@Article{info:doi/10.2196/jmir.8.4.e31,
author="Knaevelsrud, Christine
and Maercker, Andreas",
title="Does the Quality of the Working Alliance Predict Treatment Outcome in Online Psychotherapy for Traumatized Patients?",
journal="J Med Internet Res",
year="2006",
month="Dec",
day="19",
volume="8",
number="4",
pages="e31",
keywords="Online therapy",
keywords="Internet",
keywords="working alliance",
keywords="therapeutic relationship",
keywords="psychotherapy",
keywords="psychotherapeutic processes",
keywords="professional-patient relations",
keywords="treatment outcome",
abstract="Background:  The provision of online counseling and online therapy is steadily increasing. The results of a number of controlled trials investigating the efficacy of online approaches indicate that some of these new treatment alternatives might indeed be effective. Yet, little is known about how the therapeutic relationship (or working alliance) evolves over the Internet and whether it influences treatment outcome as it does in traditional face-to-face therapy.  The working alliance has been defined as the extent to which a patient and a therapist work collaboratively and purposefully and connect emotionally. Objective:  The aim of the study was to investigate the quality and predictive relevance of the therapeutic alliance for patients receiving a short-term, Internet-based, cognitive-behavioral therapy program for posttraumatic stress reactions. Methods:  After rigorous screening for exclusion criteria of high dissociative tendencies, risk of psychosis, and suicidal tendencies, 48patients, who had experienced a traumatic event in the past, were included in the online treatment study. The short form of the Working Alliance Inventory (WAI-S) was administered at the fourth treatment session. The relevance of the therapeutic relationship for treatment outcome was assessed in terms of residual gain from pretreatment assessment to the end of treatment. The revised Impact of Event Scale (IES-R) and the depression and anxiety subscales of the Brief Symptom Inventory (BSI) were used to assess treatment outcome. Results:  A total of 48 participants were included in the analysis. Overall, high alliance scores were found. In contrast to previous studies of conventional face-to-face therapy, there was only a low to modest association (.13 to .33) between the quality of the therapeutic relationship and treatment outcome. Conclusion: High alliance scores indicate that it was possible to establish a stable and positive therapeutic relationship online. However, the therapeutic relationship was found to be a less relevant predictor of the therapy outcome than in face-to-face approaches. We discuss whether this finding can be attributed to methodological reasons such as the restricted range of alliance ratings obtained or the time of administration of the WAI-S, or whether the therapeutic relationship might be less relevant to the treatment outcome of online therapy approaches. ",
doi="10.2196/jmir.8.4.e31",
url="http://www.jmir.org/2006/4/e31/",
url="http://www.ncbi.nlm.nih.gov/pubmed/17213049"
}


@Article{info:doi/10.2196/jmir.8.4.e30,
author="Levin, Esther
and Levin, Alex",
title="Evaluation of Spoken Dialogue Technology for Real-Time Health Data Collection",
journal="J Med Internet Res",
year="2006",
month="Dec",
day="11",
volume="8",
number="4",
pages="e30",
keywords="Human factors",
keywords="ecological momentary assessment",
keywords="data collection",
keywords="voice recognition",
abstract="Background:  A real-time assessment of patients' experiences is an important methodology for studies in health care, quality of life, behavioral sciences, and new drug and treatment development. Ecological momentary assessment is a methodology that allows for real-time assessment of experience and behavior in a subject's natural environment. Recently, electronic data collection techniques have been introduced, including systems utilizing interactive voice response. Objective:  The objective of this project was evaluation of spoken dialogue methodology for real-time data collection of information from patients for health, behavioral, and lifestyle studies and monitoring. While the management of the data collection process was Internet-based, this additional eHealth communication channel was based on over-the-phone natural language conversation with a dialogue system utilizing automated speech recognition technology. For this study we implemented a dialogue system for patients' assessment and monitoring of chronic pain. Methods:  Experimental evaluation of usability of the Pain Monitoring Voice Diary was performed with 24 volunteers. The volunteers were asked to contribute 10 sessions with the system over a period of 2 weeks; in practice, the number of sessions per subject ranged from 1 to 20. The subjects were asked to either relate to pain episodes in their past while answering the system's questions, or use as a guidance one of nine provided medical scenarios compiled by a pain specialist, ranging from migraines and back pain to post-surgical pain (knee injury) and cancer- and chemotherapy-related afflictions. Results:  From 24 volunteers, we collected a total of 177 dialogue sessions: 171 sessions were completed, while the caller hung up in the other 6 sessions. There were a total of 2437 dialogue turns, where a dialogue turn corresponds to one system prompt and one user utterance. The data capture rate, measuring the percentage of slots filled automatically, was 98\%, while the other 2\% were flagged for transcription. Among the utterances sent to transcription, where the user had opted for the ``none of those'' option, 70\% corresponded to the ``type of pain'' slot, 20\% to the ``symptoms'' slot, and 10\% to the ``body part'' slot, indicating that those are the grammars with the highest out-of-vocabulary rate. Conclusions:  The results of this feasibility study indicated that desired accuracy of data can be achieved with a high degree of automation (98\% in the study) and that the users were indeed capable of utilizing the flexible interface, the sessions becoming more and more efficient as users' experience increased, both in terms of session duration and avoidance of troublesome dialogue situations. ",
doi="10.2196/jmir.8.4.e30",
url="http://www.jmir.org/2006/4/e30/"
}


@Article{info:doi/10.2196/jmir.8.4.e29,
author="Beaudin, S. Jennifer
and Intille, S. Stephen
and Morris, E. Margaret",
title="To Track or Not to Track: User Reactions to Concepts in Longitudinal Health Monitoring",
journal="J Med Internet Res",
year="2006",
month="Dec",
day="7",
volume="8",
number="4",
pages="e29",
keywords="User-computer interface",
keywords="computers, handheld",
keywords="ubiquitous computing",
keywords="home monitoring",
keywords="personal monitoring",
keywords="personal tracking",
keywords="personal health record",
keywords="diaries",
keywords="self-help devices",
keywords="smart homes",
abstract="Background:  Advances in ubiquitous computing, smart homes, and sensor technologies enable novel, longitudinal health monitoring applications in the home. Many home monitoring technologies have been proposed to detect health crises, support aging-in-place, and improve medical care. Health professionals and potential end users in the lay public, however, sometimes question whether home health monitoring is justified given the cost and potential invