CSIRO framework", keywords="evaluation strategy", keywords="eHealth", keywords="telemedicine", keywords="qualitative research", keywords="formative evaluation", keywords="digital health", abstract="Background: A total of 8 Dutch university hospitals are at the forefront of contributing meaningfully to a future-proof health care system. To stimulate nationwide collaboration and knowledge-sharing on the topic of evidence-based eHealth, the Dutch university hospitals joined forces from 2016 to 2019 with the first Citrien Fund (CF) program eHealth; 29 eHealth projects with various subjects and themes were selected, supported, and evaluated. To determine the accomplishment of the 10 deliverables for the CF program eHealth and to contribute to the theory and practice of formative evaluation of eHealth in general, a comprehensive evaluation was deemed essential. Objective: The first aim of this study is to evaluate whether the 10 deliverables of the CF program eHealth were accomplished. The second aim is to evaluate the progress of the 29 eHealth projects to determine the barriers to and facilitators of the development of the CF program eHealth projects. Methods: To achieve the first aim of this study, an evaluation study was carried out using an adapted version of the Commonwealth Scientific and Industrial Research Organization framework. A mixed methods study, consisting of a 2-part questionnaire and semistructured interviews, was conducted to analyze the second aim of the study. Results: The 10 deliverables of the CF program eHealth were successfully achieved. The program yielded 22 tangible eHealth solutions, and significant knowledge on the development and use of eHealth solutions. We have learned that the patient is enthusiastic about accessing and downloading their own medical data but the physicians are more cautious. It was not always possible to implement the Dutch set of standards for interoperability, owing to a lack of information technology (IT) capacities. In addition, more attention needed to be paid to patients with low eHealth skills, and education in such cases is important. The eHealth projects' progress aspects such as planning, IT services, and legal played an important role in the success of the 29 projects. The in-depth interviews illustrated that a novel eHealth solution should fulfill a need, that partners already having the knowledge and means to accelerate development should be involved, that clear communication with IT developers and other stakeholders is crucial, and that having a dedicated project leader with sufficient time is of utmost importance for the success of a project. Conclusions: The 8 Dutch university hospitals were able to collaborate successfully and stimulate through a bottom-up approach, nationwide eHealth development and knowledge-sharing. In total, 22 tangible eHealth solutions were developed, and significant eHealth knowledge about their development and use was shared. The eHealth projects' progress aspects such as planning, IT services, and legal played an important role in the successful progress of the projects and should therefore be closely monitored when developing novel eHealth solutions. International Registered Report Identifier (IRRID): RR2-10.1016/j.ceh.2020.12.002 ", doi="10.2196/25170", url="https://www.jmir.org/2021/11/e25170", url="http://www.ncbi.nlm.nih.gov/pubmed/34842536" } @Article{info:doi/10.2196/33012, author="Dahlhausen, Florian and Zinner, Maximillian and Bieske, Linn and Ehlers, P. Jan and Boehme, Philip and Fehring, Leonard", title="Physicians' Attitudes Toward Prescribable mHealth Apps and Implications for Adoption in Germany: Mixed Methods Study", journal="JMIR Mhealth Uhealth", year="2021", month="Nov", day="23", volume="9", number="11", pages="e33012", keywords="mobile health", keywords="mHealth", keywords="digital health", keywords="apps", keywords="physicians", keywords="general practitioners", keywords="technology acceptance", keywords="adoption", abstract="Background: In October 2020, Germany became the first country, worldwide, to approve certain mobile health (mHealth) apps, referred to as DiGA (Digitale Gesundheitsanwendungen, in German, meaning digital health applications), for prescription with costs covered by standard statutory health insurance. Yet, this option has only been used to a limited extent so far. Objective: The aim of this study was to investigate physicians' and psychotherapists' current attitudes toward mHealth apps, barriers to adoption, and potential remedies. Methods: We conducted a two-stage sequential mixed methods study. In phase one, semistructured interviews were conducted with physicians and psychotherapists for questionnaire design. In phase two, an online survey was conducted among general practitioners, physicians, and psychotherapists. Results: A total of 1308 survey responses by mostly outpatient-care general practitioners, physicians, and psychotherapists from across Germany who could prescribe DiGA were recorded, making this the largest study on mHealth prescriptions to date. A total of 62.1\% (807/1299) of respondents supported the opportunity to prescribe DiGA. Improved adherence (997/1294, 77.0\%), health literacy (842/1294, 65.1\%), and disease management (783/1294, 60.5\%) were most frequently seen as benefits of DiGA. However, only 30.3\% (393/1299) of respondents planned to prescribe DiGA, varying greatly by medical specialty. Professionals are still facing substantial barriers, such as insufficient information (1135/1295, 87.6\%), reimbursement for DiGA-related medical services (716/1299, 55.1\%), medical evidence (712/1298, 54.9\%), legal uncertainties (680/1299, 52.3\%), and technological uncertainties (658/1299, 50.7\%). To support professionals who are unsure of prescribing DiGA, extended information campaigns (1104/1297, 85.1\%) as well as recommendations from medical associations (1041/1297, 80.3\%) and medical colleagues (1024/1297, 79.0\%) were seen as the most impactful remedies. Conclusions: To realize the benefits from DiGA through increased adoption, additional information sharing about DiGA from trusted bodies, reimbursement for DiGA-related medical services, and further medical evidence are recommended. ", doi="10.2196/33012", url="https://mhealth.jmir.org/2021/11/e33012", url="http://www.ncbi.nlm.nih.gov/pubmed/34817385" } @Article{info:doi/10.2196/33509, author="Schopow, Nikolas and Osterhoff, Georg and von Dercks, Nikolaus and Girrbach, Felix and Josten, Christoph and Stehr, Sebastian and Hepp, Pierre", title="Central COVID-19 Coordination Centers in Germany: Description, Economic Evaluation, and Systematic Review", journal="JMIR Public Health Surveill", year="2021", month="Nov", day="18", volume="7", number="11", pages="e33509", keywords="telemedical consultation", keywords="patient allocation", keywords="algorithm-based treatment", keywords="telemedicine", keywords="telehealth", keywords="consultation", keywords="allocation", keywords="algorithm", keywords="treatment", keywords="COVID-19", keywords="coordination", keywords="Germany", keywords="economic", keywords="review", keywords="establishment", keywords="management", abstract="Background: During the COVID-19 pandemic, Central COVID-19 Coordination Centers (CCCCs) have been established at several hospitals across Germany with the intention to assist local health care professionals in efficiently referring patients with suspected or confirmed SARS-CoV-2 infection to regional hospitals and therefore to prevent the collapse of local health system structures. In addition, these centers coordinate interhospital transfers of patients with COVID-19 and provide or arrange specialized telemedical consultations. Objective: This study describes the establishment and management of a CCCC at a German university hospital. Methods: We performed economic analyses (cost, cost-effectiveness, use, and utility) according to the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) criteria. Additionally, we conducted a systematic review to identify publications on similar institutions worldwide. The 2 months with the highest local incidence of COVID-19 cases (December 2020 and January 2021) were considered. Results: During this time, 17.3 requests per day were made to the CCCC regarding admission or transfer of patients with COVID-19. The majority of requests were made by emergency medical services (601/1068, 56.3\%), patients with an average age of 71.8 (SD 17.2) years were involved, and for 737 of 1068 cases (69\%), SARS-CoV-2 had already been detected by a positive polymerase chain reaction test. In 59.8\% (639/1068) of the concerned patients, further treatment by a general practitioner or outpatient presentation in a hospital could be initiated after appropriate advice, 27.2\% (291/1068) of patients were admitted to normal wards, and 12.9\% (138/1068) were directly transmitted to an intensive care unit. The operating costs of the CCCC amounted to more than {\texteuro}52,000 (US \$60,031) per month. Of the 334 patients with detected SARS-CoV-2 who were referred via EMS or outpatient physicians, 302 (90.4\%) were triaged and announced in advance by the CCCC. No other published economic analysis of COVID-19 coordination or management institutions at hospitals could be found. Conclusions: Despite the high cost of the CCCC, we were able to show that it is a beneficial concept to both the providing hospital and the public health system. However, the most important benefits of the CCCC are that it prevents hospitals from being overrun by patients and that it avoids situations in which physicians must weigh one patient's life against another's. ", doi="10.2196/33509", url="https://publichealth.jmir.org/2021/11/e33509", url="http://www.ncbi.nlm.nih.gov/pubmed/34623955" } @Article{info:doi/10.2196/27748, author="Javier, J. Sarah and Wu, Justina and Smith, L. Donna and Kanwal, Fasiha and Martin, A. Lindsey and Clark, Jack and Midboe, M. Amanda", title="A Web-Based, Population-Based Cirrhosis Identification and Management System for Improving Cirrhosis Care: Qualitative Formative Evaluation", journal="JMIR Form Res", year="2021", month="Nov", day="9", volume="5", number="11", pages="e27748", keywords="cirrhosis", keywords="informatics", keywords="care coordination", keywords="implementation", keywords="Consolidated Framework for Implementation Research (CFIR)", keywords="quality improvement", abstract="Background: Cirrhosis, or scarring of the liver, is a debilitating condition that affects millions of US adults. Early identification, linkage to care, and retention of care are critical for preventing severe complications and death from cirrhosis. Objective: The purpose of this study is to conduct a preimplementation formative evaluation to identify factors that could impact implementation of the Population-Based Cirrhosis Identification and Management System (P-CIMS) in clinics serving patients with cirrhosis. P-CIMS is a web-based informatics tool designed to facilitate patient outreach and cirrhosis care management. Methods: Semistructured interviews were conducted between January and May 2016 with frontline providers in liver disease and primary care clinics at 3 Veterans Health Administration medical centers. A total of 10 providers were interviewed, including 8 physicians and midlevel providers from liver-related specialty clinics and 2 primary care providers who managed patients with cirrhosis. The Consolidated Framework for Implementation Research guided the development of the interview guides. Inductive consensus coding and content analysis were used to analyze transcribed interviews and abstracted coded passages, elucidated themes, and insights. Results: The following themes and subthemes emerged from the analyses: outer setting: needs and resources for patients with cirrhosis; inner setting: readiness for implementation (subthemes: lack of resources, lack of leadership support), and implementation climate (subtheme: competing priorities); characteristics of individuals: role within clinic; knowledge and beliefs about P-CIMS (subtheme: perceived and realized benefits; useful features; suggestions for improvement); and perceptions of current practices in managing cirrhosis cases (subthemes: preimplementation process for identifying and linking patients to cirrhosis care; structural and social barriers to follow-up). Overall, P-CIMS was viewed as a powerful tool for improving linkage and retention, but its integration in the clinical workflow required leadership support, time, and staffing. Providers also cited the need for more intuitive interface elements to enhance usability. Conclusions: P-CIMS shows promise as a powerful tool for identifying, linking, and retaining care in patients living with cirrhosis. The current evaluation identified several improvements and advantages of P-CIMS over current care processes and provides lessons for others implementing similar population-based identification and management tools in populations with chronic disease. ", doi="10.2196/27748", url="https://formative.jmir.org/2021/11/e27748", url="http://www.ncbi.nlm.nih.gov/pubmed/34751653" } @Article{info:doi/10.2196/23789, author="Steinkamp, Jackson and Sharma, Abhinav and Bala, Wasif and Kantrowitz, J. Jacob", title="A Fully Collaborative, Noteless Electronic Medical Record Designed to Minimize Information Chaos: Software Design and Feasibility Study", journal="JMIR Form Res", year="2021", month="Nov", day="9", volume="5", number="11", pages="e23789", keywords="electronic medical records", keywords="clinical notes", keywords="information chaos", keywords="information overload", keywords="clinician burnout", keywords="software design", keywords="problem-oriented medical record", keywords="medical records", keywords="electronic records", keywords="documentation", keywords="clinical", keywords="software", abstract="Background: Clinicians spend large amounts of their workday using electronic medical records (EMRs). Poorly designed documentation systems contribute to the proliferation of out-of-date information, increased time spent on medical records, clinician burnout, and medical errors. Beyond software interfaces, examining the underlying paradigms and organizational structures for clinical information may provide insights into ways to improve documentation systems. In particular, our attachment to the note as the major organizational unit for storing unstructured medical data may be a cause of many of the problems with modern clinical documentation. Notes, as currently understood, systematically incentivize information duplication and information scattering, both within a single clinician's notes over time and across multiple clinicians' notes. Therefore, it is worthwhile to explore alternative paradigms for unstructured data organization. Objective: The aim of this study is to demonstrate the feasibility of building an EMR that does not use notes as the core organizational unit for unstructured data and which is designed specifically to disincentivize information duplication and information scattering. Methods: We used specific design principles to minimize the incentive for users to duplicate and scatter information. By default, the majority of a patient's medical history remains the same over time, so users should not have to redocument that information. Clinicians on different teams or services mostly share the same medical information, so all data should be collaboratively shared across teams and services (while still allowing for disagreement and nuance). In all cases where a clinician must state that information has remained the same, they should be able to attest to the information without redocumenting it. We designed and built a web-based EMR based on these design principles. Results: We built a medical documentation system that does not use notes and instead treats the chart as a single, dynamically updating, and fully collaborative workspace. All information is organized by clinical topic or problem. Version history functionality is used to enable granular tracking of changes over time. Our system is highly customizable to individual workflows and enables each individual user to decide which data should be structured and which should be unstructured, enabling individuals to leverage the advantages of structured templating and clinical decision support as desired without requiring programming knowledge. The system is designed to facilitate real-time, fully collaborative documentation and communication among multiple clinicians. Conclusions: We demonstrated the feasibility of building a non--note-based, fully collaborative EMR system. Our attachment to the note as the only possible atomic unit of unstructured medical data should be reevaluated, and alternative models should be considered. ", doi="10.2196/23789", url="https://formative.jmir.org/2021/11/e23789", url="http://www.ncbi.nlm.nih.gov/pubmed/34751651" } @Article{info:doi/10.2196/25159, author="Trupia, Vanessa Dilara and Mathieu-Fritz, Alexandre and Duong, Anh Tu", title="The Sociological Perspective of Users' Invisible Work: A Qualitative Research Framework for Studying Digital Health Innovations Integration", journal="J Med Internet Res", year="2021", month="Nov", day="4", volume="23", number="11", pages="e25159", keywords="digital health innovations", keywords="qualitative analysis", keywords="sociological framework", keywords="invisible work", keywords="patient work", keywords="user work", keywords="participatory health care", keywords="chronic illness", keywords="self-quantification", abstract="Background: When new technology is integrated into a care pathway, it faces resistance due to the changes it introduces into the existing context. To understand the success or failure of digital health innovations, it is necessary to pay attention to the adjustments that users must perform to make them work, by reshaping the context and sometimes by altering the ways in which they perform activities. This adaptation work, most of which remains invisible, constitutes an important factor in the success of innovations and the ways in which they transform care practices. Objective: This work aims to present a sociological framework for studying new health technology uses through a qualitative analysis of the different types of tasks and activities that users, both health professionals and patients, must perform to integrate these technologies and make them work in their daily routine. Methods: This paper uses a three-part method to structure a theoretical model to study users' invisible work. The first part of the method includes a thematic literature review, previously published by one of the coauthors, of major sociological studies conducted on digital health innovations integration into existing care organizations and practices. The second part extends this review to introduce definitions and applications of the users' invisible work concept. The third part consists of producing a theoretical framework to study the concept according to the different contexts and practices of the users. Results: The paper proposes four dimensions (organizational, interactional, practical, and experiential), each composed of a set of criteria that allow a comparative analysis of different users' work according to different health technologies. Conclusions: This framework can be applied both as an analytical tool in a research protocol and as an agenda to identify less visible adoption criteria for digital health technologies. ", doi="10.2196/25159", url="https://www.jmir.org/2021/11/e25159", url="http://www.ncbi.nlm.nih.gov/pubmed/34734832" } @Article{info:doi/10.2196/30545, author="Gilbert, Stephen and Fenech, Matthew and Hirsch, Martin and Upadhyay, Shubhanan and Biasiucci, Andrea and Starlinger, Johannes", title="Algorithm Change Protocols in the Regulation of Adaptive Machine Learning--Based Medical Devices", journal="J Med Internet Res", year="2021", month="Oct", day="26", volume="23", number="10", pages="e30545", keywords="artificial intelligence", keywords="machine learning", keywords="regulation", keywords="algorithm change protocol", keywords="healthcare", keywords="regulatory framework", keywords="health care", doi="10.2196/30545", url="https://www.jmir.org/2021/10/e30545", url="http://www.ncbi.nlm.nih.gov/pubmed/34697010" } @Article{info:doi/10.2196/30940, author="Wiljer, David and Salhia, Mohammad and Dolatabadi, Elham and Dhalla, Azra and Gillan, Caitlin and Al-Mouaswas, Dalia and Jackson, Ethan and Waldorf, Jacqueline and Mattson, Jane and Clare, Megan and Lalani, Nadim and Charow, Rebecca and Balakumar, Sarmini and Younus, Sarah and Jeyakumar, Tharshini and Peteanu, Wanda and Tavares, Walter", title="Accelerating the Appropriate Adoption of Artificial Intelligence in Health Care: Protocol for a Multistepped Approach", journal="JMIR Res Protoc", year="2021", month="Oct", day="6", volume="10", number="10", pages="e30940", keywords="artificial intelligence", keywords="health care providers", keywords="education", keywords="learning", keywords="patient care", keywords="adoption", keywords="mHealth", abstract="Background: Significant investments and advances in health care technologies and practices have created a need for digital and data-literate health care providers. Artificial intelligence (AI) algorithms transform the analysis, diagnosis, and treatment of medical conditions. Complex and massive data sets are informing significant health care decisions and clinical practices. The ability to read, manage, and interpret large data sets to provide data-driven care and to protect patient privacy are increasingly critical skills for today's health care providers. Objective: The aim of this study is to accelerate the appropriate adoption of data-driven and AI-enhanced care by focusing on the mindsets, skillsets, and toolsets of point-of-care health providers and their leaders in the health system. Methods: To accelerate the adoption of AI and the need for organizational change at a national level, our multistepped approach includes creating awareness and capacity building, learning through innovation and adoption, developing appropriate and strategic partnerships, and building effective knowledge exchange initiatives. Education interventions designed to adapt knowledge to the local context and address any challenges to knowledge use include engagement activities to increase awareness, educational curricula for health care providers and leaders, and the development of a coaching and practice-based innovation hub. Framed by the Knowledge-to-Action framework, we are currently in the knowledge creation stage to inform the curricula for each deliverable. An environmental scan and scoping review were conducted to understand the current state of AI education programs as reported in the academic literature. Results: The environmental scan identified 24 AI-accredited programs specific to health providers, of which 11 were from the United States, 6 from Canada, 4 from the United Kingdom, and 3 from Asian countries. The most common curriculum topics across the environmental scan and scoping review included AI fundamentals, applications of AI, applied machine learning in health care, ethics, data science, and challenges to and opportunities for using AI. Conclusions: Technologies are advancing more rapidly than organizations, and professionals can adopt and adapt to them. To help shape AI practices, health care providers must have the skills and abilities to initiate change and shape the future of their discipline and practices for advancing high-quality care within the digital ecosystem. International Registered Report Identifier (IRRID): PRR1-10.2196/30940 ", doi="10.2196/30940", url="https://www.researchprotocols.org/2021/10/e30940", url="http://www.ncbi.nlm.nih.gov/pubmed/34612839" } @Article{info:doi/10.2196/24200, author="Braunack-Mayer, Annette and Fabrianesi, Belinda and Street, Jackie and O'Shaughnessy, Pauline and Carter, M. Stacy and Engelen, Lina and Carolan, Lucy and Bosward, Rebecca and Roder, David and Sproston, Kylie", title="Sharing Government Health Data With the Private Sector: Community Attitudes Survey", journal="J Med Internet Res", year="2021", month="Oct", day="1", volume="23", number="10", pages="e24200", keywords="big data", keywords="health information systems", keywords="health data", keywords="private sector", keywords="data linkage", keywords="public opinion", keywords="consent", keywords="trust", keywords="public interest", keywords="social license", abstract="Background: The use of government health data for secondary purposes, such as monitoring the quality of hospital services, researching the health needs of populations, and testing how well new treatments work, is increasing. This increase in the secondary uses of health data has led to increased interest in what the public thinks about data sharing, in particular, the possibilities of sharing with the private sector for research and development. Although international evidence demonstrates broad public support for the secondary use of health data, this support does not extend to sharing health data with the private sector. If governments intend to share health data with the private sector, knowing what the public thinks will be important. This paper reports a national survey to explore public attitudes in Australia toward sharing health data with private companies for research on and development of therapeutic drugs and medical devices. Objective: This study aims to explore public attitudes in Australia toward sharing government health data with the private sector. Methods: A web-based survey tool was developed to assess attitudes about sharing government health data with the private sector. A market research company was employed to administer the web-based survey in June 2019. Results: The survey was completed by 2537 individuals residing in Australia. Between 51.8\% and 57.98\% of all participants were willing to share their data, with slightly fewer in favor of sharing to improve health services (51.99\%) and a slightly higher proportion in favor of sharing for research and development (57.98\%). There was a preference for opt-in consent (53.44\%) and broad support for placing conditions on sharing health information with private companies (62\% to 91.99\%). Wide variability was also observed in participants' views about the extent to which the private sector could be trusted and how well they would behave if entrusted with people's health information. In their qualitative responses, the participants noted concerns about private sector corporate interests, corruption, and profit making and expressed doubt about the Australian government's capacity to manage data sharing safely. The percentages presented are adjusted against the Australian population. Conclusions: This nationally representative survey provides preliminary evidence that Australians are uncertain about sharing their health data with the private sector. Although just over half of all the respondents supported sharing health data with the private sector, there was also strong support for strict conditions on sharing data and for opt-in consent and significant concerns about how well the private sector would manage government health data. Addressing public concern about sharing government health data with the private sector will require more and better engagement to build community understanding about how agencies can collect, share, protect, and use their personal data. ", doi="10.2196/24200", url="https://www.jmir.org/2021/10/e24200", url="http://www.ncbi.nlm.nih.gov/pubmed/34596573" } @Article{info:doi/10.2196/28897, author="Hart, Joanna and Summer, Amy and Yadav, N. Kuldeep and Peace, Summer and Hong, David and Konu, Michael and Clapp, T. Justin", title="Content and Communication of Inpatient Family Visitation Policies During the COVID-19 Pandemic: Sequential Mixed Methods Study", journal="J Med Internet Res", year="2021", month="Sep", day="24", volume="23", number="9", pages="e28897", keywords="family-centered care", keywords="hospital policy", keywords="public health", keywords="health communication", keywords="ethics", keywords="health systems", keywords="public perceptions", keywords="COVID-19", keywords="pandemic", abstract="Background: Inpatient health care facilities restricted inpatient visitation due to the COVID-19 pandemic. There is no existing evidence of how they communicated these policies to the public nor the impact of their communication choices on public perception. Objective: This study aims to describe patterns of inpatient visitation policies during the initial peak of the COVID-19 pandemic in the United States and the communication of these policies to the general public, as well as to identify communication strategies that maximize positive impressions of the facility despite visitation restrictions. Methods: We conducted a sequential, exploratory, mixed methods study including a qualitative analysis of COVID-19 era visitation policies published on Pennsylvania-based facility websites, as captured between April 30 and May 20, 2020 (ie, during the first peak of the COVID-19 pandemic in the United States). We also conducted a factorial survey-based experiment to test how key elements of hospitals' visitation policy communication are associated with individuals' willingness to seek care in October 2020. For analysis of the policies, we included all inpatient facilities in Pennsylvania. For the factorial experiment, US adults were drawn from internet research panels. The factorial survey-based experiment presented composite policies that varied in their justification for restricted visitation, the degree to which the facility expressed ownership of the policy, and the inclusion of family-centered care support plans. Our primary outcome was participants' willingness to recommend the hypothetical facility using a 5-point Likert scale. Results: We identified 104 unique policies on inpatient visitation from 363 facilities' websites. The mean Flesch-Kincaid Grade Level for the policies was 14.2. Most policies prohibited family presence (99/104, 95.2\%). Facilities justified the restricted visitation policies on the basis of community protection (59/104, 56.7\%), authorities' guidance or regulations (34/104, 32.7\%), or scientific rationale (23/104, 22.1\%). A minority (38/104, 36.5\%) addressed how restrictive visitation may impair family-centered care. Most of the policies analyzed used passive voice to communicate restrictions. A total of 1321 participants completed the web-based survey. Visitation policy elements significantly associated with willingness to recommend the facility included justifications based on community protection (OR 1.44, 95\% CI 1.24-1.68) or scientific rationale (OR 1.30, 95\% CI 1.12-1.51), rather than those based on a governing authority. The facility expressed a high degree of ownership over the decision (OR 1.16, 95\% CI 1.04-1.29), rather than a low degree of ownership; and inclusion of family-centered care support plans (OR 2.80, 95\% CI 2.51-3.12), rather than no such support. Conclusions: Health systems can immediately improve public receptiveness of restrictive visitation policies by emphasizing community protection, ownership over the facility's policy, and promoting family-centered care. ", doi="10.2196/28897", url="https://www.jmir.org/2021/9/e28897", url="http://www.ncbi.nlm.nih.gov/pubmed/34406968" } @Article{info:doi/10.2196/28635, author="Huemer, Matthias and Jahn-Kuch, Daniela and Hofmann, Guenter and Andritsch, Elisabeth and Farkas, Clemens and Schaupp, Walter and Masel, Katharina Eva and Jost, J. Philipp and Pichler, Martin", title="Trends and Patterns in the Public Awareness of Palliative Care, Euthanasia, and End-of-Life Decisions in 3 Central European Countries Using Big Data Analysis From Google: Retrospective Analysis", journal="J Med Internet Res", year="2021", month="Sep", day="20", volume="23", number="9", pages="e28635", keywords="Google Trends", keywords="end-of-life decisions", keywords="assisted suicide", keywords="euthanasia", keywords="palliative care", keywords="health care policy", abstract="Background: End-of-life decisions, specifically the provision of euthanasia and assisted suicide services, challenge traditional medical and ethical principles. Austria and Germany have decided to liberalize their laws restricting assisted suicide, thus reigniting the debate about a meaningful framework in which the practice should be embedded. Evidence of the relevance of assisted suicide and euthanasia for the general population in Germany and Austria is limited. Objective: The aim of this study is to examine whether the public awareness documented by search activities in the most frequently used search engine, Google, on the topics of palliative care, euthanasia, and advance health care directives changed with the implementation of palliative care services and new governmental regulations concerning end-of-life decisions. Methods: We searched for policies, laws, and regulations promulgated or amended in Austria, Germany, and Switzerland between 2004 and 2020 and extracted data on the search volume for each search term topic from Google Trends as a surrogate of public awareness and interest. Annual averages were analyzed using the Joinpoint Regression Program. Results: Important policy changes yielded significant changes in search trends for the investigated topics. The enactment of laws regulating advance health care directives coincided with a significant drop in the volume of searches for the topic of euthanasia in all 3 countries (Austria: ?24.48\%, P=.02; Germany: ?14.95\%, P<.001; Switzerland: ?11.75\%, P=.049). Interest in palliative care increased with the availability of care services and the implementation of laws and policies to promote palliative care (Austria: 22.69\%, P=.01; Germany: 14.39, P<.001; Switzerland: 17.59\%, P<.001). The search trends for advance health care directives showed mixed results. While interest remained steady in Austria within the study period, it increased by 3.66\% (P<.001) in Switzerland and decreased by 2.85\% (P<.001) in Germany. Conclusions: Our results demonstrate that legal measures securing patients' autonomy at the end of life may lower the search activities for topics related to euthanasia and assisted suicide. Palliative care may be a meaningful way to raise awareness of the different options for end-of-life care and to guide patients in their decision-making process regarding the same. ", doi="10.2196/28635", url="https://www.jmir.org/2021/9/e28635", url="http://www.ncbi.nlm.nih.gov/pubmed/34542419" } @Article{info:doi/10.2196/26317, author="LaMonica, M. Haley and Roberts, E. Anna and Lee, Yeeun Grace and Davenport, A. Tracey and Hickie, B. Ian", title="Privacy Practices of Health Information Technologies: Privacy Policy Risk Assessment Study and Proposed Guidelines", journal="J Med Internet Res", year="2021", month="Sep", day="16", volume="23", number="9", pages="e26317", keywords="privacy", keywords="mental health", keywords="technology", keywords="digital tools", keywords="smartphone", keywords="apps", abstract="Background: Along with the proliferation of health information technologies (HITs), there is a growing need to understand the potential privacy risks associated with using such tools. Although privacy policies are designed to inform consumers, such policies have consistently been found to be confusing and lack transparency. Objective: This study aims to present consumer preferences for accessing privacy information; develop and apply a privacy policy risk assessment tool to assess whether existing HITs meet the recommended privacy policy standards; and propose guidelines to assist health professionals and service providers with understanding the privacy risks associated with HITs, so that they can confidently promote their safe use as a part of care. Methods: In phase 1, participatory design workshops were conducted with young people who were attending a participating headspace center, their supportive others, and health professionals and service providers from the centers. The findings were knowledge translated to determine participant preferences for the presentation and availability of privacy information and the functionality required to support its delivery. Phase 2 included the development of the 23-item privacy policy risk assessment tool, which incorporated material from international privacy literature and standards. This tool was then used to assess the privacy policies of 34 apps and e-tools. In phase 3, privacy guidelines, which were derived from learnings from a collaborative consultation process with key stakeholders, were developed to assist health professionals and service providers with understanding the privacy risks associated with incorporating HITs as a part of clinical care. Results: When considering the use of HITs, the participatory design workshop participants indicated that they wanted privacy information to be easily accessible, transparent, and user-friendly to enable them to clearly understand what personal and health information will be collected and how these data will be shared and stored. The privacy policy review revealed consistently poor readability and transparency, which limited the utility of these documents as a source of information. Therefore, to enable informed consent, the privacy guidelines provided ensure that health professionals and consumers are fully aware of the potential for privacy risks in using HITs to support health and well-being. Conclusions: A lack of transparency in privacy policies has the potential to undermine consumers' ability to trust that the necessary measures are in place to secure and protect the privacy of their personal and health information, thus precluding their willingness to engage with HITs. The application of the privacy guidelines will improve the confidence of health professionals and service providers in the privacy of consumer data, thus enabling them to recommend HITs to provide or support care. ", doi="10.2196/26317", url="https://www.jmir.org/2021/9/e26317", url="http://www.ncbi.nlm.nih.gov/pubmed/34528895" } @Article{info:doi/10.2196/26580, author="Aminoff, Hedvig and Meijer, Sebastiaan", title="Context and Complexity in Telemedicine Evaluation: Work Domain Analysis in a Surgical Setting", journal="JMIR Perioper Med", year="2021", month="Sep", day="16", volume="4", number="2", pages="e26580", keywords="telemedicine", keywords="telemedicine evaluation", keywords="ERCP", keywords="work domain analysis", keywords="abstraction hierarchy", keywords="complexity", keywords="context", keywords="cognitive systems engineering", doi="10.2196/26580", url="https://periop.jmir.org/2021/2/e26580", url="http://www.ncbi.nlm.nih.gov/pubmed/34528894" } @Article{info:doi/10.2196/24295, author="Geva, A. Gil and Ketko, Itay and Nitecki, Maya and Simon, Shoham and Inbar, Barr and Toledo, Itay and Shapiro, Michael and Vaturi, Barak and Votta, Yoni and Filler, Daniel and Yosef, Roey and Shpitzer, A. Sagi and Hir, Nabil and Peri Markovich, Michal and Shapira, Shachar and Fink, Noam and Glasberg, Elon and Furer, Ariel", title="Data Empowerment of Decision-Makers in an Era of a Pandemic: Intersection of ``Classic'' and Artificial Intelligence in the Service of Medicine", journal="J Med Internet Res", year="2021", month="Sep", day="10", volume="23", number="9", pages="e24295", keywords="COVID-19", keywords="medical informatics", keywords="decision-making", keywords="pandemic", keywords="data", keywords="policy", keywords="validation", keywords="accuracy", keywords="data analysis", abstract="Background: The COVID-19 outbreak required prompt action by health authorities around the world in response to a novel threat. With enormous amounts of information originating in sources with uncertain degree of validation and accuracy, it is essential to provide executive-level decision-makers with the most actionable, pertinent, and updated data analysis to enable them to adapt their strategy swiftly and competently. Objective: We report here the origination of a COVID-19 dedicated response in the Israel Defense Forces with the assembly of an operational Data Center for the Campaign against Coronavirus. Methods: Spearheaded by directors with clinical, operational, and data analytics orientation, a multidisciplinary team utilized existing and newly developed platforms to collect and analyze large amounts of information on an individual level in the context of SARS-CoV-2 contraction and infection. Results: Nearly 300,000 responses to daily questionnaires were recorded and were merged with other data sets to form a unified data lake. By using basic as well as advanced analytic tools ranging from simple aggregation and display of trends to data science application, we provided commanders and clinicians with access to trusted, accurate, and personalized information and tools that were designed to foster operational changes and mitigate the propagation of the pandemic. The developed tools aided in the in the identification of high-risk individuals for severe disease and resulted in a 30\% decline in their attendance to their units. Moreover, the queue for laboratory examination for COVID-19 was optimized using a predictive model and resulted in a high true-positive rate of 20\%, which is more than twice as high as the baseline rate (2.28\%, 95\% CI 1.63\%-3.19\%). Conclusions: In times of ambiguity and uncertainty, along with an unprecedented flux of information, health organizations may find multidisciplinary teams working to provide intelligence from diverse and rich data a key factor in providing executives relevant and actionable support for decision-making. ", doi="10.2196/24295", url="https://www.jmir.org/2021/9/e24295", url="http://www.ncbi.nlm.nih.gov/pubmed/34313589" } @Article{info:doi/10.2196/25797, author="Desveaux, Laura and Budhwani, Suman and Stamenova, Vess and Bhattacharyya, Onil and Shaw, James and Bhatia, Sacha R.", title="Closing the Virtual Gap in Health Care: A Series of Case Studies Illustrating the Impact of Embedding Evaluation Alongside System Initiatives", journal="J Med Internet Res", year="2021", month="Sep", day="3", volume="23", number="9", pages="e25797", keywords="virtual care", keywords="primary care", keywords="embedded research", keywords="implementation", keywords="knowledge exchange", keywords="health policy", doi="10.2196/25797", url="https://www.jmir.org/2021/9/e25797", url="http://www.ncbi.nlm.nih.gov/pubmed/34477560" } @Article{info:doi/10.2196/26700, author="Gehri, Beatrice and Bachnick, Stefanie and Schwendimann, Ren{\'e} and Simon, Michael", title="Matching Registered Nurse Services With Changing Care Demands in Psychiatric Hospitals: Protocol for a Multicenter Observational Study (MatchRN Psychiatry Study)", journal="JMIR Res Protoc", year="2021", month="Aug", day="17", volume="10", number="8", pages="e26700", keywords="quality of care", keywords="psychiatric hospitals", keywords="nurses", keywords="patient routine data", keywords="work environment", keywords="Switzerland", abstract="Background: The quality of care is often poorly assessed in mental health settings, and accurate evaluation requires the monitoring and comparison of not only the outcomes but also the structures and processes. The resulting data allow hospital administrators to compare their patient outcome data against those reported nationally. As Swiss psychiatric hospitals are planned and coordinated at the cantonal level, they vary considerably. In addition, nursing care structures and processes, such as nurse staffing, are only reported and aggregated at the national level, whereas nurse outcomes, such as job satisfaction or intention to leave, have yet to be assessed in Swiss psychiatric hospitals. Because they lack these key figures, psychiatric hospitals' quality of care cannot be reasonably described. Objective: This study's purpose is to describe health care quality by exploring hospital structures such as nurse staffing and the work environment; processes such as the rationing of care; nurse outcomes, including job satisfaction and work-life balance; and patients' symptom burden. Methods: MatchRN Psychiatry is a multicenter observational study of Swiss psychiatric hospitals. The sample for this study included approximately 1300 nurses from 113 units of 13 psychiatric hospitals in Switzerland's German-speaking region. In addition, routine patient assessment data from each participating hospital were included. The nurse survey consisted of 164 items covering three dimensions---work environment, patient safety climate, and the rationing of care. The unit-level questionnaire included 57 items, including the number of beds, number of nurses, and nurses' education levels. Routine patient data included items such as main diagnosis, the number and duration of freedom-restrictive measures, and symptom burden at admission and discharge. Data were collected between September 2019 and June 2021. The data will be analyzed descriptively by using multilevel regression linear mixed models and generalized linear mixed models to explore associations between variables of interest. Results: The response rate from the nurse survey was 71.49\% (1209/1691). All data are currently being checked for consistency and plausibility. The MatchRN Psychiatry study is funded by the participating psychiatric hospitals and the Swiss Psychiatric Nursing Leaders Association (Vereinigung Pflegekader Psychiatrie Schweiz). Conclusions: For the first time, the MatchRN Psychiatry study will systematically evaluate the quality of care in psychiatric hospitals in Switzerland in terms of organizational structures, processes, and patient and nurse outcomes. The participating psychiatric hospitals will benefit from findings that are relevant to the future planning of nurse staffing. The findings of this study will contribute to improvement strategies for nurses' work environments and patient experiences in Swiss psychiatric hospitals. International Registered Report Identifier (IRRID): DERR1-10.2196/26700 ", doi="10.2196/26700", url="https://www.researchprotocols.org/2021/8/e26700", url="http://www.ncbi.nlm.nih.gov/pubmed/34402796" } @Article{info:doi/10.2196/18198, author="Broekhuis, Marijke and van Velsen, Lex and Peute, Linda and Halim, Meilani and Hermens, Hermie", title="Conceptualizing Usability for the eHealth Context: Content Analysis of Usability Problems of eHealth Applications", journal="JMIR Form Res", year="2021", month="Jul", day="27", volume="5", number="7", pages="e18198", keywords="usability benchmarking", keywords="eHealth systems", keywords="content analysis", keywords="usability framework", keywords="summative evaluation", keywords="mobile phone", abstract="Background: Usability tests can be either formative (where the aim is to detect usability problems) or summative (where the aim is to benchmark usability). There are ample formative methods that consider user characteristics and contexts (ie, cognitive walkthroughs, interviews, and verbal protocols). This is especially valuable for eHealth applications, as health conditions can influence user-system interactions. However, most summative usability tests do not consider eHealth-specific factors that could potentially affect the usability of a system. One of the reasons for this is the lack of fine-grained frameworks or models of usability factors that are unique to the eHealth domain. Objective: In this study, we aim to develop an ontology of usability problems, specifically for eHealth applications, with patients as primary end users. Methods: We analyzed 8 data sets containing the results of 8 formative usability tests for eHealth applications. These data sets contained 400 usability problems that could be used for analysis. Both inductive and deductive coding were used to create an ontology from 6 data sets, and 2 data sets were used to validate the framework by assessing the intercoder agreement. Results: We identified 8 main categories of usability factors, including basic system performance, task-technology fit, accessibility, interface design, navigation and structure, information and terminology, guidance and support, and satisfaction. These 8 categories contained a total of 21 factors: 14 general usability factors and 7 eHealth-specific factors. Cohen $\kappa$ was calculated for 2 data sets on both the category and factor levels, and all Cohen $\kappa$ values were between 0.62 and 0.67, which is acceptable. Descriptive analysis revealed that approximately 69.5\% (278/400) of the usability problems can be considered as general usability factors and 30.5\% (122/400) as eHealth-specific usability factors. Conclusions: Our ontology provides a detailed overview of the usability factors for eHealth applications. Current usability benchmarking instruments include only a subset of the factors that emerged from our study and are therefore not fully suited for summative evaluations of eHealth applications. Our findings support the development of new usability benchmarking tools for the eHealth domain. ", doi="10.2196/18198", url="https://formative.jmir.org/2021/7/e18198", url="http://www.ncbi.nlm.nih.gov/pubmed/34313594" } @Article{info:doi/10.2196/23779, author="Yang, Feng and Shu, Huilin and Zhang, Xiaoqian", title="Understanding ``Internet Plus Healthcare'' in China: Policy Text Analysis", journal="J Med Internet Res", year="2021", month="Jul", day="26", volume="23", number="7", pages="e23779", keywords="internet plus health care", keywords="China", keywords="policy analysis", keywords="COVID-19", keywords="epidemic", abstract="Background: The combination of the internet and healthcare has excellent benefits and far-reaching positive effects in improving service efficiency and promoting social equity. The role of the ``internet plus healthcare'' (IPHC) has been recognized, especially during the COVID-19 pandemic. This new healthcare model is also familiar to people and shows a bright prospect. Objective: This article seeks to accurately understand and fully grasp the characteristics of IPHC policies that can enlighten the formulation of future policies. Methods: The content analysis method was used to analyze China's IPHC policies collected from the Beida Fabao database and several official websites. Results: We found that the development of IPHC policy has gone through 4 stages and is currently entering a phase of rapid development. IPHC policymakers are primarily health administrative departments. In addition, policy instruments are classified into either supply, environment, or demand, and policy themes can be summarized into 4 categories: facilities, technology, service, and management. Conclusions: China's IPHC policy has good prospects from the perspective of development trends. The health administrative departments mainly lead the development of China's IPHC policy. It is suggested that these departments involve other stakeholders (ie, medical workers, medical industries, and technology sectors) in formulating policies. Policies prefer to use supply-based and environment-based policy instruments. The policy themes emphasize improving infrastructure construction and high-quality diagnostic and treatment services, strengthening the supporting role of information technology, and ensuring all stakeholders understand their responsibilities. ", doi="10.2196/23779", url="https://www.jmir.org/2021/7/e23779", url="http://www.ncbi.nlm.nih.gov/pubmed/34309581" } @Article{info:doi/10.2196/22330, author="Lai, Yunfeng and Chen, Shengqi and Li, Meng and Ung, Lam Carolina Oi and Hu, Hao", title="Policy Interventions, Development Trends, and Service Innovations of Internet Hospitals in China: Documentary Analysis and Qualitative Interview Study", journal="J Med Internet Res", year="2021", month="Jul", day="20", volume="23", number="7", pages="e22330", keywords="internet hospital", keywords="health policy", keywords="medical service", keywords="public hospital", keywords="digital health", keywords="China", abstract="Background: Internet hospitals have been encouraged by the Chinese government to develop an innovative medical service model that mainly uses new internet-based technologies to increase access to health care and improve the quality and efficiency of health care delivery. However, the academic exploration of the institutional and sectoral development of internet hospitals in China is scarce in the existing literature. Objective: This study aimed to investigate the policy interventions, development trends, and service innovations of internet hospitals in China. It is expected that the findings from this study will contribute to the further innovation of internet hospitals in China and provide references for the international development of internet hospitals for personalized digital health and patient-centric services. Methods: This study analyzed official policies related to internet hospitals that were implemented by the government in China since 2005. The data of formally approved internet hospitals were collected from official websites to analyze development trends. In-depth semistructured interviews were conducted with 58 key stakeholders who represented comprehensive viewpoints about the service innovations of internet hospitals between March and November 2019. Results: In total, 25 policies that promoted the development of internet hospitals in China were identified. These policies encompassed informatization infrastructure construction, medical resource integration, development model design, service model design, and payment model design. Of the 268 internet hospitals that had received an official license from the government, 153 public internet hospitals had been built mainly by medical institutions. Public tertiary hospitals were the main actors in founding internet hospitals that were created to provide services that targeted patients with common diseases or chronic diseases or patients living in remote and rural areas. Promoting convenient access to high-quality medical resources and saving patients' and their families' time were the key values of internet hospitals. Conclusions: The policy interventions strongly promoted the development of internet hospitals in China. Public tertiary hospitals led the development of internet hospitals. However, internet hospitals in China have mainly played roles that are complementary to those of physical medical institutions. The service model of internet hospitals needs more distinguished innovations to provide personalized digital health and patient-centric services. ", doi="10.2196/22330", url="https://www.jmir.org/2021/7/e22330", url="http://www.ncbi.nlm.nih.gov/pubmed/34283025" } @Article{info:doi/10.2196/25266, author="Schmit, Cason and Giannouchos, Theodoros and Ramezani, Mahin and Zheng, Qi and Morrisey, A. Michael and Kum, Hye-Chung", title="US Privacy Laws Go Against Public Preferences and Impede Public Health and Research: Survey Study", journal="J Med Internet Res", year="2021", month="Jul", day="5", volume="23", number="7", pages="e25266", keywords="privacy", keywords="law", keywords="medical informatics", keywords="conjoint analysis", keywords="surveys and questionnaires", keywords="public health", keywords="information dissemination", keywords="health policy", keywords="public policy", keywords="big data", abstract="Background: Reaping the benefits from massive volumes of data collected in all sectors to improve population health, inform personalized medicine, and transform biomedical research requires the delicate balance between the benefits and risks of using individual-level data. There is a patchwork of US data protection laws that vary depending on the type of data, who is using it, and their intended purpose. Differences in these laws challenge big data projects using data from different sources. The decisions to permit or restrict data uses are determined by elected officials; therefore, constituent input is critical to finding the right balance between individual privacy and public benefits. Objective: This study explores the US public's preferences for using identifiable data for different purposes without their consent. Methods: We measured data use preferences of a nationally representative sample of 504 US adults by conducting a web-based survey in February 2020. The survey used a choice-based conjoint analysis. We selected choice-based conjoint attributes and levels based on 5 US data protection laws (Health Insurance Portability and Accountability Act, Family Educational Rights and Privacy Act, Privacy Act of 1974, Federal Trade Commission Act, and the Common Rule). There were 72 different combinations of attribute levels, representing different data use scenarios. Participants were given 12 pairs of data use scenarios and were asked to choose the scenario they were the most comfortable with. We then simulated the population preferences by using the hierarchical Bayes regression model using the ChoiceModelR package in R. Results: Participants strongly preferred data reuse for public health and research than for profit-driven, marketing, or crime-detection activities. Participants also strongly preferred data use by universities or nonprofit organizations over data use by businesses and governments. Participants were fairly indifferent about the different types of data used (health, education, government, or economic data). Conclusions: Our results show a notable incongruence between public preferences and current US data protection laws. Our findings appear to show that the US public favors data uses promoting social benefits over those promoting individual or organizational interests. This study provides strong support for continued efforts to provide safe access to useful data sets for research and public health. Policy makers should consider more robust public health and research data use exceptions to align laws with public preferences. In addition, policy makers who revise laws to enable data use for research and public health should consider more comprehensive protection mechanisms, including transparent use of data and accountability. ", doi="10.2196/25266", url="https://www.jmir.org/2021/7/e25266", url="http://www.ncbi.nlm.nih.gov/pubmed/36260399" } @Article{info:doi/10.2196/25331, author="Iorfino, Frank and Occhipinti, Jo-An and Skinner, Adam and Davenport, Tracey and Rowe, Shelley and Prodan, Ante and Sturgess, Julie and Hickie, B. Ian", title="The Impact of Technology-Enabled Care Coordination in a Complex Mental Health System: A Local System Dynamics Model", journal="J Med Internet Res", year="2021", month="Jun", day="30", volume="23", number="6", pages="e25331", keywords="medical informatics", keywords="internet", keywords="care coordination", keywords="complex systems", keywords="simulation", keywords="health systems", keywords="policy", keywords="mental health", abstract="Background: Prior to the COVID-19 pandemic, major shortcomings in the way mental health care systems were organized were impairing the delivery of effective care. The mental health impacts of the pandemic, the recession, and the resulting social dislocation will depend on the extent to which care systems will become overwhelmed and on the strategic investments made across the system to effectively respond. Objective: This study aimed to explore the impact of strengthening the mental health system through technology-enabled care coordination on mental health and suicide outcomes. Methods: A system dynamics model for the regional population catchment of North Coast New South Wales, Australia, was developed that incorporated defined pathways from social determinants of mental health to psychological distress, mental health care, and suicidal behavior. The model reproduced historic time series data across a range of outcomes and was used to evaluate the relative impact of a set of scenarios on attempted suicide (ie, self-harm hospitalizations), suicide deaths, mental health--related emergency department (ED) presentations, and psychological distress over the period from 2021 to 2030. These scenarios include (1) business as usual, (2) increase in service capacity growth rate by 20\%, (3) standard telehealth, and (4) technology-enabled care coordination. Each scenario was tested using both pre-- and post--COVID-19 social and economic conditions. Results: Technology-enabled care coordination was forecast to deliver a reduction in self-harm hospitalizations and suicide deaths by 6.71\% (95\% interval 5.63\%-7.87\%), mental health--related ED presentations by 10.33\% (95\% interval 8.58\%-12.19\%), and the prevalence of high psychological distress by 1.76 percentage points (95\% interval 1.35-2.32 percentage points). Scenario testing demonstrated that increasing service capacity growth rate by 20\% or standard telehealth had substantially lower impacts. This pattern of results was replicated under post--COVID-19 conditions with technology-enabled care coordination being the only tested scenario, which was forecast to reduce the negative impact of the pandemic on mental health and suicide. Conclusions: The use of technology-enabled care coordination is likely to improve mental health and suicide outcomes. The substantially lower effectiveness of targeting individual components of the mental health system (ie, increasing service capacity growth rate by 20\% or standard telehealth) reiterates that strengthening the whole system has the greatest impact on patient outcomes. Investments into more of the same types of programs and services alone will not be enough to improve outcomes; instead, new models of care and the digital infrastructure to support them and their integration are needed. ", doi="10.2196/25331", url="https://www.jmir.org/2021/6/e25331", url="http://www.ncbi.nlm.nih.gov/pubmed/34077384" } @Article{info:doi/10.2196/26694, author="Persson, Johanna and Rydenf{\"a}lt, Christofer", title="Why Are Digital Health Care Systems Still Poorly Designed, and Why Is Health Care Practice Not Asking for More? Three Paths Toward a Sustainable Digital Work Environment", journal="J Med Internet Res", year="2021", month="Jun", day="22", volume="23", number="6", pages="e26694", keywords="digital systems", keywords="electronic health records", keywords="digital work environment", keywords="ergonomics", keywords="usability", keywords="human-centered design", doi="10.2196/26694", url="https://www.jmir.org/2021/6/e26694", url="http://www.ncbi.nlm.nih.gov/pubmed/34156336" } @Article{info:doi/10.2196/26391, author="Nichol, A. Ariadne and Batten, N. Jason and Halley, C. Meghan and Axelrod, K. Julia and Sankar, L. Pamela and Cho, K. Mildred", title="A Typology of Existing Machine Learning--Based Predictive Analytic Tools Focused on Reducing Costs and Improving Quality in Health Care: Systematic Search and Content Analysis", journal="J Med Internet Res", year="2021", month="Jun", day="22", volume="23", number="6", pages="e26391", keywords="machine learning", keywords="artificial intelligence", keywords="ethics", keywords="regulation", keywords="health care quality", keywords="costs", abstract="Background: Considerable effort has been devoted to the development of artificial intelligence, including machine learning--based predictive analytics (MLPA) for use in health care settings. The growth of MLPA could be fueled by payment reforms that hold health care organizations responsible for providing high-quality, cost-effective care. Policy analysts, ethicists, and computer scientists have identified unique ethical and regulatory challenges from the use of MLPA in health care. However, little is known about the types of MLPA health care products available on the market today or their stated goals. Objective: This study aims to better characterize available MLPA health care products, identifying and characterizing claims about products recently or currently in use in US health care settings that are marketed as tools to improve health care efficiency by improving quality of care while reducing costs. Methods: We conducted systematic database searches of relevant business news and academic research to identify MLPA products for health care efficiency meeting our inclusion and exclusion criteria. We used content analysis to generate MLPA product categories and characterize the organizations marketing the products. Results: We identified 106 products and characterized them based on publicly available information in terms of the types of predictions made and the size, type, and clinical training of the leadership of the companies marketing them. We identified 5 categories of predictions made by MLPA products based on publicly available product marketing materials: disease onset and progression, treatment, cost and utilization, admissions and readmissions, and decompensation and adverse events. Conclusions: Our findings provide a foundational reference to inform the analysis of specific ethical and regulatory challenges arising from the use of MLPA to improve health care efficiency. ", doi="10.2196/26391", url="https://www.jmir.org/2021/6/e26391", url="http://www.ncbi.nlm.nih.gov/pubmed/34156338" } @Article{info:doi/10.2196/23715, author="Archer, Norman and Lokker, Cynthia and Ghasemaghaei, Maryam and DiLiberto, Deborah", title="eHealth Implementation Issues in Low-Resource Countries: Model, Survey, and Analysis of User Experience", journal="J Med Internet Res", year="2021", month="Jun", day="18", volume="23", number="6", pages="e23715", keywords="eHealth", keywords="low-resource countries", keywords="eHealth implementation effectiveness", keywords="end user survey", keywords="eHealth utilization", abstract="Background: The implementation of eHealth in low-resource countries (LRCs) is challenged by limited resources and infrastructure, lack of focus on eHealth agendas, ethical and legal considerations, lack of common system interoperability standards, unreliable power, and shortage of trained workers. Objective: The aim of this study is to describe and study the current situation of eHealth implementation in a small number of LRCs from the perspectives of their professional eHealth users. Methods: We developed a structural equation model that reflects the opinions of professional eHealth users who work on LRC health care front lines. We recruited country coordinators from 4 LRCs to help recruit survey participants: India, Egypt, Nigeria, and Kenya. Through a web-based survey that focused on barriers to eHealth implementation, we surveyed 114 participants. We analyzed the information using a structural equation model to determine the relationships among the constructs in the model, including the dependent variable, eHealth utilization. Results: Although all the model constructs were important to participants, some constructs, such as user characteristics, perceived privacy, and perceived security, did not play a significant role in eHealth utilization. However, the constructs related to technology infrastructure tended to reduce the impact of concerns and uncertainties (path coefficient=?0.32; P=.001), which had a negative impact on eHealth utilization (path coefficient=?0.24; P=.01). Constructs that were positively related to eHealth utilization were implementation effectiveness (path coefficient=0.45; P<.001), the countries where participants worked (path coefficient=0.29; P=.004), and whether they worked for privately or publicly funded institutions (path coefficient=0.18; P<.001). As exploratory research, the model had a moderately good fit for eHealth utilization (adjusted R2=0.42). Conclusions: eHealth success factors can be categorized into 5 groups; our study focused on frontline eHealth workers' opinions concerning 2 of these groups: technology and its support infrastructure and user acceptance. We found significant disparities among the responses from different participant groups. Privately funded organizations tended to be further ahead with eHealth utilization than those that were publicly funded. Moreover, participant comments identified the need for more use of telemedicine in remote and rural regions in these countries. An understanding of these differences can help regions or countries that are lagging in the implementation and use of eHealth technologies. Our approach could also be applied to detailed studies of the other 3 categories of success factors: short- and long-term funding, organizational factors, and political or legislative aspects. ", doi="10.2196/23715", url="https://www.jmir.org/2021/6/e23715", url="http://www.ncbi.nlm.nih.gov/pubmed/34142967" } @Article{info:doi/10.2196/27345, author="Huang, Mian and Wang, Jian and Nicholas, Stephen and Maitland, Elizabeth and Guo, Ziyue", title="Development, Status Quo, and Challenges to China's Health Informatization During COVID-19: Evaluation and Recommendations", journal="J Med Internet Res", year="2021", month="Jun", day="17", volume="23", number="6", pages="e27345", keywords="health informatization", keywords="COVID-19", keywords="health policy", keywords="digital health", keywords="health information technology", keywords="China", doi="10.2196/27345", url="https://www.jmir.org/2021/6/e27345", url="http://www.ncbi.nlm.nih.gov/pubmed/34061761" } @Article{info:doi/10.2196/24601, author="Dang, Ha Thu and Nguyen, Anh Tuan and Hoang Van, Minh and Santin, Olinda and Tran, Thi Oanh Mai and Schofield, Penelope", title="Patient-Centered Care: Transforming the Health Care System in Vietnam With Support of Digital Health Technology", journal="J Med Internet Res", year="2021", month="Jun", day="4", volume="23", number="6", pages="e24601", keywords="building blocks", keywords="digital health", keywords="eHealth", keywords="patient-centered care", keywords="telemedicine", keywords="Vietnam", abstract="Background: Over the recent decades, Vietnam has attained remarkable achievements in all areas of health care. However, shortcomings including health disparities persist particularly with a rapidly aging population. This has resulted in a shift in the disease burden from communicable to noncommunicable diseases such as dementia, cancer, and diabetes. These medical conditions require long-term care, which causes an accelerating crisis for the health sector and society. The current health care system in Vietnam is unlikely to cope with these challenges. Objective: The aim of this paper was to explore the opportunities, challenges, and necessary conditions for Vietnam in transforming toward a patient-centered care model to produce better health for people and reduce health care costs. Methods: We examine the applicability of a personalized and integrated Bespoke Health Care System (BHS) for Vietnam using a strength, weakness, opportunity, and threat analysis and examining the successes or failures of digital health care innovations in Vietnam. We then make suggestions for successful adoption of the BHS model in Vietnam. Results: The BHS model of patient-centered care empowers patients to become active participants in their own health care. Vietnam's current policy, social, technological, and economic environment favors the transition of its health care system toward the BHS model. Nevertheless, the country is in an early stage of health care digitalization. The legal and regulatory system to protect patient privacy and information security is still lacking. The readiness to implement electronic medical records, a core element of the BHS, varies across health providers and clinical practices. The scarcity of empirical evidence and evaluation regarding the effectiveness and sustainability of digital health initiatives is an obstacle to the Vietnamese government in policymaking, development, and implementation of health care digitalization. Conclusions: Implementing a personalized and integrated health care system may help Vietnam to address health care needs, reduce pressure on the health care system and society, improve health care delivery, and promote health equity. However, in order to adopt the patient-centered care system and digitalized health care, a whole-system approach in transformation and operation with a co-design in the whole span of a digital health initiative developing process are necessary. ", doi="10.2196/24601", url="https://www.jmir.org/2021/6/e24601", url="http://www.ncbi.nlm.nih.gov/pubmed/34085939" } @Article{info:doi/10.2196/26402, author="Montazeri, Maryam and Multmeier, Jan and Novorol, Claire and Upadhyay, Shubhanan and Wicks, Paul and Gilbert, Stephen", title="Optimization of Patient Flow in Urgent Care Centers Using a Digital Tool for Recording Patient Symptoms and History: Simulation Study", journal="JMIR Form Res", year="2021", month="May", day="21", volume="5", number="5", pages="e26402", keywords="symptom assessment app", keywords="discrete event simulation", keywords="health care system", keywords="patient flow modeling", keywords="patient flow", keywords="simulation", keywords="urgent care", keywords="waiting times", abstract="Background: Crowding can negatively affect patient and staff experience, and consequently the performance of health care facilities. Crowding can potentially be eased through streamlining and the reduction of duplication in patient history-taking through the use of a digital symptom-taking app. Objective: We simulated the introduction of a digital symptom-taking app on patient flow. We hypothesized that waiting times and crowding in an urgent care center (UCC) could be reduced, and that this would be more efficient than simply adding more staff. Methods: A discrete-event approach was used to simulate patient flow in a UCC during a 4-hour time frame. The baseline scenario was a small UCC with 2 triage nurses, 2 doctors, 1 treatment/examination nurse, and 1 discharge administrator in service. We simulated 33 scenarios with different staff numbers or different potential time savings through the app. We explored average queue length, waiting time, idle time, and staff utilization for each scenario. Results: Discrete-event simulation showed that even a few minutes saved through patient app-based self-history recording during triage could result in significantly increased efficiency. A modest estimated time saving per patient of 2.5 minutes decreased the average patient wait time for triage by 26.17\%, whereas a time saving of 5 minutes led to a 54.88\% reduction in patient wait times. Alternatively, adding an additional triage nurse was less efficient, as the additional staff were only required at the busiest times. Conclusions: Small time savings in the history-taking process have potential to result in substantial reductions in total patient waiting time for triage nurses, with likely effects of reduced patient anxiety, staff anxiety, and improved patient care. Patient self-history recording could be carried out at home or in the waiting room via a check-in kiosk or a portable tablet computer. This formative simulation study has potential to impact service provision and approaches to digitalization at scale. ", doi="10.2196/26402", url="https://formative.jmir.org/2021/5/e26402", url="http://www.ncbi.nlm.nih.gov/pubmed/34018963" } @Article{info:doi/10.2196/27340, author="Gillan, Caitlin and Hodges, Brian and Wiljer, David and Dobrow, Mark", title="Health Care Professional Association Agency in Preparing for Artificial Intelligence: Protocol for a Multi-Case Study", journal="JMIR Res Protoc", year="2021", month="May", day="19", volume="10", number="5", pages="e27340", keywords="artificial intelligence", keywords="health professions", keywords="normalization process theory", keywords="case study", abstract="Background: The emergence of artificial intelligence (AI) in health care has impacted health care systems, including employment, training, education, and professional regulation. It is incumbent on health professional associations to assist their membership in defining and preparing for AI-related change. Health professional associations, or the national groups convened to represent the interests of the members of a profession, play a unique role in establishing the sociocultural, normative, and regulative elements of health care professions. Objective: The aim of this paper is to present a protocol for a proposed study of how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice. Methods: An exploratory multi-case study approach will be used. This study will be informed by the normalization process theory (NPT), which suggests behavioral constructs required for complex change, providing a novel lens through which to consider the agency of macrolevel actors in practice change. A total of 4 health professional associations will be studied, each representing an instrumental case and related fields selected for their early consideration of AI technologies. Data collection will consist of key informant interviews, observation of relevant meetings, and document review. Individual and collective sensemaking activities and action toward change will be identified using stakeholder network mapping. A hybrid inductive and deductive model will be used for a concurrent thematic analysis, mapping emergent themes against the NPT framework to assess fit and identify areas of discordance. Results: As of January 2021, we have conducted 17 interviews, with representation across the 4 health professional associations. Of these 17 interviews, 15 (88\%) have been transcribed. Document review is underway and complete for one health professional association and nearly complete for another. Observation opportunities have been challenged by competing priorities during COVID-19 and may require revisiting. A linear cross-case analytic approach will be taken to present the data, highlighting both guidance for the implementation of AI and implications for the application of NPT at the macro level. The ability to inform consideration of AI will depend on the degree to which the engaged health professional associations have considered this topic at the time of the study and, hence, what priority it has been assigned within the health professional association and what actions have been taken to consider or prepare for it. The fact that this may differ between health professional associations and practice environments will require consideration throughout the analysis. Conclusions: Ultimately, this protocol outlines a case study approach to understand how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice. International Registered Report Identifier (IRRID): DERR1-10.2196/27340 ", doi="10.2196/27340", url="https://www.researchprotocols.org/2021/5/e27340", url="http://www.ncbi.nlm.nih.gov/pubmed/34009136" } @Article{info:doi/10.2196/25547, author="Lal, Shalini and Siafa, Lyna and Lee, Hajin and Adair, E. Carol", title="Priority Given to Technology in Government-Based Mental Health and Addictions Vision and Strategy Documents: Systematic Policy Review", journal="J Med Internet Res", year="2021", month="May", day="5", volume="23", number="5", pages="e25547", keywords="e-mental health", keywords="digital mental health", keywords="virtual care", keywords="technology", keywords="mental health", keywords="addictions", keywords="review", keywords="policy", keywords="e-health", keywords="mHealth", keywords="digital health", keywords="tele", abstract="Background: The use of information and communication technologies (ICTs) to deliver mental health and addictions (MHA) services is a global priority, especially considering the urgent shift towards virtual delivery of care in response to the COVID-19 pandemic. It is important to monitor the evolving role of technology in MHA services. Given that MHA policy documents represent the highest level of priorities for a government's vision and strategy for mental health care, one starting point is to measure the frequency with which technology is mentioned and the terms used to describe its use in MHA policy documents (before, during, and after COVID-19). Yet, to our knowledge, no such review of the extent to which ICTs are referred to in Canadian MHA policy documents exists to date. Objective: The objective of this systematic policy review was to examine the extent to which technology is addressed in Canadian government--based MHA policy documents prior to the COVID-19 pandemic to establish a baseline for documenting change. Methods: We reviewed 22 government-based MHA policy documents, published between 2011 and 2019 by 13 Canadian provinces and territories. We conducted content analysis to synthesize the policy priorities addressed in these documents into key themes, and then systematically searched for and tabulated the use of 39 technology-related keywords (in English and French) to describe and compare jurisdictions. Results: Technology was addressed in every document, however, to a varying degree. Of the 39 searched keywords, we identified 22 categories of keywords pertaining to the use of technology to deliver MHA services and information. The 6 most common categories were tele (n=16/22), phone (n=12/22), tech (n=11/22), online (n=10/22), line (n=10/22), and web (n=10/22), with n being the number of policy documents in which the category was mentioned out of 22 documents. The use of terms referring to advanced technologies, such as virtual (n=6/22) and app (n= 4/22), were less frequent. Additionally, policy documents from some provinces and territories (eg, Alberta and Newfoundland and Labrador) mentioned a diverse range of ICTs, whereas others described only 1 form of ICT. Conclusions: This review indicates that technology has been given limited strategic attention in Canadian MHA policy. Policy makers may have limited knowledge on the evidence and potential of using technology in this field, highlighting the value for knowledge translation and collaborative initiatives among policy makers and researchers. The development of a pan-Canadian framework for action addressing the integration and coordination of technology in mental health services can also guide initiatives in this field. Our findings provide a prepandemic baseline and replicable methods to monitor how the use of technology-supported services and innovations emerge relative to other priorities in MHA policy during and after the COVID-19 pandemic. ", doi="10.2196/25547", url="https://www.jmir.org/2021/5/e25547", url="http://www.ncbi.nlm.nih.gov/pubmed/33949955" } @Article{info:doi/10.2196/23914, author="Kazevman, Gill and Mercado, Marck and Hulme, Jennifer and Somers, Andrea", title="Prescribing Phones to Address Health Equity Needs in the COVID-19 Era: The PHONE-CONNECT Program", journal="J Med Internet Res", year="2021", month="Apr", day="6", volume="23", number="4", pages="e23914", keywords="digital health equity", keywords="health inequity", keywords="digital determinants of health", keywords="emergency medicine", keywords="COVID-19", keywords="public health", keywords="health policy", keywords="primary care", keywords="cell phone", doi="10.2196/23914", url="https://www.jmir.org/2021/4/e23914", url="http://www.ncbi.nlm.nih.gov/pubmed/33760753" } @Article{info:doi/10.2196/17456, author="Zegers, L. Catharina M. and Witteveen, Annemieke and Schulte, J. Mieke H. and Henrich, F. Julia and Vermeij, Anouk and Klever, Brigit and Dekker, Andre", title="Mind Your Data: Privacy and Legal Matters in eHealth", journal="JMIR Form Res", year="2021", month="Mar", day="17", volume="5", number="3", pages="e17456", keywords="data", keywords="privacy", keywords="eHealth", doi="10.2196/17456", url="https://formative.jmir.org/2021/3/e17456", url="http://www.ncbi.nlm.nih.gov/pubmed/33729163" } @Article{info:doi/10.2196/23306, author="Esdar, Moritz and H{\"u}bner, Ursula and Thye, Johannes and Babitsch, Birgit and Liebe, Jan-David", title="The Effect of Innovation Capabilities of Health Care Organizations on the Quality of Health Information Technology: Model Development With Cross-sectional Data", journal="JMIR Med Inform", year="2021", month="Mar", day="15", volume="9", number="3", pages="e23306", keywords="organizational innovation", keywords="health information management", keywords="organizational culture", keywords="diffusion of innovation", keywords="hospital information systems", keywords="organizational change management", abstract="Background: Large health organizations often struggle to build complex health information technology (HIT) solutions and are faced with ever-growing pressure to continuously innovate their information systems. Limited research has been conducted that explores the relationship between organizations' innovative capabilities and HIT quality in the sense of achieving high-quality support for patient care processes. Objective: The aim of this study is to explain how core constructs of organizational innovation capabilities are linked to HIT quality based on a conceptual sociotechnical model on innovation and quality of HIT, called the IQHIT model, to help determine how better information provision in health organizations can be achieved. Methods: We designed a survey to assess various domains of HIT quality, innovation capabilities of health organizations, and context variables and administered it to hospital chief information officers across Austria, Germany, and Switzerland. Data from 232 hospitals were used to empirically fit the model using partial least squares structural equation modeling to reveal associations and mediating and moderating effects. Results: The resulting empirical IQHIT model reveals several associations between the analyzed constructs, which can be summarized in 2 main insights. First, it illustrates the linkage between the constructs measuring HIT quality by showing that the professionalism of information management explains the degree of HIT workflow support (R{\texttwosuperior}=0.56), which in turn explains the perceived HIT quality (R{\texttwosuperior}=0.53). Second, the model shows that HIT quality was positively influenced by innovation capabilities related to the top management team, the information technology department, and the organization at large. The assessment of the model's statistical quality criteria indicated valid model specifications, including sufficient convergent and discriminant validity for measuring the latent constructs that underlie the measures of HIT quality and innovation capabilities. Conclusions: The proposed sociotechnical IQHIT model points to the key role of professional information management for HIT workflow support in patient care and perceived HIT quality from the viewpoint of hospital chief information officers. Furthermore, it highlights that organizational innovation capabilities, particularly with respect to the top management team, facilitate HIT quality and suggests that health organizations establish this link by applying professional information management practices. The model may serve to stimulate further scientific work in the field of HIT adoption and diffusion and to provide practical guidance to managers, policy makers, and educators on how to achieve better patient care using HIT. ", doi="10.2196/23306", url="https://medinform.jmir.org/2021/3/e23306", url="http://www.ncbi.nlm.nih.gov/pubmed/33720029" } @Article{info:doi/10.2196/24122, author="Rizvi, Rubina and VanHouten, Courtney and Bright, J. Tiffani and McKillop, M. Mollie and Alevy, Shira and Brotman, David and Sands-Lincoln, Megan and Snowdon, Jane and Robinson, J. Barbie and Staats, Carolyn and Jackson, P. Gretchen and Kassler, J. William", title="The Perceived Impact and Usability of a Care Management and Coordination System in Delivering Services to Vulnerable Populations: Mixed Methods Study", journal="J Med Internet Res", year="2021", month="Mar", day="12", volume="23", number="3", pages="e24122", keywords="vulnerable population", keywords="managed care", keywords="data integration", keywords="advanced technologies", keywords="usability", keywords="mixed methods study", abstract="Background: People with complex needs, such as those experiencing homelessness, require concurrent, seamless support from multiple social service agencies. Sonoma County, California has one of the nation's largest homeless populations among largely suburban communities. To support client-centered care, the county deployed a Care Management and Coordination System (CMCS). This system comprised the Watson Care Manager (WCM), a front-end system, and Connect 360, which is an integrated data hub that aggregates information from various systems into a single client record. Objective: The aim of this study is to evaluate the perceived impact and usability of WCM in delivering services to the homeless population in Sonoma County. Methods: A mixed methods study was conducted to identify ways in which WCM helps to coordinate care. Interviews, observations, and surveys were conducted, and transcripts and field notes were thematically analyzed and directed by a grounded theory approach. Responses to the Technology Acceptance Model survey were analyzed. Results: A total of 16 participants were interviewed, including WCM users (n=8) and department leadership members (n=8). In total, 3 interdisciplinary team meetings were observed, and 8 WCM users were surveyed. WCM provided a central shared platform where client-related, up-to-date, comprehensive, and reliable information from participating agencies was consolidated. Factors that facilitated WCM use were users' enthusiasm regarding the tool functionalities, scalability, and agency collaboration. Constraining factors included the suboptimal awareness of care delivery goals and functionality of the system among the community, sensitivities about data sharing and legal requirements, and constrained funding from government and nongovernment organizations. Overall, users found WCM to be a useful tool that was easy to use and helped to enhance performance. Conclusions: WCM supports the delivery of care to individuals with complex needs. Integration of data and information in a CMCS can facilitate coordinated care. Future research should examine WCM and similar CMCSs in diverse populations and settings. ", doi="10.2196/24122", url="https://www.jmir.org/2021/3/e24122", url="http://www.ncbi.nlm.nih.gov/pubmed/33709928" } @Article{info:doi/10.2196/23951, author="Kanfe, G. Shuma and Endehabtu, F. Berhanu and Ahmed, H. Mohammedjud and Mengestie, D. Nebyu and Tilahun, Binyam", title="Commitment Levels of Health Care Providers in Using the District Health Information System and the Associated Factors for Decision Making in Resource-Limited Settings: Cross-sectional Survey Study", journal="JMIR Med Inform", year="2021", month="Mar", day="4", volume="9", number="3", pages="e23951", keywords="commitment", keywords="district health information system", keywords="decision making", keywords="performance monitoring", keywords="health facilities", keywords="information use", abstract="Background: Changing the culture of information use, which is one of the transformation agendas of the Ministry of Health of Ethiopia, cannot become real unless health care providers are committed to using locally collected data for evidence-based decision making. The commitment of health care providers has paramount influence on district health information system 2 (DHIS2) data utilization for decision making. Evidence is limited on health care providers' level of commitment to using DHIS2 data in Ethiopia. Therefore, this study aims to fill this evidence gap. Objective: This study aimed to assess the levels of commitment of health care providers and the factors influencing their commitment levels in using DHIS2 data for decision making at public health care facilities in the Ilu Aba Bora zone of the Oromia national regional state, Ethiopia in 2020. Methods: The cross-sectional quantitative study supplemented by qualitative methods was conducted from February 26, 2020 to April 17, 2020. A total of 264 participants were approached. SPSS version 20 software was used for data entry and analysis. Descriptive and analytical statistics, including bivariable and multivariable analyses, were performed. Thematic analysis was conducted for the qualitative data. Results: Of the 264 respondents, 121 (45.8\%, 95\% CI 40.0\%-52.8\%) respondents showed high commitment levels to use DHIS2 data. The variables associated with the level of commitment to use DHIS2 data were found to be provision of feedback for DHIS2 data use (adjusted odds ratio [AOR] 1.85, 95\% CI 1.02-3.33), regular supervision and managerial support (AOR 2.84, 95\% CI 1.50-5.37), information use culture (AOR 1.92, 95\% CI 1.03-3.59), motivation to use DHIS2 data (AOR 1.80, 95\% CI 1.00-3.25), health needs (AOR 3.96, 95\% CI 2.11-7.41), and competency in DHIS2 tasks (AOR 2.41, 95\% CI 1.27-4.55). Conclusions: In general, less than half of the study participants showed high commitment levels to use DHIS2 data for decision making in health care. Providing regular supportive supervision and feedback and increasing the motivation and competency of the health care providers in performing DHIS2 data tasks will help in promoting their levels of commitment that can result in the cultural transformation of data use for evidence-based decision making in health care. ", doi="10.2196/23951", url="https://medinform.jmir.org/2021/3/e23951", url="http://www.ncbi.nlm.nih.gov/pubmed/33661133" } @Article{info:doi/10.2196/18590, author="Thapa, Subash and Nielsen, Bo Jesper and Aldahmash, M. Abdullah and Qadri, R. Fatima and Leppin, Anja", title="Willingness to Use Digital Health Tools in Patient Care Among Health Care Professionals and Students at a University Hospital in Saudi Arabia: Quantitative Cross-sectional Survey", journal="JMIR Med Educ", year="2021", month="Feb", day="19", volume="7", number="1", pages="e18590", keywords="attitude", keywords="digital health", keywords="electronic medical record", keywords="health care professionals", keywords="health care students", keywords="Saudi Arabia", keywords="self-efficacy", keywords="telemedicine", keywords="willingness to use", abstract="Background: The adoption rate of digital health in the health care sector is low in many countries. A facilitating factor for successful implementation and adoption of digital health is acceptance by current and future health care professionals. Objective: This study was conducted to identify factors associated with willingness to use digital health tools in patient care among health care professionals and students. Methods: This was a quantitative cross-sectional survey study conducted among health care professionals and students at a university hospital in Riyadh, Saudi Arabia. A nonprobability convenience sampling procedure was used to recruit participants. Data were collected using a self-completed e-questionnaire that was distributed by email. Chi-square tests, t tests, and logistic regression were used to analyze the data. Results: We found that 181 out of 218 health care professionals (83.0\%; 75.6\% [59/78] physicians; 87.1\% [122/140] nurses) and 115 out of 154 students (74.7\%; 80.0\% [76/95] medical students and 66.1\% [39/59] nursing students) were willing to use digital tools in patient care. Willingness to use digital tools was significantly associated with attitude (Adjusted Odds Ratios [AOR] 1.96; 95\% CI 1.14-3.36) and self-efficacy (AOR 1.64; 95\% CI 1.17-2.30) among health care professionals, and with current year of study (AOR 2.08; 95\% CI 1.18-3.68) and self-efficacy (AOR 1.77; 95\% CI 1.17-2.69) among students. No significant difference in willingness to use digital tools was found between physicians and nurses (P=.113), and between medical and nursing students (P=.079). Conclusions: The findings of this study should encourage policy makers and hospital managers to implement relevant eHealth interventions within routine health care systems in Saudi Arabia. For successful implementation, digital health education programs should be implemented simultaneously, so that current and future health care professionals are able to develop required positive attitudes as well as practical skills and competencies. ", doi="10.2196/18590", url="http://mededu.jmir.org/2021/1/e18590/", url="http://www.ncbi.nlm.nih.gov/pubmed/33605896" } @Article{info:doi/10.2196/24813, author="Liang, Jun and Li, Ying and Zhang, Zhongan and Shen, Dongxia and Xu, Jie and Zheng, Xu and Wang, Tong and Tang, Buzhou and Lei, Jianbo and Zhang, Jiajie", title="Adoption of Electronic Health Records (EHRs) in China During the Past 10 Years: Consecutive Survey Data Analysis and Comparison of Sino-American Challenges and Experiences", journal="J Med Internet Res", year="2021", month="Feb", day="18", volume="23", number="2", pages="e24813", keywords="medical informatics", keywords="health information technologies", keywords="electronic health records", keywords="hospitals", keywords="Sino-American", abstract="Background: The adoption rate of electronic health records (EHRs) in hospitals has become a main index to measure digitalization in medicine in each country. Objective: This study summarizes and shares the experiences with EHR adoption in China and in the United States. Methods: Using the 2007-2018 annual hospital survey data from the Chinese Health Information Management Association (CHIMA) and the 2008-2017 United States American Hospital Association Information Technology Supplement survey data, we compared the trends in EHR adoption rates in China and the United States. We then used the Bass model to fit these data and to analyze the modes of diffusion of EHRs in these 2 countries. Finally, using the 2007, 2010, and 2014 CHIMA and Healthcare Information and Management Systems Services survey data, we analyzed the major challenges faced by hospitals in China and the United States in developing health information technology. Results: From 2007 to 2018, the average adoption rates of the sampled hospitals in China increased from 18.6\% to 85.3\%, compared to the increase from 9.4\% to 96\% in US hospitals from 2008 to 2017. The annual average adoption rates in Chinese and US hospitals were 6.1\% and 9.6\%, respectively. However, the annual average number of hospitals adopting EHRs was 1500 in China and 534 in the US, indicating that the former might require more effort. Both countries faced similar major challenges for hospital digitalization. Conclusions: The adoption rates of hospital EHRs in China and the United States have both increased significantly in the past 10 years. The number of hospitals that adopted EHRs in China exceeded 16,000, which was 3.3 times that of the 4814 nonfederal US hospitals. This faster adoption outcome may have been a benefit of top-level design and government-led policies, particularly the inclusion of EHR adoption as an important indicator for performance evaluation and the appointment of public hospitals. ", doi="10.2196/24813", url="http://www.jmir.org/2021/2/e24813/", url="http://www.ncbi.nlm.nih.gov/pubmed/33599615" } @Article{info:doi/10.2196/19651, author="Yang, Qian and Tai-Seale, Ming and Liu, Stephanie and Shen, Yi and Zhang, Xiaobin and Xiao, Xiaohua and Zhang, Kejun", title="Measuring Public Reaction to Violence Against Doctors in China: Interrupted Time Series Analysis of Media Reports", journal="J Med Internet Res", year="2021", month="Feb", day="16", volume="23", number="2", pages="e19651", keywords="violence against doctors", keywords="government intervention", keywords="public opinion", keywords="patient--physician relationship", abstract="Background: Violence against doctors in China is a serious problem that has attracted attention from both domestic and international media. Objective: This study investigates readers' responses to media reports on violence against doctors to identify attitudes toward perpetrators and physicians and examine if such trends are influenced by national policies. Methods: We searched 17 Chinese violence against doctors reports in international media sources from 2011 to 2020. We then tracked back the original reports and web crawled the 19,220 comments in China. To ascertain the possible turning point of public opinion, we searched violence against doctors--related policies from Tsinghua University ipolicy database from 2011 to 2020, and found 19 policies enacted by the Chinese central government aimed at alleviating the intense patient--physician relationship. We then conducted a series of interrupted time series analyses to examine the influence of these policies on public sentiment toward violence against doctors over time. Results: The interrupted time series analysis (ITSA) showed that the change in public sentiment toward violence against doctors reports was temporally associated with government interventions. The declarations of 10 of the public policies were followed by increases in the proportion of online public opinion in support of doctors (average slope changes of 0.010, P<.05). A decline in the proportion of online public opinion that blamed doctors (average level change of --0.784, P<.05) followed the declaration of 3 policies. Conclusions: The government's administrative interventions effectively shaped public opinion but only temporarily. Continued public policy interventions are needed to sustain the reduction of hostility toward medical doctors. ", doi="10.2196/19651", url="http://www.jmir.org/2021/2/e19651/", url="http://www.ncbi.nlm.nih.gov/pubmed/33591282" } @Article{info:doi/10.2196/25495, author="Laukka, Elina and P{\"o}lkki, Tarja and Heponiemi, Tarja and Kaihlanen, Anu-Marja and Kanste, Outi", title="Leadership in Digital Health Services: Protocol for a Concept Analysis", journal="JMIR Res Protoc", year="2021", month="Feb", day="4", volume="10", number="2", pages="e25495", keywords="health care", keywords="leadership", keywords="health services", keywords="concept analysis", keywords="telehealth", abstract="Background: Due to the rapid digitalization of health care, leadership is becoming more complex. Leadership in digital health services is a term that has been used in the literature with various meanings. Conceptualization of leadership in digital health services is needed to deliver higher quality digital health services, update existing leadership practices, and advance research. Objective: The aim of this study is to outline a concept analysis that aims to clarify and define the concept of leadership in digital health services. Methods: The concept analysis will be performed using the Walker and Avant model, which involves eight steps: concept selection, determination of aims, identification of uses, determination of defining attributes, construction of a model case, construction of additional cases, identification of antecedents and consequences, and definition of empirical referents. A scoping literature search will be performed following the search protocol for scoping reviews by the Joanna Briggs Institute to identify all relevant literature on leadership in digital health services. Searches will be conducted in 6 scientific databases (CINAHL, MEDLINE, Scopus, ProQuest, Web of Science, and the Finnish database Medic), and unpublished studies and gray literature will be searched using Google Scholar, EBSCO Open Dissertations, and MedNar. Results: An initial limited search of MEDLINE was undertaken on October 19, 2020, resulting in 883 records. The results of the concept analysis will be submitted for publication by July 2021. Conclusions: A robust conceptualization of leadership in digital health services is needed to support research, leadership, and education. The concept analysis model of Walker and Avant will be used to meet this need. As leadership in digital health services appears to be an interprofessional and intersectoral collaboration, defining this concept may also facilitate collaboration between professionals and sectors. The concept analysis to be conducted will also expand our understanding of leadership in digital health services. International Registered Report Identifier (IRRID): PRR1-10.2196/25495 ", doi="10.2196/25495", url="http://www.researchprotocols.org/2021/2/e25495/", url="http://www.ncbi.nlm.nih.gov/pubmed/33538702" } @Article{info:doi/10.2196/23562, author="Xu, Xin and Hu, Jiming and Lyu, Xiaoguang and Huang, He and Cheng, Xingyu", title="Exploring the Interdisciplinary Nature of Precision Medicine?Network Analysis and Visualization", journal="JMIR Med Inform", year="2021", month="Jan", day="11", volume="9", number="1", pages="e23562", keywords="precision medicine", keywords="interdisciplinary", keywords="social network analysis", keywords="co-occurrence analysis", abstract="Background: Interdisciplinary research is an important feature of precision medicine. However, the accurate cross-disciplinary status of precision medicine is still unclear. Objective: The aim of this study is to present the nature of interdisciplinary collaboration in precision medicine based on co-occurrences and social network analysis. Methods: A total of 7544 studies about precision medicine, published between 2010 and 2019, were collected from the Web of Science database. We analyzed interdisciplinarity with descriptive statistics, co-occurrence analysis, and social network analysis. An evolutionary graph and strategic diagram were created to clarify the development of streams and trends in disciplinary communities. Results: The results indicate that 105 disciplines are involved in precision medicine research and cover a wide range. However, the disciplinary distribution is unbalanced. Current cross-disciplinary collaboration in precision medicine mainly focuses on clinical application and technology-associated disciplines. The characteristics of the disciplinary collaboration network are as follows: (1) disciplinary cooperation in precision medicine is not mature or centralized; (2) the leading disciplines are absent; (3) the pattern of disciplinary cooperation is mostly indirect rather than direct. There are 7 interdisciplinary communities in the precision medicine collaboration network; however, their positions in the network differ. Community 4, with disciplines such as genetics and heredity in the core position, is the most central and cooperative discipline in the interdisciplinary network. This indicates that Community 4 represents a relatively mature direction in interdisciplinary cooperation in precision medicine. Finally, according to the evolution graph, we clearly present the development streams of disciplinary collaborations in precision medicine. We describe the scale and the time frame for development trends and distributions in detail. Importantly, we use evolution graphs to accurately estimate the developmental trend of precision medicine, such as biological big data processing, molecular imaging, and widespread clinical applications. Conclusions: This study can help researchers, clinicians, and policymakers comprehensively understand the overall network of interdisciplinary cooperation in precision medicine. More importantly, we quantitatively and precisely present the history of interdisciplinary cooperation and accurately predict the developing trends of interdisciplinary cooperation in precision medicine. ", doi="10.2196/23562", url="http://medinform.jmir.org/2021/1/e23562/", url="http://www.ncbi.nlm.nih.gov/pubmed/33427681" } @Article{info:doi/10.2196/16268, author="Mallidou, Anastasia and Dordunoo, Dzifa and Borycki, Elizabeth and Kushniruk, Andre and Sadeghi-Yekta, Kirsten and Fraser, Julie and Asuri, Sirisha", title="Perspectives and Experiences of Policy Makers, Researchers, Health Information Technology Professionals, and the Public on Evidence-Based Health Policies: Protocol for a Qualitative Study", journal="JMIR Res Protoc", year="2020", month="Dec", day="17", volume="9", number="12", pages="e16268", keywords="evidence-based health policy", keywords="knowledge translation", keywords="transparency", keywords="policy makers", keywords="researchers", keywords="knowledge producers", keywords="health information technology", abstract="Background: Evidence-based health policy (EBHP) development is critical to the judicious use of public funds. EBHPs increase transparency, accountability, effectiveness, and efficiency of policies. Encouraging collaboration between researchers or knowledge producers and policy makers is important because both communities have distinct professional cultures, resulting in them working separately without understanding each other. Knowledge sharing is a complex process that requires understanding of cultural aspects that may reduce cultural differences and increase the use of common language. Health information technology (HIT) is a useful tool to increase knowledge translation, which may result in the transparent use of evidence and networking in developing EBHPs. Our vision is to leverage HIT tools for a better health system that includes digitalized, open source, evidence-based, and transparent ways for collaboration and development of robust mechanisms and for sharing of synthesized evidence with knowledge user--friendly forms. Objective: The aim of this study is to develop a conceptual framework on Knowledge translation and health Information Technology for Transparency (KhITT) in policy making and EBHPs (ie, the KhITT framework). The framework will be informed by the views of four key stakeholder groups (ie, policy makers, knowledge producers, HIT professionals, and the public) toward EBHP. The informants may also describe practices that demonstrate the EBHP development process and suggest technology platforms to enable this process. Methods: We propose an exploratory, descriptive qualitative study to take place in British Columbia, Canada, using in-depth semistructured interviews. To ensure data saturation and trustworthiness, we will use a nonprobability, purposive snowball sample of up to 15 eligible participants in each of the four stakeholder groups. We will analyze the data using content analysis. Results: The KhITT framework focuses on various stakeholders' perspectives to better understand their perceived needs and priorities in identifying issues with EBHP, in order to make informed recommendations. Ethics approval has been obtained by the harmonized Behavioural Research Ethics Board at the University of British Columbia. We anticipate that we will complete data collection and analysis by December 2020. Preliminary results will be published in summer 2021. Conclusions: Our ultimate goal of this study is to develop a conceptual framework and describe the technology platforms that would enable the EBHP process. We anticipate that our rigorous content analysis will be able to produce insights and themes that are able to address our objectives, contribute to an in-depth understanding of the EBHP process within British Columbia, highlight all influential factors, explicitly disseminate and communicate the study results, identify issues with EBHP and provide informed recommendations to address them, and enhance efforts toward transparent EBHPs. International Registered Report Identifier (IRRID): PRR1-10.2196/16268 ", doi="10.2196/16268", url="http://www.researchprotocols.org/2020/12/e16268/", url="http://www.ncbi.nlm.nih.gov/pubmed/33331825" } @Article{info:doi/10.2196/18666, author="Sugawara, Yuya and Murakami, Masayasu and Narimatsu, Hiroto", title="Use of Social Media by Hospitals and Clinics in Japan: Descriptive Study", journal="JMIR Med Inform", year="2020", month="Nov", day="27", volume="8", number="11", pages="e18666", keywords="social media", keywords="internet", keywords="hospitals", keywords="health promotion", keywords="Japan", abstract="Background: The use of social media by hospitals has become widespread in the United States and Western European countries. However, in Japan, the extent to which hospitals and clinics use social media is unknown. Furthermore, recent revisions to the Medical Care Act may subject social media content to regulation. Objective: The purpose of this study was to examine social media use in Japanese hospitals and clinics. We investigated the adoption of social media, analyzed social media content, and compared content with medical advertising guidelines. Methods: We randomly sampled 300 hospitals and 300 clinics from a list of medical institutions that was compiled by the Ministry of Health, Labour and Welfare. We performed web and social media (Facebook and Twitter) searches using the hospital and clinic names to determine whether they had social media accounts. We collected Facebook posts and Twitter tweets and categorized them based on their content (eg, health promotion, participation in academic meetings and publications, public relations or news announcements, and recruitment). We compared the collected content with medical advertising guidelines. Results: We found that 26.0\% (78/300) of the hospitals and 7.7\% (23/300) of the clinics used Facebook, Twitter, or both. Public relations or news announcements accounted for 53.99\% (724/1341) of the Facebook posts by hospitals and 58.4\% (122/209) of the Facebook posts by clinics. In hospitals, 16/1341 (1.19\%) Facebook posts and 6/574 (1.0\%) tweets and in clinics, 8/209 (3.8\%) Facebook posts and 15/330 (4.5\%) tweets could conflict medical advertising guidelines. Conclusions: Fewer hospitals and clinics in Japan use social media as compared to other countries. Social media were mainly used for public relations. Some content disseminated by medical institutions could conflict with medical advertising guidelines. This study may serve as a reference for medical institutions to guide social media usage and may help improve medical website advertising in Japan. ", doi="10.2196/18666", url="https://medinform.jmir.org/2020/11/e18666", url="http://www.ncbi.nlm.nih.gov/pubmed/33245281" } @Article{info:doi/10.2196/23353, author="Sragow, Michael Howard and Bidell, Eileen and Mager, Douglas and Grannis, Shaun", title="Universal Patient Identifier and Interoperability for Detection of Serious Drug Interactions: Retrospective Study", journal="JMIR Med Inform", year="2020", month="Nov", day="20", volume="8", number="11", pages="e23353", keywords="patient identification", keywords="pharmacy benefit manager", keywords="interoperability", keywords="adverse drug event", keywords="identity management", keywords="identifier", keywords="pharmacy", keywords="pharmaceuticals", keywords="drug", abstract="Background: The United States, unlike other high-income countries, currently has no national unique patient identifier to facilitate health information exchange. Because of security and privacy concerns, Congress, in 1998, prevented the government from promulgating a unique patient identifier. The Health and Human Services funding bill that was enacted in 2019 requires that Health and Human Services report their recommendations on patient identification to Congress. While there are anecdotes of incomplete health care data due to patient misidentification, to date there have been insufficient large-scale analyses measuring improvements to patient care that a unique patient identifier might provide. This lack of measurement has made it difficult for policymakers to balance security and privacy concerns against the value of potential improvements. Objective: We sought to determine the frequency of serious drug-drug interaction alerts discovered because a pharmacy benefits manager uses a universal patient identifier and estimate undiscovered serious drug-drug interactions because pharmacy benefit managers do not yet fully share patient records. Methods: We conducted a retrospective study of serious drug-drug interaction alerts provided from September 1, 2016 to August 31, 2019 to retail pharmacies by a national pharmacy benefit manager that uses a unique patient identifier. We compared each alert to the contributing prescription and determined whether the unique patient identifier was necessary in order to identify the crossover alert. We classified each alert's disposition as override, abandonment, or replacement. Using the crossover alert rate and sample population size, we inferred a rate of missing serious drug-drug interaction alerts for the United States. We performed logistic regression in order to identify factors correlated with crossover and alert outcomes. Results: Among a population of 49.7 million patients, 242,646 serious drug-drug interaction alerts occurred in 3 years. Of these, 2388 (1.0\%) crossed insurance and were discovered because the pharmacy benefit manager used a unique patient identifier. We estimate that up to 10\% of serious drug-drug alerts in the United States go undetected by pharmacy benefit managers because of unexchanged information or pharmacy benefit managers that do not use a unique patient identifier. These information gaps may contribute, annually, to up to 6000 patients in the United States receiving a contraindicated medication. Conclusions: Comprehensive patient identification across disparate data sources can help protect patients from serious drug-drug interactions. To better safeguard patients, providers should (1) adopt a comprehensive patient identification strategy and (2) share patient prescription history to improve clinical decision support. ", doi="10.2196/23353", url="http://medinform.jmir.org/2020/11/e23353/", url="http://www.ncbi.nlm.nih.gov/pubmed/33216009" } @Article{info:doi/10.2196/18156, author="Margineanu, Ioana and Louka, Christina and Vincenti-Gonzalez, Maria and Saktiawati, Iswari Antonia Morita and Schierle, Johannes and Abass, Mohammed Kabiru and Akkerman, Onno and Alffenaar, Jan-Willem and Ranchor, V. Adelita and Stienstra, Ymkje", title="Patients and Medical Staff Attitudes Toward the Future Inclusion of eHealth in Tuberculosis Management: Perspectives From Six Countries Evaluated using a Qualitative Framework", journal="JMIR Mhealth Uhealth", year="2020", month="Nov", day="2", volume="8", number="11", pages="e18156", keywords="eHealth", keywords="tuberculosis", keywords="policy", keywords="clinical", keywords="patient", keywords="perspective", abstract="Background: Digitally delivering healthcare services is very attractive for tuberculosis (TB) management as this disease has a complex diagnosis and lengthy management and involves multiple medical and nonmedical specialists. Especially in low- and middle-income countries, eHealth could potentially offer cost-effective solutions to bridge financial, social, time, and distance challenges. Objective: The goal of the research is to understand what would make eHealth globally applicable and gain insight into different TB situations, opportunities, and challenges. Methods: We performed focus group interviews with TB experts and patients from 6 different countries on 4 different continents. The focus group interviews followed the theory of planned behavior framework to offer structured recommendations for a versatile eHealth solution. The focus group interviews were preceded by a general demographic and technology use questionnaire. Questionnaire results were analyzed using basic statistics in Excel (Microsoft Corporation). Focus group interview data were analyzed using ATLAS.ti 8 (ATLAS.ti Scientific Software Development GmbH) by assigning codes to quotations and grouping codes into the 5 domains within the framework. Results: A total of 29 patients and 32 medical staff members were included in our study. All medical staff had used the internet, whereas 31\% (9/61) of patients had never been online. The codes with the most quotations were information in relation to eHealth (144 quotations) and communication (67 quotations). The consensus among all participants from all countries is that there are important communication and information gaps that could be bridged by an eHealth app. Participants from different countries also highlighted different challenges, such as a majority of asylum-seeker patients or lack of infrastructure that could be addressed with an eHealth app. Conclusions: Within the 6 countries interviewed, there is high enthusiasm toward eHealth in TB. A potential app could first target information and communication gaps in TB, with additional modules aimed at setting-specific challenges. ", doi="10.2196/18156", url="https://mhealth.jmir.org/2020/11/e18156", url="http://www.ncbi.nlm.nih.gov/pubmed/33136052" } @Article{info:doi/10.2196/17214, author="Ekeland, Granstrom Anne and Linstad, Helen Line", title="Elaborating Models of eHealth Governance: Qualitative Systematic Review", journal="J Med Internet Res", year="2020", month="Oct", day="28", volume="22", number="10", pages="e17214", keywords="digital transformations in health care", keywords="health policy goals", keywords="national and international governance models", abstract="Background: Large-scale national eHealth policy programs have gained attention not only for benefits but also for several unintended consequences and failed expectations. Given the complex and mixed accounts of the results, questions have been raised on how large-scale digitalization programs are governed to reach health policy goals of quality improvement and equal access along with necessary digital transformations. In this qualitative systematic review, we investigate the following question: How is governance implemented and considered in the studies included in the qualitative review? Objective: The aim of this study is to arrive at informed and recognizable conceptualizations and considerations of models of governance connected to eHealth, as presented and discussed in the scientific literature. In turn, we hope our results will help inform the discussion of how to govern such processes to obtain collectively negotiated objectives. Methods: A qualitative systematic review is a method for integrating or comparing with the findings from qualitative studies. It looks for ``themes'' or ``constructs'' that lie in or across individual qualitative studies. This type of review produces a narrative synthesis with thematic analysis and includes interpretive conceptual models. The goal is an interpretation and broadens the understanding of a particular phenomenon. We searched the PubMed database using predefined search terms and selected papers published from 2010 onwards. We specified the criteria for selection and quality assessment. Results: The search returned 220 papers. We selected 44 abstracts for full-text reading, and 11 papers were included for full-text synthesis. On the basis of the 11 papers, we constructed four governance models to categorize and conceptualize the findings. The models are political governance, normally depicting top-down processes; medical governance, which normally depicts bottom-up processes; the internet and global model, emphasizing international business strategies coupled with the internet; self-governance, which builds upon the development of the internet and Internet of Things, which has paved the way for personal governance and communication of one's own health data. Conclusions: Collective negotiations between the nation-state and global policy actors, medical and self-governance actors, and global business and industry actors are essential. Technological affordances represent both positive and negative opportunities concerning the realization of health policy goals, and future studies should scrutinize this dynamic. ", doi="10.2196/17214", url="http://www.jmir.org/2020/10/e17214/", url="http://www.ncbi.nlm.nih.gov/pubmed/33112247" } @Article{info:doi/10.2196/20482, author="Alon, Noy and Stern, Dora Ariel and Torous, John", title="Assessing the Food and Drug Administration's Risk-Based Framework for Software Precertification With Top Health Apps in the United States: Quality Improvement Study", journal="JMIR Mhealth Uhealth", year="2020", month="Oct", day="26", volume="8", number="10", pages="e20482", keywords="mobile health", keywords="smartphone", keywords="Food and Drug Administration", keywords="software", keywords="mobile phone", abstract="Background: As the development of mobile health apps continues to accelerate, the need to implement a framework that can standardize the categorization of these apps to allow for efficient yet robust regulation is growing. However, regulators and researchers are faced with numerous challenges, as apps have a wide variety of features, constant updates, and fluid use cases for consumers. As past regulatory efforts have failed to match the rapid innovation of these apps, the US Food and Drug Administration (FDA) has proposed that the Software Precertification (Pre-Cert) Program and a new risk-based framework could be the solution. Objective: This study aims to determine whether the risk-based framework proposed by the FDA's Pre-Cert Program could standardize categorization of top health apps in the United States. Methods: In this quality improvement study during summer 2019, the top 10 apps for 6 disease conditions (addiction, anxiety, depression, diabetes, high blood pressure, and schizophrenia) in Apple iTunes and Android Google Play Store in the United States were classified using the FDA's risk-based framework. Data on the presence of well-defined app features, user engagement methods, popularity metrics, medical claims, and scientific backing were collected. Results: The FDA's risk-based framework classifies an app's risk by the disease condition it targets and what information that app provides. Of the 120 apps tested, 95 apps were categorized as targeting a nonserious health condition, whereas only 7 were categorized as targeting a serious condition and 18 were categorized as targeting a critical condition. As the majority of apps targeted a nonserious condition, their risk categorization was largely determined by the information they provided. The apps that were assessed as not requiring FDA review were more likely to be associated with the integration of external devices than those assessed as requiring FDA review (15/58, 26\% vs 5/62, 8\%; P=.03) and health information collection (24/58, 41\% vs 9/62, 15\%; P=.008). Apps exempt from the review were less likely to offer health information (25/58, 43\% vs 45/62, 72\%; P<.001), to connect users with professional care (7/58, 12\% vs 14/62, 23\%; P=.04), and to include an intervention (8/58, 14\% vs 35/62, 55\%; P<.001). Conclusions: The FDA's risk-based framework has the potential to improve the efficiency of the regulatory review process for health apps. However, we were unable to identify a standard measure that differentiated apps requiring regulatory review from those that would not. Apps exempt from the review also carried concerns regarding privacy and data security. Before the framework is used to assess the need for a formal review of digital health tools, further research and regulatory guidance are needed to ensure that the Pre-Cert Program operates in the greatest interest of public health. ", doi="10.2196/20482", url="http://mhealth.jmir.org/2020/10/e20482/", url="http://www.ncbi.nlm.nih.gov/pubmed/32927429" } @Article{info:doi/10.2196/18426, author="Cui, Fangfang and Ma, Qianqian and He, Xianying and Zhai, Yunkai and Zhao, Jie and Chen, Baozhan and Sun, Dongxu and Shi, Jinming and Cao, Mingbo and Wang, Zhenbo", title="Implementation and Application of Telemedicine in China: Cross-Sectional Study", journal="JMIR Mhealth Uhealth", year="2020", month="Oct", day="23", volume="8", number="10", pages="e18426", keywords="telemedicine", keywords="Chinese hospital", keywords="implementation", keywords="application", keywords="influencing factors", abstract="Background: Telemedicine has been used widely in China and has benefited a large number of patients, but little is known about the overall development of telemedicine. Objective: The aim of this study was to perform a national survey to identify the overall implementation and application of telemedicine in Chinese tertiary hospitals and provide a scientific basis for the successful expansion of telemedicine in the future. Methods: The method of probability proportionate to size sampling was adopted to collect data from 161 tertiary hospitals in 29 provinces, autonomous regions, and municipalities. Charts and statistical tests were applied to compare the development of telemedicine, including management, network, data storage, software and hardware equipment, and application of telemedicine. Ordinal logistic regression was used to analyze the relationship between these factors and telemedicine service effect. Results: Approximately 93.8\% (151/161) of the tertiary hospitals carried out telemedicine services in business-to-business mode. The most widely used type of telemedicine network was the virtual private network with a usage rate of 55.3\% (89/161). Only a few tertiary hospitals did not establish data security and cybersecurity measures. Of the 161 hospitals that took part in the survey, 100 (62.1\%) conducted remote videoconferencing supported by hardware instead of software. The top 5 telemedicine services implemented in the hospitals were teleconsultation, remote education, telediagnosis of medical images, tele-electrocardiography, and telepathology, with coverage rates of 86.3\% (139/161), 57.1\% (92/161), 49.7\% (80/161), 37.9\% (61/161), and 33.5\% (54/161), respectively. The average annual service volume of teleconsultation reached 714 cases per hospital. Teleconsultation and telediagnosis were the core charging services. Multivariate analysis indicated that the adoption of direct-to-consumer mode (P=.003), support from scientific research funds (P=.01), charging for services (P<.001), number of medical professionals (P=.04), network type (P=.02), sharing data with other hospitals (P=.04), and expertise level (P=.03) were related to the effect of teleconsultation. Direct-to-consumer mode (P=.01), research funding (P=.01), charging for services (P=.01), establishment of professional management departments (P=.04), and 15 or more instances of remote education every month (P=.01) were found to significantly influence the effect of remote education. Conclusions: A variety of telemedicine services have been implemented in tertiary hospitals in China with a promising prospect, but the sustainability and further standardization of telemedicine in China are still far from accomplished. ", doi="10.2196/18426", url="http://mhealth.jmir.org/2020/10/e18426/", url="http://www.ncbi.nlm.nih.gov/pubmed/33095175" } @Article{info:doi/10.2196/16835, author="Casillas, Alejandra and Abhat, Anshu and Mahajan, Anish and Moreno, Gerardo and Brown, F. Arleen and Simmons, Sara and Szilagyi, Peter", title="Portals of Change: How Patient Portals Will Ultimately Work for Safety Net Populations", journal="J Med Internet Res", year="2020", month="Oct", day="23", volume="22", number="10", pages="e16835", keywords="patient portal", keywords="safety net", keywords="health disparities", keywords="digital divide", doi="10.2196/16835", url="https://www.jmir.org/2020/10/e16835", url="http://www.ncbi.nlm.nih.gov/pubmed/33094732" } @Article{info:doi/10.2196/19542, author="Azodo, Ijeoma and Williams, Robin and Sheikh, Aziz and Cresswell, Kathrin", title="Opportunities and Challenges Surrounding the Use of Data From Wearable Sensor Devices in Health Care: Qualitative Interview Study", journal="J Med Internet Res", year="2020", month="Oct", day="22", volume="22", number="10", pages="e19542", keywords="wearable sensor devices", keywords="health care", keywords="data", keywords="qualitative", abstract="Background: Wearable sensors connected via networked devices have the potential to generate data that may help to automate processes of care, engage patients, and increase health care efficiency. The evidence of effectiveness of such technologies is, however, nascent and little is known about unintended consequences. Objective: Our objective was to explore the opportunities and challenges surrounding the use of data from wearable sensor devices in health care. Methods: We conducted a qualitative, theoretically informed, interview-based study to purposefully sample international experts in health care, technology, business, innovation, and social sciences, drawing on sociotechnical systems theory. We used in-depth interviews to capture perspectives on development, design, and use of data from wearable sensor devices in health care, and employed thematic analysis of interview transcripts with NVivo to facilitate coding. Results: We interviewed 16 experts. Although the use of data from wearable sensor devices in health and care has significant potential in improving patient engagement, there are a number of issues that stakeholders need to negotiate to realize these benefits. These issues include the current gap between data created and meaningful interpretation in health and care contexts, integration of data into health care professional decision making, negotiation of blurring lines between consumer and medical care, and pervasive monitoring of health across previously disconnected contexts. Conclusions: Stakeholders need to actively negotiate existing challenges to realize the integration of data from wearable sensor devices into electronic health records. Viewing wearables as active parts of a connected digital health and care infrastructure, in which various business, personal, professional, and health system interests align, may help to achieve this. ", doi="10.2196/19542", url="http://www.jmir.org/2020/10/e19542/", url="http://www.ncbi.nlm.nih.gov/pubmed/33090107" } @Article{info:doi/10.2196/18801, author="Yang Meier, Dong and Barthelmess, Petra and Sun, Wei and Liberatore, Florian", title="Wearable Technology Acceptance in Health Care Based on National Culture Differences: Cross-Country Analysis Between Chinese and Swiss Consumers", journal="J Med Internet Res", year="2020", month="Oct", day="22", volume="22", number="10", pages="e18801", keywords="wearables", keywords="health care wearables", keywords="wearables acceptance", keywords="cross culture", keywords="national culture", keywords="Chinese", keywords="Swiss", keywords="moderator", keywords="digital health", keywords="health technology acceptance", keywords="smartwatch", abstract="Background: The advancement of wearable devices and growing demand of consumers to monitor their own health have influenced the medical industry. Health care providers, insurers, and global technology companies intend to develop more wearable devices incorporating medical technology and to target consumers worldwide. However, acceptance of these devices varies considerably among consumers of different cultural backgrounds. Consumer willingness to use health care wearables is influenced by multiple factors that are of varying importance in various cultures. However, there is insufficient knowledge of the extent to which social and cultural factors affect wearable technology acceptance in health care. Objective: The aims of this study were to examine the influential factors on the intention to adopt health care wearables, and the differences in the underlying motives and usage barriers between Chinese and Swiss consumers. Methods: A new model for acceptance of health care wearables was conceptualized by incorporating predictors of different theories such as technology acceptance, health behavior, and privacy calculus based on an existing framework. To verify the model, a web-based survey in both the Chinese and German languages was conducted in China and Switzerland, resulting in 201 valid Chinese and 110 valid Swiss respondents. A multigroup partial least squares path analysis was applied to the survey data. Results: Performance expectancy ($\beta$=.361, P<.001), social influence ($\beta$=.475, P<.001), and hedonic motivation ($\beta$=.111, P=.01) all positively affected the behavioral intention of consumers to adopt wearables, whereas effort expectancy, functional congruence, health consciousness, and perceived privacy risk did not demonstrate a significant impact on behavioral intention. The group-specific path coefficients indicated health consciousness ($\beta$=.150, P=.01) as a factor positively affecting only the behavior intention of the Chinese respondents, whereas the factors affecting only the behavioral intention of the Swiss respondents proved to be effort expectancy ($\beta$=.165, P=.02) and hedonic motivation ($\beta$=.212, P=.02). Performance expectancy asserted more of an influence on the behavioral intention of the Swiss ($\beta$=.426, P<.001) than the Chinese ($\beta$=.271, P<.001) respondents, whereas social influence had a greater influence on the behavioral intention of the Chinese ($\beta$=.321, P<.001) than the Swiss ($\beta$=.217, P=.004) respondents. Overall, the Chinese consumers displayed considerably higher behavioral intention (P<.001) than the Swiss. These discrepancies are explained by differences in national culture. Conclusions: This is one of the first studies to investigate consumers' intention to adopt wearables from a cross-cultural perspective. This provides a theoretical and methodological foundation for future research, as well as practical implications for global vendors and insurers developing and promoting health care wearables with appropriate features in different countries. The testimonials and support by physicians, evidence of measurement accuracy, and easy handling of health care wearables would be useful in promoting the acceptance of wearables in Switzerland. The opinions of in-group members, involvement of employers, and multifunctional apps providing credible health care advice and solutions in cooperation with health care institutions would increase acceptance among the Chinese. ", doi="10.2196/18801", url="http://www.jmir.org/2020/10/e18801/", url="http://www.ncbi.nlm.nih.gov/pubmed/33090108" } @Article{info:doi/10.2196/18148, author="van Lieshout, Florence and Yang, Rebecca and Stamenova, Vess and Agarwal, Payal and Cornejo Palma, Daniel and Sidhu, Aman and Engel, Katrina and Erwood, Adam and Bhatia, Sacha R. and Bhattacharyya, Onil and Shaw, James", title="Evaluating the Implementation of a Remote-Monitoring Program for Chronic Obstructive Pulmonary Disease: Qualitative Methods from a Service Design Perspective", journal="J Med Internet Res", year="2020", month="Oct", day="9", volume="22", number="10", pages="e18148", keywords="service design", keywords="digital health", keywords="innovation", keywords="implementation science", keywords="remote monitoring", keywords="telemedicine", abstract="Background: Implementing digital health technologies is complex but can be facilitated by considering the features of the tool that is being implemented, the team that will use it, and the routines that will be affected. Objective: The goal of this study was to assess the implementation of a remote-monitoring initiative for patients with chronic obstructive pulmonary disease in Ontario, Canada using the Tool+Team+Routine framework and to refine this approach to conceptualize the adoption of technologies in health care. Methods: This study was a qualitative research project that took place alongside a randomized controlled trial comparing a technology-enabled self-monitoring program with a technology-enabled self- and remote-monitoring program in patients with chronic obstructive pulmonary disease and with standard care. This study included interviews with 5 remote-monitoring patients, 3 self-monitoring patients, 2 caregivers, 5 health care providers, and 3 hospital administrators. The interview questions were structured around the 3 main concepts of the Tool+Team+Routine framework. Results: Findings emphasized that (1) technologies can alter relationships between providers and patients, and that these relationships drove the development of a new service arising from the technology, in our case, and (2) technologies can create additional work that is not visible to management as a result of not being considered within the scope of the service. Conclusions: Literature on the implementation of digital health technologies has still not reconciled the importance of interpersonal relationships to conventional implementation strategies. By acknowledging the centrality of such relationships, implementation teams can better plan for the adaptations required in order to make new technologies work for patients and health care providers. Further work will need to address how specific individuals administering a remote-monitoring program work to build relationships, and how these relationships and other sources of activity might lead to technological scope creep---an unanticipated expanding scope of work activities in relation to the function of the tool. ", doi="10.2196/18148", url="https://www.jmir.org/2020/10/e18148", url="http://www.ncbi.nlm.nih.gov/pubmed/33034565" } @Article{info:doi/10.2196/20406, author="Szczepura, Ala and Holliday, Nikki and Neville, Catriona and Johnson, Karen and Khan, Khan Amir Jahan and Oxford, W. Samuel and Nduka, Charles", title="Raising the Digital Profile of Facial Palsy: National Surveys of Patients' and Clinicians' Experiences of Changing UK Treatment Pathways and Views on the Future Role of Digital Technology", journal="J Med Internet Res", year="2020", month="Oct", day="5", volume="22", number="10", pages="e20406", keywords="Bell palsy", keywords="facial nerve paralysis", keywords="patient experience", keywords="treatment pathway", keywords="facial exercise therapy", keywords="neuromuscular retraining", keywords="treatment adherence", keywords="digital technology", keywords="outcome measures", keywords="telerehabilitation", keywords="biosensors", keywords="COVID-19", abstract="Background: Facial nerve palsy leaves people unable to move muscles on the affected side of their face. Challenges exist in patients accessing facial neuromuscular retraining (NMR), a therapy used to strengthen muscle and improve nerve function. Access to therapy could potentially be improved through the use of digital technology. However, there is limited research available on patients' and clinicians' views about the potential benefits of such telerehabilitation based on their lived experiences of treatment pathways. Objective: This study aims to gather information about facial palsy treatment pathways in the United Kingdom, barriers to accessing NMR, factors influencing patient adherence, measures used to monitor recovery, and the potential value of emerging wearable digital technology. Methods: Separate surveys of patients with facial palsy and facial therapy specialists were conducted. Questionnaires explored treatment pathways and views on telerehabilitation, were co-designed with users, and followed a similar format to enable cross-referencing of responses. A follow-up survey of national specialists investigated methods used to monitor recovery in greater detail. Analysis of quantitative data was conducted allowing for data distribution. Open-text responses were analyzed using thematic content analysis. Results: A total of 216 patients with facial palsy and 25 specialist therapists completed the national surveys. Significant variations were observed in individual treatment pathways. Patients reported an average of 3.27 (SD 1.60) different treatments provided by various specialists, but multidisciplinary team reviews were rare. For patients diagnosed most recently, there was evidence of more rapid initial prescribing of corticosteroids (prednisolone) and earlier referral for NMR therapy. Barriers to NMR referral included difficulties accessing funding, shortage of specialist therapists, and limited awareness of NMR among general practitioners. Patients traveled long distances to reach an NMR specialist center; 9\% (8/93) of adults reported traveling ?115 miles. The thematic content analysis demonstrates positive attitudes to the introduction of digital technology, with similar incentives and barriers identified by both patients and clinicians. The follow-up survey of 28 specialists uncovered variations in the measures currently used to monitor recovery and no agreed definitions of a clinically significant change for any of these. The main barriers to NMR adherence identified by patients and therapists could all be addressed by using suitable real-time digital technology. Conclusions: The study findings provide valuable information on facial palsy treatment pathways and views on the future introduction of digital technology. Possible ways in which emerging sensor-based digital technology can improve rehabilitation and provide more rigorous evidence on effectiveness are described. It is suggested that one legacy of the COVID-19 pandemic will be lower organizational barriers to this introduction of digital technology to assist NMR delivery, especially if cost-effectiveness can be demonstrated. ", doi="10.2196/20406", url="https://www.jmir.org/2020/10/e20406", url="http://www.ncbi.nlm.nih.gov/pubmed/32763890" } @Article{info:doi/10.2196/19415, author="Salisbury, Chris and Quigley, Anna and Hex, Nick and Aznar, Camille", title="Private Video Consultation Services and the Future of Primary Care", journal="J Med Internet Res", year="2020", month="Oct", day="1", volume="22", number="10", pages="e19415", keywords="remote consultation", keywords="primary health care", keywords="general practice", keywords="delivery of health care", keywords="access to health care", keywords="mobile phone", doi="10.2196/19415", url="https://www.jmir.org/2020/10/e19415", url="http://www.ncbi.nlm.nih.gov/pubmed/32812887" } @Article{info:doi/10.2196/19644, author="Cresswell, Kathrin and Williams, Robin and Carlile, Narath and Sheikh, Aziz", title="Accelerating Innovation in Health Care: Insights From a Qualitative Inquiry Into United Kingdom and United States Innovation Centers", journal="J Med Internet Res", year="2020", month="Sep", day="25", volume="22", number="9", pages="e19644", keywords="innovation", keywords="health information technology", keywords="health care", abstract="Background: Digital health innovations are being prioritized on international policy agendas in the hope that they will help to address the existing health system challenges. Objective: The aim of this study was to explore the setup, design, facilities, and strategic priorities of leading United Kingdom and United States health care innovation centers to identify transferable lessons for accelerating their creation and maximizing their impact. Methods: We conducted qualitative case studies consisting of semistructured, audio-recorded interviews with decision makers and center staff in 6 innovation centers. We also conducted nonparticipant observations of meetings and center tours, where we took field notes. Qualitative data were analyzed initially within and then across cases facilitated by QSR International's NVivo software. Results: The centers had different institutional arrangements, including university-associated institutes or innovation laboratories, business accelerators or incubators, and academic health science partnership models. We conducted interviews with 34 individuals, 1 group interview with 3 participants, and observations of 4 meetings. Although the centers differed significantly in relation to their mission, structure, and governance, we observed key common characteristics. These included high-level leadership support and incentives to engage in innovation activities, a clear mission to address identified gaps within their respective organizational and health system settings, physical spaces that facilitated networking through open-door policies, flat managerial structures characterized by new organizational roles for which boundary spanning was key, and a wider innovation ecosystem that was strategically and proactively engaged with the center facilitating external partnerships. Conclusions: Although innovation in health care settings is unpredictable, we offer insights that may help those establishing innovation centers. The key in this respect is the ability to support different kinds of innovations at different stages through adequate support structures, including the development of new career pathways. ", doi="10.2196/19644", url="http://www.jmir.org/2020/9/e19644/", url="http://www.ncbi.nlm.nih.gov/pubmed/32975524" } @Article{info:doi/10.2196/16444, author="Heidel, Alexandra and Hagist, Christian", title="Potential Benefits and Risks Resulting From the Introduction of Health Apps and Wearables Into the German Statutory Health Care System: Scoping Review", journal="JMIR Mhealth Uhealth", year="2020", month="Sep", day="23", volume="8", number="9", pages="e16444", keywords="health apps", keywords="wearables", keywords="digital health application", keywords="mHealth", abstract="Background: Germany is the first country worldwide that has introduced a digital care act as an incentive system to enhance the use of digital health devices, namely health apps and wearables, among its population. The act allows physicians to prescribe statutory financed and previously certified health apps and wearables to patients. This initiative has the potential to improve treatment quality through better disease management and monitoring. Objective: The aim of this paper was to outline the key concepts related to the potential risks and benefits discussed in the current literature about health apps and wearables. Furthermore, this study aimed to answer the research question: Which risks and benefits may result from the implementation of the digital care act in Germany? Methods: We conducted the scoping study by searching the databases PubMed, Google Scholar, and JMIR using the keywords health apps and wearables. We discussed 55 of 136 identified articles published in the English language from 2015 to March 2019 in this paper using a qualitative thematic analysis approach. Results: We identified four key themes within the articles: Effectivity of health apps and wearables to improve health; users of health apps and wearables; the potential of bring-your-own, self-tracked data; and concerns and data privacy risks. Within these themes, we identified three main stages of benefits for the German health care system: Usage of health apps and wearables; continuing to use health apps and wearables; and sharing bring-your-own; self-tracked data with different agents in the health care sector. Conclusions: The digital care act could lead to an improvement in treatment quality through better patient monitoring, disease management, personalized therapy, and better health education. However, physicians should play an active role in recommendingand supervising health app use to reach digital-illiterate or health-illiterate people. Age must not be an exclusion criterion. Yet, concerns about data privacy and security are very strong in Germany. Transparency about data processing should be provided at all times for continuing success of the digital care act in Germany. ", doi="10.2196/16444", url="http://mhealth.jmir.org/2020/9/e16444/", url="http://www.ncbi.nlm.nih.gov/pubmed/32965231" } @Article{info:doi/10.2196/19923, author="Dang, Huyen and Dao, Sang and Carnahan, Emily and Kawakyu, Nami and Duong, Hong and Nguyen, Trung and Nguyen, Doan and Nguyen, Linh and Rivera, Maya and Ngo, Tuan and Werner, Laurie and Nguyen, Nga", title="Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation", journal="J Med Internet Res", year="2020", month="Sep", day="22", volume="22", number="9", pages="e19923", keywords="immunization", keywords="immunization information system", keywords="electronic immunization registry", keywords="scale-up", keywords="digital health intervention", keywords="mHealth", keywords="eHealth", abstract="Background: Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam's National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries. Objective: The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam. Methods: This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the ``axes of scale,'' to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation. Results: The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up. Conclusions: The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations. ", doi="10.2196/19923", url="http://www.jmir.org/2020/9/e19923/", url="http://www.ncbi.nlm.nih.gov/pubmed/32960184" } @Article{info:doi/10.2196/21691, author="Kazi, Momin Abdul and Qazi, Ahmed Saad and Ahsan, Nazia and Khawaja, Sadori and Sameen, Fareeha and Saqib, Muhammad and Khan Mughal, Ayub Muhammad and Wajidali, Zabin and Ali, Sikander and Ahmed, Moueed Rao and Kalimuddin, Hussain and Rauf, Yasir and Mahmood, Fatima and Zafar, Saad and Abbasi, Ahmad Tufail and Khoumbati, Khalil-Ur-Rahmen and Abbasi, A. Munir and Stergioulas, K. Lampros", title="Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis", journal="J Med Internet Res", year="2020", month="Sep", day="3", volume="22", number="9", pages="e21691", keywords="digital health", keywords="eHealth", keywords="LMICs", keywords="mHealth", keywords="Pakistan", keywords="SWOT", keywords="telehealth", abstract="Background: Digital health is well-positioned in low and middle-income countries (LMICs) to revolutionize health care due, in part, to increasing mobile phone access and internet connectivity. This paper evaluates the underlying factors that can potentially facilitate or hinder the progress of digital health in Pakistan. Objective: The objective of this study is to identify the current digital health projects and studies being carried out in Pakistan, as well as the key stakeholders involved in these initiatives. We aim to follow a mixed-methods strategy and to evaluate these projects and studies through a strengths, weaknesses, opportunities, and threats (SWOT) analysis to identify the internal and external factors that can potentially facilitate or hinder the progress of digital health in Pakistan. Methods: This study aims to evaluate digital health projects carried out in the last 5 years in Pakistan with mixed methods. The qualitative and quantitative data obtained from field surveys were categorized according to the World Health Organization's (WHO) recommended building blocks for health systems research, and the data were analyzed using a SWOT analysis strategy. Results: Of the digital health projects carried out in the last 5 years in Pakistan, 51 are studied. Of these projects, 46\% (23/51) used technology for conducting research, 30\% (15/51) used technology for implementation, and 12\% (6/51) used technology for app development. The health domains targeted were general health (23/51, 46\%), immunization (13/51, 26\%), and diagnostics (5/51, 10\%). Smartphones and devices were used in 55\% (28/51) of the interventions, and 59\% (30/51) of projects included plans for scaling up. Artificial intelligence (AI) or machine learning (ML) was used in 31\% (16/51) of projects, and 74\% (38/51) of interventions were being evaluated. The barriers faced by developers during the implementation phase included the populations' inability to use the technology or mobile phones in 21\% (11/51) of projects, costs in 16\% (8/51) of projects, and privacy concerns in 12\% (6/51) of projects. Conclusions: We conclude that while digital health has a promising future in Pakistan, it is still in its infancy at the time of this study. However, due to the coronavirus disease 2019 (COVID-19) pandemic, there is an increase in demand for digital health and implementation of health outcomes following global social distancing protocols, especially in LMICs. Hence, there is a need for active involvement by public and private organizations to regulate, mobilize, and expand the digital health sector for the improvement of health care systems in countries. ", doi="10.2196/21691", url="https://www.jmir.org/2020/9/e21691", url="http://www.ncbi.nlm.nih.gov/pubmed/32880584" } @Article{info:doi/10.2196/18780, author="Li, Yazi and Lu, Chunji and Liu, Yang", title="Medical Insurance Information Systems in China: Mixed Methods Study", journal="JMIR Med Inform", year="2020", month="Sep", day="1", volume="8", number="9", pages="e18780", keywords="medical insurance", keywords="medical insurance information system", keywords="health information exchange", keywords="information infrastructure", keywords="big data", keywords="policy review", keywords="privacy protection", abstract="Background: Since the People's Republic of China (PRC), or China, established the basic medical insurance system (MIS) in 1998, the medical insurance information systems (MIISs) in China have effectively supported the operation of the MIS through several phases of development; the phases included a stand-alone version, the internet, and big data. In 2018, China's national medical security systems were integrated, while MIISs were facing reconstruction. We summarized China's experience in medical insurance informatization over the past 20 years, aiming to provide a reference for the building of a new basic MIS for China and for developing countries. Objective: This paper aims to sort out medical insurance informatization policies throughout the years, use questionnaires to determine the status quo of provincial MIIS-building in China and the relevant policies, provide references and suggestions for the top-level design and implementation of the information systems in the transitional period of China's MIS reform, and provide a reference for the building of MIISs in developing countries. Methods: We conducted policy analysis by collecting the laws, regulations, and policy documents---issued from 1998 to 2020---on China's medical insurance and its informatization; we also analyzed the US Health Insurance Portability and Accountability Act and other relevant policies. We conducted a questionnaire survey by sending out questionnaires to 31 Chinese, provincial, medical security bureaus to collect information about network links, system functions, data exchange, standards and specifications, and building modes, among other items. We conducted a literature review by searching for documents about relevant laws and policies, building methods, application results, and other documents related to MIISs; we conducted searches using PubMed, Elsevier, China National Knowledge Infrastructure, and other major literature databases. We conducted telephone interviews to verify the results of questionnaires and to understand the focus issues concerning the building of China's national MIISs during the period of integration and transition of China's MIS. Results: In 74\% (23/31) of the regions in China, MIISs were networked through dedicated fiber optic lines. In 65\% (20/31) of the regions in China, MIISs supported identity recognition based on both ID cards and social security cards. In 55\% (17/31) of the regions in China, MIISs at provincial and municipal levels were networked and have gathered basic medical insurance data, whereas MIISs were connected to health insurance companies in 35\% (11/31) of the regions in China. China's MIISs are comprised of 11 basic functional modules, among which the modules of business operation, transregional referral, reimbursement, and monitoring systems are widely applied. MIISs in 83\% (20/24) of Chinese provinces have stored data on coverage, payment, and settlement compensation of medical insurance. However, in terms of data security and privacy protection, pertinent policies are absent and data utilization is not in-depth enough. Respondents to telephone interviews universally reflected on the following issues and suggestions: in the period of integration and transition of MISs, close attention should be paid to the top-level design, and repeated investment should be avoided for the building of MIISs; MIISs should be adapted to the health care reform, and efforts should be made to strengthen the informatization support for the reform of payment methods; and MIISs should be adapted for the widespread application of mobile phones and should provide insured persons with more self-service functions. Conclusions: In the future, the building of China's basic MIISs should be deployed at the national, provincial, prefectural, and municipal levels on a unified basis. Efforts should be made to strengthen the development of standard codes, data exchange, and data utilization. Work should be done to formulate the rules and regulations for security and privacy protection and to balance the right to be informed with the mining and utilization of big data. Efforts should be made to intensify the interconnectivity between MISs and other health systems and to strengthen the application of medical insurance information in public health monitoring and early warning systems; this would ultimately improve the degree of trust from stakeholders, including individuals, medical service providers, and public health institutions, in the basic MIISs. ", doi="10.2196/18780", url="https://medinform.jmir.org/2020/9/e18780", url="http://www.ncbi.nlm.nih.gov/pubmed/32673209" } @Article{info:doi/10.2196/19950, author="Drissi, Nidal and Ouhbi, Sofia and Janati Idrissi, Abdou Mohammed and Fernandez-Luque, Luis and Ghogho, Mounir", title="Connected Mental Health: Systematic Mapping Study", journal="J Med Internet Res", year="2020", month="Aug", day="28", volume="22", number="8", pages="e19950", keywords="mental health", keywords="connected health", keywords="eHealth", keywords="mobile health", keywords="telehealth", keywords="mHealth", keywords="mobile phone", keywords="health informatics", keywords="review", keywords="interdisciplinary research", keywords="information technology", keywords="information systems", abstract="Background: Although mental health issues constitute an increasing global burden affecting a large number of people, the mental health care industry is still facing several care delivery barriers such as stigma, education, and cost. Connected mental health (CMH), which refers to the use of information and communication technologies in mental health care, can assist in overcoming these barriers. Objective: The aim of this systematic mapping study is to provide an overview and a structured understanding of CMH literature available in the Scopus database. Methods: A total of 289 selected publications were analyzed based on 8 classification criteria: publication year, publication source, research type, contribution type, empirical type, mental health issues, targeted cohort groups, and countries where the empirically evaluated studies were conducted. Results: The results showed that there was an increasing interest in CMH publications; journals were the main publication channels of the selected papers; exploratory research was the dominant research type; advantages and challenges of the use of technology for mental health care were the most investigated subjects; most of the selected studies had not been evaluated empirically; depression and anxiety were the most addressed mental disorders; young people were the most targeted cohort groups in the selected publications; and Australia, followed by the United States, was the country where most empirically evaluated studies were conducted. Conclusions: CMH is a promising research field to present novel approaches to assist in the management, treatment, and diagnosis of mental health issues that can help overcome existing mental health care delivery barriers. Future research should be shifted toward providing evidence-based studies to examine the effectiveness of CMH solutions and identify related issues. ", doi="10.2196/19950", url="http://www.jmir.org/2020/8/e19950/", url="http://www.ncbi.nlm.nih.gov/pubmed/32857055" } @Article{info:doi/10.2196/17022, author="Krasuska, Marta and Williams, Robin and Sheikh, Aziz and Franklin, Dean Bryony and Heeney, Catherine and Lane, Wendy and Mozaffar, Hajar and Mason, Kathy and Eason, Sally and Hinder, Susan and Dunscombe, Rachel and Potts, W. Henry W. and Cresswell, Kathrin", title="Technological Capabilities to Assess Digital Excellence in Hospitals in High Performing Health Care Systems: International eDelphi Exercise", journal="J Med Internet Res", year="2020", month="Aug", day="18", volume="22", number="8", pages="e17022", keywords="digital excellence", keywords="digital maturity", keywords="Delphi technique", keywords="hospitals, eHealth", abstract="Background: Hospitals worldwide are developing ambitious digital transformation programs as part of broader efforts to create digitally advanced health care systems. However, there is as yet no consensus on how best to characterize and assess digital excellence in hospitals. Objective: Our aim was to develop an international agreement on a defined set of technological capabilities to assess digital excellence in hospitals. Methods: We conducted a two-stage international modified electronic Delphi (eDelphi) consensus-building exercise, which included a qualitative analysis of free-text responses. In total, 31 international health informatics experts participated, representing clinical, academic, public, and vendor organizations. Results: We identified 35 technological capabilities that indicate digital excellence in hospitals. These are divided into two categories: (a) capabilities within a hospital (n=20) and (b) capabilities enabling communication with other parts of the health and social care system, and with patients and carers (n=15). The analysis of free-text responses pointed to the importance of nontechnological aspects of digitally enabled change, including social and organizational factors. Examples included an institutional culture characterized by a willingness to transform established ways of working and openness to risk-taking. The availability of a range of skills within digitization teams, including technological, project management and business expertise, and availability of resources to support hospital staff, were also highlighted. Conclusions: We have identified a set of criteria for assessing digital excellence in hospitals. Our findings highlight the need to broaden the focus from technical functionalities to wider digital transformation capabilities. ", doi="10.2196/17022", url="https://www.jmir.org/2020/8/e17022", url="http://www.ncbi.nlm.nih.gov/pubmed/32808938" } @Article{info:doi/10.2196/18087, author="Suver, Christine and Thorogood, Adrian and Doerr, Megan and Wilbanks, John and Knoppers, Bartha", title="Bringing Code to Data: Do Not Forget Governance", journal="J Med Internet Res", year="2020", month="Jul", day="28", volume="22", number="7", pages="e18087", keywords="data management", keywords="privacy", keywords="ethics, research", keywords="data science", keywords="machine learning", doi="10.2196/18087", url="http://www.jmir.org/2020/7/e18087/", url="http://www.ncbi.nlm.nih.gov/pubmed/32540846" } @Article{info:doi/10.2196/16753, author="Rojas Mezarina, Leonardo and Silva-Valencia, Javier and Escobar-Agreda, Stefan and Espinoza Herrera, Hector Daniel and Egoavil, S. Miguel and Maceda Kuljich, Mirko and Inga-Berrospi, Fiorella and Ronceros, Sergio", title="Need for the Development of a Specific Regulatory Framework for Evaluation of Mobile Health Apps in Peru: Systematic Search on App Stores and Content Analysis", journal="JMIR Mhealth Uhealth", year="2020", month="Jul", day="10", volume="8", number="7", pages="e16753", keywords="mhealth apps", keywords="mHealth", keywords="regulatory framework", keywords="Peru, eHealth", abstract="Background: In Peru, there is an increase in the creation of mobile health (mHealth) apps; however, this situation could present problems related to the quality of information these apps share, data security and privacy, usability, and effectiveness, as there is no specific local regulation about their creation and use. Objective: The objective of this study was to review mHealth apps created, uploaded, or used in Peru, and perform an analysis of the national regulatory framework that could be applied to evaluate whether there is a need to develop and implement a specific regulation to these apps. Methods: A total of 3 reviews were performed. First, we reviewed information about Peruvian mHealth apps created up to May 2019 from scientific publications, news, government communications, and virtual stores, and evaluated their purpose, creator, and the available evidence of their usability and effectiveness. The second review was carried out by taking a sample of the 10 most commonly used mHealth apps in Peru (regardless of the country of creation), to evaluate the information they collect and classify them according to the possible risks that they could present in terms of security and privacy. In addition, we evaluated whether they refer to or endorse the information they provided. Finally, in the third review, we searched for Peruvian standards related to electronic health (eHealth) that involve information technology that can be applied to regulate these apps. Results: A total of 66 apps meeting our inclusion criteria were identified; of these, 47\% (n=31) belonged to government agencies and 47\% (n=31) were designed for administrative purposes (private and government agencies). There was no evidence about the usability or effectiveness of any of these apps. Concerning the 10 most commonly used mHealth apps in Peru, about the half of them gathered user information that could be leaked, changed, or lost, thus posing a great harm to their users or to their related patients. In addition, 6/10 (60\%) of these apps did not mention the source of the information they provided. Among the Peruvian norms, the Law on the Protection of Personal Data, Law on Medical Devices, and administrative directives on standards and criteria for health information systems have some regulations that could be applied to these apps; however, these do not fully cover all aspects concerning the evaluation of security and privacy of data, quality of provided information, and evidence of an app's usability and effectiveness. Conclusions: Because many Peruvian mHealth apps have issues related to security and privacy of data, quality of information provided, and lack of available evidence of their usability and effectiveness, there is an urgent need to develop a regulatory framework based on existing medical device and health information system norms in order to promote the evaluation and regulation of all the aforesaid aspects, including the creation of a national repository for these apps that describes all these characteristics. ", doi="10.2196/16753", url="https://mhealth.jmir.org/2020/7/e16753", url="http://www.ncbi.nlm.nih.gov/pubmed/32352926" } @Article{info:doi/10.2196/14283, author="Talhouk, Reem and Akik, Chaza and Araujo-Soares, Vera and Ahmad, Balsam and Mesmar, Sandra and Olivier, Patrick and Balaam, Madeline and Montague, Kyle and Garbett, Andrew and Ghattas, Hala", title="Integrating Health Technologies in Health Services for Syrian Refugees in Lebanon: Qualitative Study", journal="J Med Internet Res", year="2020", month="Jul", day="6", volume="22", number="7", pages="e14283", keywords="Syrian refugees", keywords="Lebanon", keywords="health technologies", keywords="eHealth", keywords="mHealth", keywords="primary health care", abstract="Background: Lebanon currently hosts around one million Syrian refugees. There has been an increasing interest in integrating eHealth and mHealth technologies into the provision of primary health care to refugees and Lebanese citizens. Objective: We aimed to gain a deeper understanding of the potential for technology integration in primary health care provision in the context of the protracted Syrian refugee crisis in Lebanon. Methods: A total of 17 face-to-face semistructured interviews were conducted with key informants (n=8) and health care providers (n=9) involved in the provision of health care to the Syrian refugee population in Lebanon. Interviews were audio recorded and directly translated and transcribed from Arabic to English. Thematic analysis was conducted. Results: Study participants indicated that varying resources, primarily time and the availability of technologies at primary health care centers, were the main challenges for integrating technologies for the provision of health care services for refugees. This challenge is compounded by refugees being viewed by participants as a mobile population thus making primary health care centers less willing to invest in refugee health technologies. Lastly, participant views regarding the health and technology literacies of refugees varied and that was considered to be a challenge that needs to be addressed for the successful integration of refugee health technologies. Conclusions: Our findings indicate that in the context of integrating technology into the provision of health care for refugees in a low or middle income country such as Lebanon, some barriers for technology integration related to the availability of resources are similar to those found elsewhere. However, we identified participant views of refugees' health and technology literacies to be a challenge specific to the context of this refugee crisis. These challenges need to be addressed when considering refugee health technologies. This could be done by increasing the visibility of refugee capabilities and configuring refugee health technologies so that they may create spaces in which refugees are empowered within the health care system and can work toward debunking the views discovered in this study. ", doi="10.2196/14283", url="https://www.jmir.org/2020/7/e14283", url="http://www.ncbi.nlm.nih.gov/pubmed/32628121" } @Article{info:doi/10.2196/16760, author="Jones, H. Kerina and Ford, M. Elizabeth and Lea, Nathan and Griffiths, J. Lucy and Hassan, Lamiece and Heys, Sharon and Squires, Emma and Nenadic, Goran", title="Toward the Development of Data Governance Standards for Using Clinical Free-Text Data in Health Research: Position Paper", journal="J Med Internet Res", year="2020", month="Jun", day="29", volume="22", number="6", pages="e16760", keywords="ethical", keywords="legal", keywords="social implications", keywords="public engagement", keywords="free-text data", keywords="information governance", abstract="Background: Clinical free-text data (eg, outpatient letters or nursing notes) represent a vast, untapped source of rich information that, if more accessible for research, would clarify and supplement information coded in structured data fields. Data usually need to be deidentified or anonymized before they can be reused for research, but there is a lack of established guidelines to govern effective deidentification and use of free-text information and avoid damaging data utility as a by-product. Objective: This study aimed to develop recommendations for the creation of data governance standards to integrate with existing frameworks for personal data use, to enable free-text data to be used safely for research for patient and public benefit. Methods: We outlined data protection legislation and regulations relating to the United Kingdom for context and conducted a rapid literature review and UK-based case studies to explore data governance models used in working with free-text data. We also engaged with stakeholders, including text-mining researchers and the general public, to explore perceived barriers and solutions in working with clinical free-text. Results: We proposed a set of recommendations, including the need for authoritative guidance on data governance for the reuse of free-text data, to ensure public transparency in data flows and uses, to treat deidentified free-text data as potentially identifiable with use limited to accredited data safe havens, and to commit to a culture of continuous improvement to understand the relationships between the efficacy of deidentification and reidentification risks, so this can be communicated to all stakeholders. Conclusions: By drawing together the findings of a combination of activities, we present a position paper to contribute to the development of data governance standards for the reuse of clinical free-text data for secondary purposes. While working in accordance with existing data governance frameworks, there is a need for further work to take forward the recommendations we have proposed, with commitment and investment, to assure and expand the safe reuse of clinical free-text data for public benefit. ", doi="10.2196/16760", url="http://www.jmir.org/2020/6/e16760/", url="http://www.ncbi.nlm.nih.gov/pubmed/32597785" } @Article{info:doi/10.2196/17567, author="Keutzer, Lina and Simonsson, SH Ulrika", title="Medical Device Apps: An Introduction to Regulatory Affairs for Developers", journal="JMIR Mhealth Uhealth", year="2020", month="Jun", day="26", volume="8", number="6", pages="e17567", keywords="MDR", keywords="medical device regulation", keywords="medical devices, medical device software", keywords="mHealth", keywords="eHealth", keywords="mobile apps", keywords="smartphone apps", doi="10.2196/17567", url="http://mhealth.jmir.org/2020/6/e17567/", url="http://www.ncbi.nlm.nih.gov/pubmed/32589154" } @Article{info:doi/10.2196/16922, author="Musacchio, Nicoletta and Giancaterini, Annalisa and Guaita, Giacomo and Ozzello, Alessandro and Pellegrini, A. Maria and Ponzani, Paola and Russo, T. Giuseppina and Zilich, Rita and de Micheli, Alberto", title="Artificial Intelligence and Big Data in Diabetes Care: A Position Statement of the Italian Association of Medical Diabetologists", journal="J Med Internet Res", year="2020", month="Jun", day="22", volume="22", number="6", pages="e16922", keywords="artificial intelligence", keywords="big data analytics", keywords="clinical decision making", keywords="diabetes management", keywords="health care", doi="10.2196/16922", url="http://www.jmir.org/2020/6/e16922/", url="http://www.ncbi.nlm.nih.gov/pubmed/32568088" } @Article{info:doi/10.2196/18175, author="Wani, Ahmad Tafheem and Mendoza, Antonette and Gray, Kathleen", title="Hospital Bring-Your-Own-Device Security Challenges and Solutions: Systematic Review of Gray Literature", journal="JMIR Mhealth Uhealth", year="2020", month="Jun", day="18", volume="8", number="6", pages="e18175", keywords="BYOD", keywords="bring-your-own-device", keywords="health care facilities", keywords="mhealth", keywords="mobile phone", keywords="confidentiality", keywords="computer security", abstract="Background: As familiarity with and convenience of using personal devices in hospitals help improve the productivity, efficiency, and workflow of hospital staff, the health care bring-your-own-device (BYOD) market is growing consistently. However, security concerns owing to the lack of control over the personal mobile devices of staff, which may contain sensitive data such as personal health information of patients, make it one of the biggest health care information technology (IT) challenges for hospital administrations. Objective: Given that the hospital BYOD security has not been adequately addressed in peer-reviewed literature, the aim of this paper was to identify key security challenges associated with hospital BYOD usage as well as relevant solutions that can cater to the identified issues by reviewing gray literature. Therefore, this research will provide additional practical insights from current BYOD practices. Methods: A comprehensive gray literature review was conducted, which followed the stepwise guidelines and quality assessment criteria set out by Garousi et al. The searched literature included tier 1 sources such as health care cybersecurity market reports, white papers, guidelines, policies, and frameworks as well as tier 2 sources such as credible and reputed health IT magazines, databases, and news articles. Moreover, a deductive thematic analysis was conducted to organize the findings based on Schlarman's People Policy Technology model, promoting a holistic understanding of hospitals' BYOD security issues and solutions. Results: A total of 51 sources were found to match the designed eligibility criteria. From these studies, several sociotechnical issues were identified. The major challenges identified were the use of devices with insufficient security controls by hospital staff, lack of control or visibility for the management to maintain security requirements, lack of awareness among hospital staff, lack of direction or guidance for BYOD usage, poor user experience, maintenance of legal requirements, shortage of cybersecurity skills, and loss of devices. Although technologies such as mobile device management, unified endpoint management, containerization, and virtual private network allow better BYOD security management in hospitals, policies and people management measures such as strong security culture and staff awareness and training improve staff commitment in protecting hospital data. Conclusions: The findings suggest that to optimize BYOD security management in hospitals, all 3 dimensions of the security process (people, policy, and technology) need to be given equal emphasis. As the nature of cybersecurity attacks is becoming more complex, all dimensions should work in close alignment with each other. This means that with the modernization of BYOD technology, BYOD strategy, governance, education, and relevant policies and procedures also need to adapt accordingly. ", doi="10.2196/18175", url="https://mhealth.jmir.org/2020/6/e18175", url="http://www.ncbi.nlm.nih.gov/pubmed/32554388" } @Article{info:doi/10.2196/17221, author="Li, Peiyi and Luo, Yunmei and Yu, Xuexin and Wen, Jin and Mason, Elizabeth and Li, Weimin and Jalali, S. Mohammad", title="Patients' Perceptions of Barriers and Facilitators to the Adoption of E-Hospitals: Cross-Sectional Study in Western China", journal="J Med Internet Res", year="2020", month="Jun", day="11", volume="22", number="6", pages="e17221", keywords="innovation adoption", keywords="e-hospital", keywords="internet hospital", keywords="eHealth", keywords="barriers", keywords="facilitators", abstract="Background: As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users' acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China. Objective: This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients' willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology. Methods: We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients' sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals. Results: Overall, it was found that 65.6\% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (P<.001), education level (P=.046), information technology skills (P<.001), and prior experience with web-based health care services (P<.001), whereas age, income, medical insurance, and familiarity with e-hospitals were not predictors. Additionally, the prominent facilitators of e-hospitals were convenience (641/677, 94.7\%) and accessibility to skilled medical experts (489/677, 72.2\%). The most frequently perceived barrier varied among age groups; seniors most often reported their inability to operate technological devices as a barrier (144/166, 86.7\%), whereas young participants most often reported that they avoided e-hospital services because they were accustomed to face-to-face consultation (39/52, 75\%). Conclusions: We identified the variables, facilitators, and barriers that play essential roles in the adoption of e-hospitals. Based on our findings, we suggest that efforts to increase the adoption of e-hospitals should focus on making target populations accustomed to web-based health care services while maximizing ease of use and providing assistance for technological inquiries. ", doi="10.2196/17221", url="http://www.jmir.org/2020/6/e17221/", url="http://www.ncbi.nlm.nih.gov/pubmed/32525483" } @Article{info:doi/10.2196/16497, author="Byambasuren, Oyungerel and Beller, Elaine and Hoffmann, Tammy and Glasziou, Paul", title="mHealth App Prescription in Australian General Practice: Pre-Post Study", journal="JMIR Mhealth Uhealth", year="2020", month="Jun", day="1", volume="8", number="6", pages="e16497", keywords="mHealth apps", keywords="app prescription", keywords="general practice", abstract="Background: Evidence of effectiveness of mobile health (mHealth) apps as well as their usability as non-drug interventions in primary care are emerging around the globe. Objective: This study aimed to explore the feasibility of mHealth app prescription by general practitioners (GPs) and to evaluate the effectiveness of an implementation intervention to increase app prescription. Methods: A single-group, before-and-after study was conducted in Australian general practice. GPs were given prescription pads for 6 mHealth apps and reported the number of prescriptions dispensed for 4 months. After the reporting of month 2, a 2-minute video of one of the apps was randomly selected and sent to each GP. Data were collected through a prestudy questionnaire, monthly electronic reporting, and end-of-study interviews. The primary outcome was the number of app prescriptions (total, monthly, per GP, and per GP per fortnight). Secondary outcomes included confidence in prescribing apps (0-5 scale), the impact of the intervention video on subsequent prescription numbers, and acceptability of the interventions. Results: Of 40 GPs recruited, 39 commenced, and 36 completed the study. In total, 1324 app prescriptions were dispensed over 4 months. The median number of apps prescribed per GP was 30 (range 6-111 apps). The median number of apps prescribed per GP per fortnight increased from the pre-study level of 1.7 to 4.1. Confidence about prescribing apps doubled from a mean of 2 (not so confident) to 4 (very confident). App videos did not affect subsequent prescription rates substantially. Post-study interviews revealed that the intervention was highly acceptable. Conclusions: mHealth app prescription in general practice is feasible, and our implementation intervention was effective in increasing app prescription. GPs need more tailored education and training on the value of mHealth apps and knowledge of prescribable apps to be able to successfully change their prescribing habits to include apps. The future of sustainable and scalable app prescription requires a trustworthy electronic app repository of prescribable mHealth apps for GPs. ", doi="10.2196/16497", url="https://mhealth.jmir.org/2020/6/e16497", url="http://www.ncbi.nlm.nih.gov/pubmed/32478660" } @Article{info:doi/10.2196/14604, author="Marovic, Branko and Curcin, Vasa", title="Impact of the European General Data Protection Regulation (GDPR) on Health Data Management in a European Union Candidate Country: A Case Study of Serbia", journal="JMIR Med Inform", year="2020", month="Apr", day="17", volume="8", number="4", pages="e14604", keywords="privacy act", keywords="patient data privacy", keywords="data sharing", keywords="information disclosure", keywords="ethical issues", keywords="medical tourists", keywords="health care systems", keywords="public policy", keywords="policy compliance", keywords="legal aspects", keywords="international aspects", doi="10.2196/14604", url="http://medinform.jmir.org/2020/4/e14604/", url="http://www.ncbi.nlm.nih.gov/pubmed/32301736" } @Article{info:doi/10.2196/16813, author="Neinstein, Aaron and Thao, Crishyashi and Savage, Mark and Adler-Milstein, Julia", title="Deploying Patient-Facing Application Programming Interfaces: Thematic Analysis of Health System Experiences", journal="J Med Internet Res", year="2020", month="Apr", day="3", volume="22", number="4", pages="e16813", keywords="application programming interface", keywords="consumer health information", keywords="electronic health record", keywords="health information exchange", keywords="health policy", keywords="patient engagement", abstract="Background: Health systems have recently started to activate patient-facing application programming interfaces (APIs) to facilitate patient access to health data and other interactions. Objective: This study sought to ascertain health systems' understanding, strategies, governance, and organizational infrastructure around patient-facing APIs, as well as their business drivers and barriers, to facilitate national learning, policy, and progress toward adoption. Methods: We performed a content analysis of semistructured interviews with a convenience sample of 10 health systems known to be leading adopters of health technology, having either implemented or planning to implement patient-facing APIs. Results: Of the 10 health systems, eight had operational patient-facing APIs, with organizational strategy driven most by federal policy, the emergence of Health Records on iPhone, and feelings of ethical obligation. The two priority use cases identified were enablement of a patient's longitudinal health record and digital interactions with the health system. The themes most frequently cited as barriers to the increased use of patient-facing APIs were security concerns, an immature app ecosystem that does not currently offer superior functionality compared with widely adopted electronic health record (EHR)--tethered portals, a lack of business drivers, EHR vendor hesitation toward data sharing, and immature technology and standards. Conclusions: Our findings reveal heterogeneity in health system understanding and approaches to the implementation and use of patient-facing APIs. Ongoing study, targeted policy interventions, and sharing of best practices appear necessary to achieve successful national implementation. ", doi="10.2196/16813", url="https://www.jmir.org/2020/4/e16813", url="http://www.ncbi.nlm.nih.gov/pubmed/31983680" } @Article{info:doi/10.2196/17026, author="Platt, E. Jodyn and Raj, Minakshi and Wienroth, Matthias", title="An Analysis of the Learning Health System in Its First Decade in Practice: Scoping Review", journal="J Med Internet Res", year="2020", month="Mar", day="19", volume="22", number="3", pages="e17026", keywords="learning health system", keywords="review", keywords="knowledge management", keywords="bioethics", keywords="health information exchange", abstract="Background: In the past decade, Lynn Etheredge presented a vision for the Learning Health System (LHS) as an opportunity for increasing the value of health care via rapid learning from data and immediate translation to practice and policy. An LHS is defined in the literature as a system that seeks to continuously generate and apply evidence, innovation, quality, and value in health care. Objective: This review aimed to examine themes in the literature and rhetoric on the LHS in the past decade to understand efforts to realize the LHS in practice and to identify gaps and opportunities to continue to take the LHS forward. Methods: We conducted a thematic analysis in 2018 to analyze progress and opportunities over time as compared with the initial Knowledge Gaps and Uncertainties proposed in 2007. Results: We found that the literature on the LHS has increased over the past decade, with most articles focused on theory and implementation; articles have been increasingly concerned with policy. Conclusions: There is a need for attention to understanding the ethical and social implications of the LHS and for exploring opportunities to ensure that these implications are salient in implementation, practice, and policy efforts. ", doi="10.2196/17026", url="http://www.jmir.org/2020/3/e17026/", url="http://www.ncbi.nlm.nih.gov/pubmed/32191214" } @Article{info:doi/10.2196/14868, author="Pithara, Christalla and Farr, Michelle and Sullivan, A. Sarah and Edwards, B. Hannah and Hall, William and Gadd, Caroline and Walker, Julian and Hebden, Nick and Horwood, Jeremy", title="Implementing a Digital Tool to Support Shared Care Planning in Community-Based Mental Health Services: Qualitative Evaluation", journal="J Med Internet Res", year="2020", month="Mar", day="19", volume="22", number="3", pages="e14868", keywords="health care technology", keywords="mental health", keywords="community health care", keywords="patient-centered care", keywords="patient care planning", keywords="implementation science", abstract="Background: Mental health services aim to provide recovery-focused care and facilitate coproduced care planning. In practice, mental health providers can find supporting individualized coproduced care with service users difficult while balancing administrative and performance demands. To help meet this aim and using principles of coproduction, an innovative mobile digital care pathway tool (CPT) was developed to be used on a tablet computer and piloted in the West of England. Objective: The aim of this study was to examine mental health care providers' views of and experiences with the CPT during the pilot implementation phase and identify factors influencing its implementation. Methods: A total of 20 in-depth telephone interviews were conducted with providers participating in the pilot and managers in the host organization. Interviews were audio recorded, transcribed, anonymized, and thematically analyzed guided by the Consolidated Framework for Implementation Research. Results: The tool was thought to facilitate coproduced recovery-focused care planning, a policy and organizational as well as professional priority. Internet connectivity issues, system interoperability, and access to service users' health records affected use of the tool during mobile working. The organization's resources, such as information technology (IT) infrastructure and staff time and IT culture, influenced implementation. Participants' levels of use of the tool were dependent on knowledge of the tool and self-efficacy; perceived service-user needs and characteristics; and perceptions of impact on the therapeutic relationship. Training and preparation time influenced participants' confidence in using the tool. Conclusions: Findings highlight the importance of congruence between staff, organization, and external policy priorities and digital technologies in aiding intervention engagement, and the need for ongoing training and support of those intended to use the technology during and after the end of implementation interventions. ", doi="10.2196/14868", url="https://www.jmir.org/2020/3/e14868", url="http://www.ncbi.nlm.nih.gov/pubmed/32191210" } @Article{info:doi/10.2196/17006, author="Liang, Jun and Li, Ying and Zhang, Zhongan and Shen, Dongxia and Xu, Jie and Yu, Gang and Dai, Siqi and Ge, Fangmin and Lei, Jianbo", title="Evaluating the Applications of Health Information Technologies in China During the Past 11 Years: Consecutive Survey Data Analysis", journal="JMIR Med Inform", year="2020", month="Feb", day="10", volume="8", number="2", pages="e17006", keywords="medical informatics", keywords="health information technologies", keywords="China", keywords="health care reform", keywords="hospitals", abstract="Background: To achieve universal access to medical resources, China introduced its second health care reform in 2010, with health information technologies (HIT) as an important technical support point. Objective: This study is the first attempt to explore the unique contributions and characteristics of HIT development in Chinese hospitals from the three major aspects of hospital HIT---human resources, funding, and materials---in an all-around, multi-angled, and time-longitudinal manner, so as to serve as a reference for decision makers in China and the rest of the world when formulating HIT development strategies. Methods: A longitudinal research method is used to analyze the results of the CHIMA Annual Survey of Hospital Information System in China carried out by a Chinese national industrial association, CHIMA, from 2007 to 2018. The development characteristics of human resources, funding, and materials of HIT in China for the past 12 years are summarized. The Bass model is used to fit and predict the popularization trend of EMR in Chinese hospitals from 2007 to 2020. Results: From 2007 to 2018, the CHIMA Annual Survey interviewed 10,954 hospital CIOs across 32 administrative regions in Mainland China. Compared with 2007, as of 2018, in terms of human resources, the average full time equivalent (FTE) count in each hospital's IT center is still lower than the average level of US counterparts in 2014 (9.66 FTEs vs. 34 FTEs). The proportion of CIOs with a master's degree or above was 25.61\%, showing an increase of 18.51\%, among which those with computer-related backgrounds accounted for 64.75\%, however, those with a medical informatics background only accounted for 3.67\%. In terms of funding, the sampled hospitals' annual HIT investment increased from {\textyen}957,700 (US \$136,874) to {\textyen}6.376 million (US \$911,261), and the average investment per bed increased from {\textyen}4,600 (US \$658) to {\textyen}8,100 (US \$1158). In terms of information system construction, as of 2018, the average EMR implementation rate of the sampled hospitals exceeded the average level of their US counterparts in 2015 and their German counterparts in 2017 (85.26\% vs. 83.8\% vs. 68.4\%, respectively). The results of the Bass prediction model show that Chinese hospitals will likely reach an adoption rate of 91.4\% by 2020 (R2=0.95). Conclusions: In more than 10 years, based on this top-down approach, China's medical care industry has accepted government instructions and implemented the unified model planned by administrative intervention. With only about one-fifth of the required funding, and about one-fourth of the required human resources per hospital as compared to the US HITECH project, China's EMR coverage in 2018 exceeded the average level of its US counterparts in 2015 and German counterparts in 2017. This experience deserves further study and analysis by other countries. ", doi="10.2196/17006", url="https://medinform.jmir.org/2020/2/e17006", url="http://www.ncbi.nlm.nih.gov/pubmed/32039815" } @Article{info:doi/10.2196/15102, author="Pohlmann, Sabrina and Kunz, Aline and Ose, Dominik and Winkler, C. Eva and Brandner, Antje and Poss-Doering, Regina and Szecsenyi, Joachim and Wensing, Michel", title="Digitalizing Health Services by Implementing a Personal Electronic Health Record in Germany: Qualitative Analysis of Fundamental Prerequisites From the Perspective of Selected Experts", journal="J Med Internet Res", year="2020", month="Jan", day="29", volume="22", number="1", pages="e15102", keywords="personal electronic health record", keywords="implementation", keywords="qualitative analysis", keywords="digitalization", keywords="health services", abstract="Background: The implementation of a personal electronic health record (PHR) is a central objective of digitalization policies in the German health care system. Corresponding legislation was passed with the 2015 Act for Secure Digital Communication and Applications in the Health Sector (eHealth Act). However, compared with other European countries, Germany still lags behind concerning the implementation of a PHR. Objective: In order to explore potential barriers and facilitators for the adoption of a PHR in routine health care in Germany, this paper aims to identify policies, structures, and practices of the German health care system that influence the uptake and use of a PHR. Methods: A total of 33 semistructured interviews were conducted with a purposive sample of experts: 23 interviews with different health care professionals and 10 interviews with key actors of the German health care system who were telematics, eHealth, and information technology experts (eHealth experts). The interviews were transcribed verbatim and subjected to a content analysis. Results: From the expert perspective, a PHR was basically considered desirable and unavoidable. At the same time, a number of challenges for implementation in Germany have been outlined. Three crucial themes emerged: (1) documentation standards: prevailing processes of the analog bureaucratic paper world, (2) interoperability: the plurality of actors and electronic systems, and (3) political structure: the lack of clear political regulations and political incentive structures. Conclusions: With regard to the implementation of a PHR, an important precondition of a successful digitalization will be the precedent reform of the system to be digitized. Whether the recently passed Act for Faster Appointments and Better Care will be a step in the right direction remains to be seen. ", doi="10.2196/15102", url="https://www.jmir.org/2020/1/e15102", url="http://www.ncbi.nlm.nih.gov/pubmed/32012060" } @Article{info:doi/10.2196/16249, author="Sleigh, Joanna and Schneider, Manuel and Amann, Julia and Vayena, Effy", title="Visualizing an Ethics Framework: A Method to Create Interactive Knowledge Visualizations From Health Policy Documents", journal="J Med Internet Res", year="2020", month="Jan", day="14", volume="22", number="1", pages="e16249", keywords="ethics framework", keywords="health data", keywords="health policy", keywords="knowledge visualization", keywords="systems map", abstract="Background: Data have become an essential factor in driving health research and are key to the development of personalized and precision medicine. Primary and secondary use of personal data holds significant potential for research; however, it also introduces a new set of challenges around consent processes, privacy, and data sharing. Research institutions have issued ethical guidelines to address challenges and ensure responsible data processing and data sharing. However, ethical guidelines directed at researchers and medical professionals are often complex; require readers who are familiar with specific terminology; and can be hard to understand for people without sufficient background knowledge in legislation, research, and data processing practices. Objective: This study aimed to visually represent an ethics framework to make its content more accessible to its stakeholders. More generally, we wanted to explore the potential of visualizing policy documents to combat and prevent research misconduct by improving the capacity of actors in health research to handle data responsibly. Methods: We used a mixed methods approach based on knowledge visualization with 3 sequential steps: qualitative content analysis (open and axial coding, among others); visualizing the knowledge structure, which resulted from the previous step; and adding interactive functionality to access information using rapid prototyping. Results: Through our iterative methodology, we developed a tool that allows users to explore an ethics framework for data sharing through an interactive visualization. Our results represent an approach that can make policy documents easier to understand and, therefore, more applicable in practice. Conclusions: Meaningful communication and understanding each other remain a challenge in various areas of health care and medicine. We contribute to advancing communication practices through the introduction of knowledge visualization to bioethics to offer a novel way to tackle this relevant issue. ", doi="10.2196/16249", url="https://www.jmir.org/2020/1/e16249", url="http://www.ncbi.nlm.nih.gov/pubmed/31934866" } @Article{info:doi/10.2196/13649, author="Mackey, Tim and Bekki, Hirofumi and Matsuzaki, Tokio and Mizushima, Hiroshi", title="Examining the Potential of Blockchain Technology to Meet the Needs of 21st-Century Japanese Health Care: Viewpoint on Use Cases and Policy", journal="J Med Internet Res", year="2020", month="Jan", day="9", volume="22", number="1", pages="e13649", keywords="information storage and retrieval", keywords="blockchain", keywords="Japan", keywords="aging", keywords="health informatics", keywords="health policy", keywords="global health", doi="10.2196/13649", url="https://www.jmir.org/2020/1/e13649", url="http://www.ncbi.nlm.nih.gov/pubmed/31917371" } @Article{info:doi/10.2196/16377, author="Lee, J. Edmund W. and Viswanath, Kasisomayajula", title="Big Data in Context: Addressing the Twin Perils of Data Absenteeism and Chauvinism in the Context of Health Disparities Research", journal="J Med Internet Res", year="2020", month="Jan", day="7", volume="22", number="1", pages="e16377", keywords="big data", keywords="artificial intelligence", keywords="health informatics", keywords="wearable electronic devices", keywords="mobile health", keywords="social media", keywords="electronic health records", keywords="digital divide", keywords="health disparities", doi="10.2196/16377", url="https://www.jmir.org/2020/1/e16377", url="http://www.ncbi.nlm.nih.gov/pubmed/31909724" } @Article{info:doi/10.2196/14994, author="Desveaux, Laura and Soobiah, Charlene and Bhatia, Sacha R. and Shaw, James", title="Identifying and Overcoming Policy-Level Barriers to the Implementation of Digital Health Innovation: Qualitative Study", journal="J Med Internet Res", year="2019", month="Dec", day="20", volume="21", number="12", pages="e14994", keywords="health care", keywords="policy", keywords="implementation", keywords="health technology", abstract="Background: High-level policy barriers impede widespread adoption for even the most well-positioned innovations. Most of the work in this field assumes rather than analyzes the driving forces of health innovation. Objective: The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario. Objective: The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario. Methods: We completed semistructured interviews with 10 members of senior leadership across key organizations that are engaged in health care--related digital health activities. Data were analyzed using qualitative description. Results: A total of 6 key policy priorities emerged, including the need for (1) a system-level definition of innovation, (2) a clear overarching mission, and (3) clearly defined organizational roles. Operationally, there is a need to (4) standardize processes, (5) shift the emphasis to change management, and (6) align funding structures. Conclusions: These findings emphasize the critical role of the government in developing a vision and creating the foundation upon which innovation activities will be modeled. ", doi="10.2196/14994", url="http://www.jmir.org/2019/12/e14994/", url="http://www.ncbi.nlm.nih.gov/pubmed/31859679" } @Article{info:doi/10.2196/16093, author="Greenhalgh, Trisha and Wherton, Joseph and Shaw, Sara and Papoutsi, Chrysanthi and Vijayaraghavan, Shanti and Stones, Rob", title="Infrastructure Revisited: An Ethnographic Case Study of how Health Information Infrastructure Shapes and Constrains Technological Innovation", journal="J Med Internet Res", year="2019", month="Dec", day="19", volume="21", number="12", pages="e16093", keywords="information infrastructure", keywords="structuration theory", keywords="video consultations", keywords="neo-institutional theory", keywords="organizational ethnography", keywords="hidden work", keywords="actor-network theory", abstract="Background: Star defined infrastructure as something other things ``run on''; it consists mainly of ``boring things.'' Building on her classic 1999 paper, and acknowledging contemporary developments in technologies, services, and systems, we developed a new theorization of health information infrastructure with five defining characteristics: (1) a material scaffolding, backgrounded when working and foregrounded upon breakdown; (2) embedded, relational, and emergent; (3) collectively learned, known, and practiced (through technologically-supported cooperative work and organizational routines); (4) patchworked (incrementally built and fixed) and path-dependent (influenced by technical and socio-cultural legacies); and (5) institutionally supported and sustained (eg, embodying standards negotiated and overseen by regulatory and professional bodies). Objective: Our theoretical objective was, in a health care context, to explore what information infrastructure is and how it shapes, supports, and constrains technological innovation. Our empirical objective was to examine the challenges of implementing and scaling up video consultation services. Methods: In this naturalistic case study, we collected a total of 450 hours of ethnographic observations, over 100 interviews, and about 100 local and national documents over 54 months. Sensitized by the characteristics of infrastructure, we sought examples of infrastructural challenges that had slowed implementation and scale-up. We arranged data thematically to gain familiarity before undertaking an analysis informed by strong structuration, neo-institutional, and social practice theories, together with elements taken from the actor-network theory. Results: We documented scale-up challenges at three different sites in our original case study, all of which relate to ``boring things'': the selection of a platform to support video-mediated consultations, the replacement of desktop computers with virtual desktop infrastructure profiles, and problems with call quality. In a fourth subcase, configuration issues with licensed video-conferencing software limited the spread of the innovation to another UK site. In all four subcases, several features of infrastructure were evident, including: (1) intricacy and lack of dependability of the installed base; (2) interdependencies of technologies, processes, and routines, such that a fix for one problem generated problems elsewhere in the system; (3) the inertia of established routines; (4) the constraining (and, occasionally, enabling) effect of legacy systems; and (5) delays and conflicts relating to clinical quality and safety standards. Conclusions: Innovators and change agents who wish to introduce new technologies in health services and systems should: (1) attend to materiality (eg, expect bugs and breakdowns, and prioritize basic dependability over advanced functionality); (2) take a systemic and relational view of technologies (versus as an isolated tool or function); (3) remember that technology-supported work is cooperative and embedded in organizational routines, which are further embedded in other routines; (4) innovate incrementally, taking account of technological and socio-cultural legacies; (5) consider standards but also where these standards come from and what priorities and interests they represent; and (6) seek to create leeway for these standards to be adapted to different local conditions. ", doi="10.2196/16093", url="http://www.jmir.org/2019/12/e16093/", url="http://www.ncbi.nlm.nih.gov/pubmed/31855184" } @Article{info:doi/10.2196/16513, author="Curioso, H. Walter", title="Building Capacity and Training for Digital Health: Challenges and Opportunities in Latin America", journal="J Med Internet Res", year="2019", month="Dec", day="18", volume="21", number="12", pages="e16513", keywords="digital health", keywords="capacity building", keywords="training program", keywords="education", keywords="public health", keywords="telehealth", keywords="Peru", keywords="Latin America", doi="10.2196/16513", url="http://www.jmir.org/2019/12/e16513/", url="http://www.ncbi.nlm.nih.gov/pubmed/31850849" } @Article{info:doi/10.2196/15301, author="Zawati, H. Ma'n and Lang, Michael", title="Mind the App: Considerations for the Future of Mobile Health in Canada", journal="JMIR Mhealth Uhealth", year="2019", month="Nov", day="4", volume="7", number="11", pages="e15301", keywords="smartphone", keywords="mobile phone", keywords="regulation", keywords="patients", keywords="physicians", doi="10.2196/15301", url="https://mhealth.jmir.org/2019/11/e15301", url="http://www.ncbi.nlm.nih.gov/pubmed/31682580" } @Article{info:doi/10.2196/14976, author="Senft, Nicole and Butler, Evan and Everson, Jordan", title="Growing Disparities in Patient-Provider Messaging: Trend Analysis Before and After Supportive Policy", journal="J Med Internet Res", year="2019", month="Oct", day="7", volume="21", number="10", pages="e14976", keywords="eHealth", keywords="policy", keywords="communication", keywords="secure messaging", keywords="disparities", keywords="socioeconomic factors", keywords="inequality", abstract="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. ", doi="10.2196/14976", url="https://www.jmir.org/2019/10/e14976", url="http://www.ncbi.nlm.nih.gov/pubmed/31593539" } @Article{info:doi/10.2196/14956, author="Baltaxe, Erik and Czypionka, Thomas and Kraus, Markus and Reiss, Miriam and Askildsen, Erik Jan and Grenkovic, Renata and Lind{\'e}n, Skogedal Tord and Pitter, Gy{\"o}rgy J{\'a}nos and Rutten-van Molken, Maureen and Solans, Oscar and Stokes, Jonathan and Struckmann, Verena and Roca, Josep and Cano, Isaac", title="Digital Health Transformation of Integrated Care in Europe: Overarching Analysis of 17 Integrated Care Programs", journal="J Med Internet Res", year="2019", month="Sep", day="26", volume="21", number="9", pages="e14956", keywords="program evaluation", keywords="chronic patients", keywords="eHealth", keywords="elderly", keywords="integrated care", keywords="social support", keywords="telemonitoring", keywords="information and communication technology", abstract="Background: Digital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations. Objective: The aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries. Methods: A program analysis based on thick descriptions---including document examinations and semistructured interviews with relevant stakeholders---of ICC programs in Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom was performed. A total of 233 stakeholders (ie, professionals, providers, patients, carers, and policymakers) were interviewed from November 2014 to September 2016. The overarching analysis focused on the use of digital health tools and program assessment strategies. Results: Supporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programs. Only few ICC programs have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care. Conclusions: Notwithstanding the heterogeneity of the results across countries, most programs aim to evolve toward a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies toward their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools. ", doi="10.2196/14956", url="https://www.jmir.org/2019/9/e14956", url="http://www.ncbi.nlm.nih.gov/pubmed/31573914" } @Article{info:doi/10.2196/13300, author="Greenberg-Worisek, J. Alexandra and Kurani, Shaheen and Finney Rutten, J. Lila and Blake, D. Kelly and Moser, P. Richard and Hesse, W. Bradford", title="Tracking Healthy People 2020 Internet, Broadband, and Mobile Device Access Goals: An Update Using Data From the Health Information National Trends Survey", journal="J Med Internet Res", year="2019", month="Jun", day="24", volume="21", number="6", pages="e13300", keywords="Healthy People 2020", keywords="digital divide", keywords="internet", abstract="Background: As the year 2020 approaches, there is a need to evaluate progress toward the United States government's Healthy People 2020 (HP2020) health information technology and communication objectives to establish baselines upon which Healthy People 2030 objectives can be based. Objective: The aim of this study was to use the National Cancer Institute's (NCI) Health Information National Trends Survey (HINTS) to benchmark progress toward HP2020 goals related to increasing internet access using broadband, and to assess the state of the digital divide for various sociodemographic groups. Methods: We merged and analyzed data from 8 administrations of HINTS (2003-2017). Descriptive statistics were generated, and predicted marginals were calculated using interaction terms between survey year and selected sociodemographic variables of interest, including age, sex, race and ethnicity, income, education, and geography (rural versus urban), to test for differential change over time. Results: The number of users having access to the internet increased between 2003 and 2014 (63.15\% [3982/6358] to 83.41\% [2802/3629]); it remained relatively steady from 2014 to 2017 (81.15\% [2533/3283]). Broadband access increased between 2003 and 2011 (from 32.83\% [1031/3352] to 77.87\% [3375/4405]), but has been declining since (55.93\% [1364/2487] in 2017). Access via cellular network increased between 2008 and 2017 (from 6.86\% [240/4405] to 65.43\% [1436/2489]). Statistically significant disparities in overall internet access were noted in the predicted marginals for age, sex, race and ethnicity, income, and education; for age, sex, income, and geography for broadband access; and for age and sex for cellular network. Conclusions: The targets set forth in HP2020 were met for overall internet access and for internet access via cellular network; however, the target was not met for internet access via broadband. Furthermore, although the digital divide persisted by sociodemographic characteristics, the magnitude of many disparities in access decreased over time. ", doi="10.2196/13300", url="http://www.jmir.org/2019/6/e13300/", url="http://www.ncbi.nlm.nih.gov/pubmed/31237238" } @Article{info:doi/10.2196/13131, author="Khoong, C. Elaine and Cherian, Roy and Matta, Y. George and Lyles, R. Courtney and Schillinger, Dean and Ratanawongsa, Neda", title="Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis", journal="J Med Internet Res", year="2019", month="May", day="22", volume="21", number="5", pages="e13131", keywords="vulnerable populations", keywords="electronic health records", keywords="attitude to computers", keywords="physician-patient relations", keywords="communication barriers", abstract="Background: Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use. Objective: The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use. Methods: We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes. Results: Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use. Conclusions: Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients. ", doi="10.2196/13131", url="http://www.jmir.org/2019/5/e13131/", url="http://www.ncbi.nlm.nih.gov/pubmed/31120020" } @Article{info:doi/10.2196/11497, author="Opoku, Daniel and Busse, Reinhard and Quentin, Wilm", title="Achieving Sustainability and Scale-Up of Mobile Health Noncommunicable Disease Interventions in Sub-Saharan Africa: Views of Policy Makers in Ghana", journal="JMIR Mhealth Uhealth", year="2019", month="May", day="03", volume="7", number="5", pages="e11497", keywords="implementation science", keywords="mHealth", keywords="eHealth", keywords="noncommunicable diseases", keywords="disease management", keywords="sub-Saharan Africa", keywords="qualitative research", keywords="health policy", abstract="Background: A growing body of evidence shows that mobile health (mHealth) interventions may improve treatment and care for the rapidly rising number of patients with noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA). A recent realist review developed a framework highlighting the influence of context factors, including predisposing characteristics, needs, and enabling resources (PNE), for the long-term success of mHealth interventions. The views of policy makers will ultimately determine implementation and scale-up of mHealth interventions in SSA. However, their views about necessary conditions for sustainability and scale-up remain unexplored. Objective: This study aimed to understand the views of policy makers in Ghana with regard to the most important factors for successful implementation, sustainability, and scale-up of mHealth NCD interventions. Methods: Members of the technical working group responsible for Ghana's national NCD policy were interviewed about their knowledge of and attitude toward mHealth and about the most important factors contributing to long-term intervention success. Using qualitative methods and applying a qualitative content analysis approach, answers were categorized according to the PNE framework. Results: A total of 19 policy makers were contacted and 13 were interviewed. Interviewees had long-standing work experience of an average of 26 years and were actively involved in health policy making in Ghana. They were well-informed about the potential of mHealth, and they strongly supported mHealth expansion in the country. Guided by the PNE framework's categories, the policy makers ascertained which critical factors would support the successful implementation of mHealth interventions in Ghana. The policy makers mentioned many factors described in the literature as important for mHealth implementation, sustainability, and scale-up, but they focused more on enabling resources than on predisposing characteristics and need. Furthermore, they mentioned several factors that have been rather unexplored in the literature. Conclusions: The study shows that the PNE framework is useful to guide policy makers toward a more systematic assessment of context factors that support intervention implementation, sustainability, and scale-up. Furthermore, the framework was refined by adding additional factors. Policy makers may benefit from using the PNE framework at the various stages of mHealth implementation. Researchers may (and should) use the framework when investigating reasons for success (or failure) of interventions. ", doi="10.2196/11497", url="https://mhealth.jmir.org/2019/5/e11497/", url="http://www.ncbi.nlm.nih.gov/pubmed/31066706" } @Article{info:doi/10.2196/12238, author="Li, Chen and Xu, Xiangdong and Zhou, Guanghua and He, Kai and Qi, Tianliang and Zhang, Wei and Tian, Feng and Zheng, Qinghua and Hu, Jianping", title="Implementation of National Health Informatization in China: Survey About the Status Quo", journal="JMIR Med Inform", year="2019", month="Feb", day="21", volume="7", number="1", pages="e12238", keywords="health policy", keywords="health informatization", keywords="electronic health record", abstract="Background: The National Health and Family Planning Commission (NHFPC) in China organized a nationwide survey to investigate the informatization in hospitals and regional Health and Family Planning Commissions (HFPCs) in 2017. The survey obtained valid results from 79.69\% (2021/2536) of major hospitals and 81\% (26/32) of provincial and 73.1\% (307/420) of municipal HFPCs. The investigated topics covered hardware infrastructure, information resources, applications, systems, and organizations in health informatics. Objective: This study aimed to provide evidence collected from the survey regarding China's health informatization and assist policy making regarding health informatics in the 13th Five-Year Plan of China. Methods: Based on the survey, the paper presented the status quo of China's health informatization and analyzed the progress and potential problems in terms of the country's health information development policies. Results: Related policies have helped to construct 4-level information platforms and start converging the regional data to the 3 centralized databases. The principle of informatics has been transiting from finance-centered to people-centered. Alternatively, the quality, usability, and interoperability of the data still need to be improved. Conclusions: The nationwide survey shows that China's health informatization is rapidly developing. Current information platforms and databases technically support data exchanging between all provinces and cities. As China is continuing to improve the infrastructure, more advanced applications are being developed upon it. ", doi="10.2196/12238", url="http://medinform.jmir.org/2019/1/e12238/", url="http://www.ncbi.nlm.nih.gov/pubmed/30789350" } @Article{info:doi/10.2196/12902, author="Mandl, D. Kenneth and Gottlieb, Daniel and Ellis, Alyssa", title="Beyond One-Off Integrations: A Commercial, Substitutable, Reusable, Standards-Based, Electronic Health Record--Connected App", journal="J Med Internet Res", year="2019", month="Feb", day="01", volume="21", number="2", pages="e12902", keywords="electronic medical records", keywords="application programming interfaces", doi="10.2196/12902", url="http://www.jmir.org/2019/2/e12902/", url="http://www.ncbi.nlm.nih.gov/pubmed/30707097" } @Article{info:doi/10.2196/11195, author="Dibble, R. Emily and Iott, E. Bradley and Flynn, J. Allen and King, P. Darren and MacEachern, P. Mark and Friedman, P. Charles and Caverly, J. Tanner", title="A Rapid Process for Identifying and Prioritizing Technology-Based Tools for Health System Implementation", journal="JMIR Cancer", year="2018", month="Nov", day="27", volume="4", number="2", pages="e11195", keywords="patient reported outcome measures", keywords="evidence-based practice", keywords="decision support systems, clinical", keywords="medical informatics applications", keywords="practice guidelines as topic", keywords="evidence review", keywords="expert panel", keywords="health information technology", keywords="oncology care model", keywords="clinical decision support", abstract="Background: Health system decisions to put new technologies into clinical practice require a rapid and trustworthy decision-making process informed by best evidence. Objective: This study aimed to present a rapid evidence review process that can be used to inform health system leaders and clinicians seeking to implement new technology tools to improve patient-clinician decision making and patient-oriented outcomes. Methods: The rapid evidence review process we pioneered involved 5 sequential subprocesses: (1) environmental scan, (2) expert panel recruitment, (3) host evidence review panel, (4) analysis, and (5) local validation panel. We conducted an environmental scan of health information technology (IT) literature to identify relevant digital tools in oncology care. We synthesized the recent literature using current evidence review methods, creating visual summaries for use by a national panel of experts. Panelists were taken through a 6-hour modified Delphi process to prioritize tools for implementation. Findings from the rapid evidence review panel were taken to a local validation panel for further rapid review during a 3-hour session. Results: Our rapid evidence review process shows promise for informing decision making by reducing the amount of time and resources needed to identify and prioritize adoption of IT tools. Despite evidence of improved patient outcomes, panelists had substantial concerns about implementing patient-reported outcome tracking tools, voicing concerns about liability, lack of familiarity with new technology, and additional time and workflow changes such tools would require. Instead, clinicians favored technologies that did not require clinician involvement. Conclusions: Health system leaders can use the rapid evidence review process presented here to usefully inform local technology adoption, implementation, and use in practice. ", doi="10.2196/11195", url="http://cancer.jmir.org/2018/2/e11195/", url="http://www.ncbi.nlm.nih.gov/pubmed/30482740" } @Article{info:doi/10.2196/10235, author="Granja, Concei{\c{c}}{\~a}o and Janssen, Wouter and Johansen, Alise Monika", title="Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature", journal="J Med Internet Res", year="2018", month="May", day="01", volume="20", number="5", pages="e10235", keywords="telemedicine", keywords="eHealth", keywords="medical informatics", keywords="systematic review", keywords="success", keywords="failure", abstract="Background: eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality. Objective: Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure. Methods: We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles. Results: Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5\%) and on success (452/844, 53.6\%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1). Conclusions: The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved. ", doi="10.2196/10235", url="http://www.jmir.org/2018/5/e10235/", url="http://www.ncbi.nlm.nih.gov/pubmed/29716883" } @Article{info:doi/10.2196/jmir.9498, author="Herrmann, Maximilian and Boehme, Philip and Mondritzki, Thomas and Ehlers, P. Jan and Kavadias, Stylianos and Truebel, Hubert", title="Digital Transformation and Disruption of the Health Care Sector: Internet-Based Observational Study", journal="J Med Internet Res", year="2018", month="Mar", day="27", volume="20", number="3", pages="e104", keywords="digital transformation", keywords="health care sector", keywords="health care reform", keywords="incremental innovation", keywords="disruptive innovation", keywords="organizational innovation", keywords="entrepreneurship", keywords="efficiency", keywords="models", keywords="organizational", keywords="diffusion of innovation", keywords="delivery of health care", abstract="Background: Digital innovation, introduced across many industries, is a strong force of transformation. Some industries have seen faster transformation, whereas the health care sector only recently came into focus. A context where digital corporations move into health care, payers strive to keep rising costs at bay, and longer-living patients desire continuously improved quality of care points to a digital and value-based transformation with drastic implications for the health care sector. Objective: We tried to operationalize the discussion within the health care sector around digital and disruptive innovation to identify what type of technological enablers, business models, and value networks seem to be emerging from different groups of innovators with respect to their digital transformational efforts. Methods: From the Forbes 2000 and CBinsights databases, we identified 100 leading technology, life science, and start-up companies active in the health care sector. Further analysis identified projects from these companies within a digital context that were subsequently evaluated using the following criteria: delivery of patient value, presence of a comprehensive and distinctive underlying business model, solutions provided, and customer needs addressed. Results: Our methodological approach recorded more than 400 projects and collaborations. We identified patterns that show established corporations rely more on incremental innovation that supports their current business models, while start-ups engage their flexibility to explore new market segments with notable transformations of established business models. Thereby, start-ups offer higher promises of disruptive innovation. Additionally, start-ups offer more diversified value propositions addressing broader areas of the health care sector. Conclusions: Digital transformation is an opportunity to accelerate health care performance by lowering cost and improving quality of care. At an economic scale, business models can be strengthened and disruptive innovation models enabled. Corporations should look for collaborations with start-up companies to keep investment costs at bay and off the balance sheet. At the same time, the regulatory knowledge of established corporations might help start-ups to kick off digital disruption in the health care sector. ", doi="10.2196/jmir.9498", url="http://www.jmir.org/2018/3/e104/", url="http://www.ncbi.nlm.nih.gov/pubmed/29588274" } @Article{info:doi/10.2196/jmir.9367, author="L{\"a}ms{\"a}, Elina and Timonen, Johanna and Ahonen, Riitta", title="Pharmacy Customers' Experiences With Electronic Prescriptions: Cross-Sectional Survey on Nationwide Implementation in Finland", journal="J Med Internet Res", year="2018", month="Feb", day="23", volume="20", number="2", pages="e68", keywords="electronic prescribing", keywords="pharmacies", keywords="patient satisfaction", keywords="surveys and questionnaires", abstract="Background: One of the forerunners in electronic health, Finland has introduced electronic prescriptions (ePrescriptions) nationwide by law. This has led to significant changes for pharmacy customers. Despite the worldwide ambition to develop ePrescription services, there are few reports of nationally adopted systems and particularly on the experiences of pharmacy customers. Objective: The aim of this study was to investigate Finnish pharmacy customers' (1) experiences with purchasing medicines with ePrescriptions; (2) experiences with renewing ePrescriptions and acting on behalf of someone else at the pharmacy; (3) ways in which customers keep up to date with their ePrescriptions; and (4) overall satisfaction with ePrescriptions. Methods: Questionnaires were distributed to 2913 pharmacy customers aged ?18 years purchasing prescription medicines for themselves with an ePrescription in 18 community pharmacies across Finland in autumn 2015. Customers' experiences were explored with 10 structured questions. The data were stored in SPSS for Windows and subjected to descriptive analysis, chi-square, Fisher exact, Kolmogorov-Smirnov, the Mann-Whitney U, and Kruskal-Wallis tests. Results: Completed questionnaires were returned by 1288 customers, a response rate of 44.19\% (1288/2913). The majority of the respondents did not encounter any problems during pharmacy visits (1161/1278, 90.85\%) and were informed about the current status of their ePrescriptions after their medication was dispensed (1013/1276, 79.44\%). Over half of the respondents had usually received a patient instruction sheet from their physician (752/1255, 59.92\%), and nearly all of them regarded its content as clear (711/724, 98.2\%). Half of the respondents had renewed their ePrescriptions through the pharmacy (645/1281, 50.35\%), and one-third of them had acted on behalf of someone else with ePrescriptions (432/1280, 33.75\%). Problems were rarely encountered in the renewal process (49/628, 7.8\%) or when acting on behalf of another person (25/418, 6.0\%) at the pharmacy. The most common way of keeping up to date with ePrescriptions was to ask at the pharmacy (631/1278, 49.37\%). The vast majority of the respondents were satisfied with ePrescriptions as a whole (1221/1274, 95.84\%). Conclusions: Finnish pharmacy customers are satisfied with the recently implemented nationwide ePrescription system. They seldom have any difficulties purchasing medicines, renewing their ePrescriptions, or acting on behalf of someone else at the pharmacy. Customers usually keep up to date with their ePrescriptions by asking at the pharmacy. However, some customers are unaware of the practices or have difficulty keeping up to date with the status of their ePrescriptions. The provision of relevant information and assistance by health care professionals is therefore required to promote customers' adoption of the ePrescription system. ", doi="10.2196/jmir.9367", url="http://www.jmir.org/2018/2/e68/", url="http://www.ncbi.nlm.nih.gov/pubmed/29475826" } @Article{info:doi/10.2196/jmir.8977, author="Chen, Chien-I Sonia", title="Technological Health Intervention in Population Aging to Assist People to Work Smarter not Harder: Qualitative Study", journal="J Med Internet Res", year="2018", month="Jan", day="04", volume="20", number="1", pages="e3", keywords="health care", keywords="innovation", keywords="eHealth", keywords="technology", keywords="smart health", keywords="Taiwanese health care", abstract="Background: Technology-based health care has been promoted as an effective tool to enable clinicians to work smarter. However, some health stakeholders believe technology will compel users to work harder by creating extra work. Objective: The objective of this study was to investigate how and why electronic health (eHealth) has been applied in Taiwan and to suggest implications that may inspire other countries facing similar challenges. Methods: A qualitative methodology was adopted to obtain insightful inputs from deeper probing. Taiwan was selected as a typical case study, given its aging population, advanced technology, and comprehensive health care system. This study investigated 38 stakeholders in the health care ecosystem through in-depth interviews and focus groups, which provides an open, flexible, and enlightening way to study complex, dynamic, and interactive situations through informal conversation or a more structured, directed discussion. Results: First, respondents indicated that the use of technology can enable seamless patient care and clinical benefits such as flexibility in time management. Second, the results suggested that a leader's vision, authority, and management skills might influence success in health care innovation. Finally, the results implied that both internal and external organizational governance are highly relevant for implementing technology-based innovation in health care. Conclusions: This study provided Taiwanese perspectives on how to intelligently use technology to benefit health care and debated the perception that technology prevents human interaction between clinicians and patients. ", doi="10.2196/jmir.8977", url="http://www.jmir.org/2018/1/e3/", url="http://www.ncbi.nlm.nih.gov/pubmed/29301736" } @Article{info:doi/10.2196/jmir.5047, author="Flott, Kelsey and Callahan, Ryan and Darzi, Ara and Mayer, Erik", title="A Patient-Centered Framework for Evaluating Digital Maturity of Health Services: A Systematic Review", journal="J Med Internet Res", year="2016", month="Apr", day="14", volume="18", number="4", pages="e75", keywords="digital maturity", keywords="evaluation", keywords="health information exchange", keywords="patient-centered care", abstract="Background: Digital maturity is the extent to which digital technologies are used as enablers to deliver a high-quality health service. Extensive literature exists about how to assess the components of digital maturity, but it has not been used to design a comprehensive framework for evaluation. Consequently, the measurement systems that do exist are limited to evaluating digital programs within one service or care setting, meaning that digital maturity evaluation is not accounting for the needs of patients across their care pathways. Objective: The objective of our study was to identify the best methods and metrics for evaluating digital maturity and to create a novel, evidence-based tool for evaluating digital maturity across patient care pathways. Methods: We systematically reviewed the literature to find the best methods and metrics for evaluating digital maturity. We searched the PubMed database for all papers relevant to digital maturity evaluation. Papers were selected if they provided insight into how to appraise digital systems within the health service and if they indicated the factors that constitute or facilitate digital maturity. Papers were analyzed to identify methodology for evaluating digital maturity and indicators of digitally mature systems. We then used the resulting information about methodology to design an evaluation framework. Following that, the indicators of digital maturity were extracted and grouped into increasing levels of maturity and operationalized as metrics within the evaluation framework. Results: We identified 28 papers as relevant to evaluating digital maturity, from which we derived 5 themes. The first theme concerned general evaluation methodology for constructing the framework (7 papers). The following 4 themes were the increasing levels of digital maturity: resources and ability (6 papers), usage (7 papers), interoperability (3 papers), and impact (5 papers). The framework includes metrics for each of these levels at each stage of the typical patient care pathway. Conclusions: The framework uses a patient-centric model that departs from traditional service-specific measurements and allows for novel insights into how digital programs benefit patients across the health system. Trial Registration: N/A ", doi="10.2196/jmir.5047", url="http://www.jmir.org/2016/4/e75/", url="http://www.ncbi.nlm.nih.gov/pubmed/27080852" } @Article{info:doi/10.2196/jmir.5257, author="Dinesen, Birthe and Nonnecke, Brandie and Lindeman, David and Toft, Egon and Kidholm, Kristian and Jethwani, Kamal and Young, M. Heather and Spindler, Helle and Oestergaard, Ugilt Claus and Southard, A. Jeffrey and Gutierrez, Mario and Anderson, Nick and Albert, M. Nancy and Han, J. Jay and Nesbitt, Thomas", title="Personalized Telehealth in the Future: A Global Research Agenda", journal="J Med Internet Res", year="2016", month="Mar", day="01", volume="18", number="3", pages="e53", keywords="telehealth", keywords="research", keywords="individualized medicine", keywords="telemonitoring", keywords="prevention", keywords="mobile phone", doi="10.2196/jmir.5257", url="http://www.jmir.org/2016/3/e53/", url="http://www.ncbi.nlm.nih.gov/pubmed/26932229" } @Article{info:doi/10.2196/jmir.4827, author="Meurk, Carla and Leung, Janni and Hall, Wayne and Head, W. Brian and Whiteford, Harvey", title="Establishing and Governing e-Mental Health Care in Australia: A Systematic Review of Challenges and A Call For Policy-Focussed Research", journal="J Med Internet Res", year="2016", month="Jan", day="13", volume="18", number="1", pages="e10", keywords="telemedicine", keywords="e-health", keywords="e-mental health", keywords="e-therapy", keywords="Internet", keywords="online", keywords="cognitive behavioural therapy", keywords="anxiety", keywords="anxiety disorders", keywords="depression", keywords="depressive disorder", keywords="Australia", keywords="research translation", keywords="evidence-informed policy", keywords="implementation", abstract="Background: Growing evidence attests to the efficacy of e-mental health services. There is less evidence on how to facilitate the safe, effective, and sustainable implementation of these services. Objective: We conducted a systematic review on e-mental health service use for depressive and anxiety disorders to inform policy development and identify policy-relevant gaps in the evidence base. Methods: Following the PRISMA protocol, we identified research (1) conducted in Australia, (2) on e-mental health services, (3) for depressive or anxiety disorders, and (4) on e-mental health usage, such as barriers and facilitators to use. Databases searched included Cochrane, PubMed, PsycINFO, CINAHL, Embase, ProQuest Social Science, and Google Scholar. Sources were assessed according to area and level of policy relevance. Results: The search yielded 1081 studies; 30 studies were included for analysis. Most reported on self-selected samples and samples of online help-seekers. Studies indicate that e-mental health services are predominantly used by females, and those who are more educated and socioeconomically advantaged. Ethnicity was infrequently reported on. Studies examining consumer preferences found a preference for face-to-face therapy over e-therapies, but not an aversion to e-therapy. Content relevant to governance was predominantly related to the organizational dimensions of e-mental health services, followed by implications for community education. Financing and payment for e-services and governance of the information communication technology were least commonly discussed. Conclusions: Little research focuses explicitly on policy development and implementation planning; most research provides an e-services perspective. Research is needed to provide community and policy-maker perspectives. General population studies of prospective treatment seekers that include ethnicity and socioeconomic status and quantify relative preferences for all treatment modalities are necessary. ", doi="10.2196/jmir.4827", url="http://www.jmir.org/2016/1/e10/", url="http://www.ncbi.nlm.nih.gov/pubmed/26764181" } @Article{info:doi/10.2196/jmir.3817, author="Carey, Mariko and Noble, Natasha and Mansfield, Elise and Waller, Amy and Henskens, Frans and Sanson-Fisher, Rob", title="The Role of eHealth in Optimizing Preventive Care in the Primary Care Setting", journal="J Med Internet Res", year="2015", month="May", day="22", volume="17", number="5", pages="e126", keywords="eHealth", keywords="Internet", keywords="prevention", keywords="general practice", keywords="family practice", keywords="evidence-based practice", doi="10.2196/jmir.3817", url="http://www.jmir.org/2015/5/e126/", url="http://www.ncbi.nlm.nih.gov/pubmed/26001983" } @Article{info:doi/10.2196/medinform.3937, author="Dreyer, A. Nancy and Blackburn, Stella and Hliva, Valerie and Mt-Isa, Shahrul and Richardson, Jonathan and Jamry-Dziurla, Anna and Bourke, Alison and Johnson, Rebecca", title="Balancing the Interests of Patient Data Protection and Medication Safety Monitoring in a Public-Private Partnership", journal="JMIR Med Inform", year="2015", month="Apr", day="15", volume="3", number="2", pages="e18", keywords="pharmacovgilance", keywords="pregnancy", keywords="Internet", keywords="public-private partnerships", keywords="data protection", keywords="ethics", doi="10.2196/medinform.3937", url="http://medinform.jmir.org/2015/2/e18/", url="http://www.ncbi.nlm.nih.gov/pubmed/25881627" } @Article{info:doi/10.2196/ijmr.2346, author="Larsen, Eli and Mydske, Kristen Per", title="Developing Electronic Cooperation Tools: A Case From Norwegian Health Care", journal="Interact J Med Res", year="2013", month="Jun", day="19", volume="2", number="1", pages="e9", keywords="health communication", keywords="public policy", keywords="communication barriers", abstract="Background: Many countries aim to create electronic cooperational tools in health care, but the progress is rather slow. Objective: The study aimed to uncover how the authoritys' financing policies influence the development of electronic cooperational tools within public health care. Methods: An interpretative approach was used in this study. We performed 30 semistructured interviews with vendors, policy makers, and public authorities. Additionally, we conducted an extensive documentation study and participated in 18 workshops concerning information and communication technology (ICT) in Norwegian health care. Results: We found that the interorganizational communication in sectors like health care, that have undergone an independent development of their internal information infrastructure would find it difficult to create electronic services that interconnect the organizations because such connections would affect all interconnected organizations within the heterogenic structure. The organizations would, to a large extent, depend on new functionality in existing information systems. Electronic patient records play a central role in all parts of the health care sector and therefore dependence is established to the information systems and theirs vendors. The Norwegian government authorities, which run more than 80\% of the Norwegian health care, have not taken extraordinary steps to compensate for this dependency--the government's political philosophy is that each health care institution should pay for further electronic patient record development. However, cooperational tools are complex due to the number of players involved and the way they are intertwined with the overall workflow. The customers are not able to buy new functionalities on the drawing table, while the electronic patient record vendors are not willing to take the economic risk in developing cooperational tools. Thus, the market mechanisms in the domain are challenged. We also found that public projects that were only financed for the first steps of project management could partially explain why many initiatives did not get past the initial planning and specification stages, but were stopped before further development could be made. Vendors were often unwilling to provide further own contribution without guaranteed return. Conclusions: We propose that the authorities take a coordinating role and provide financial help for development of electronic cooperational tools for health because the regular market mechanisms are insufficient to push these developments to the market. It is, however, critical that the role of users be considered, and for users to decide which developments should go forward. ", doi="10.2196/ijmr.2346", url="http://www.i-jmr.org/2013/1/e9/", url="http://www.ncbi.nlm.nih.gov/pubmed/23782708" }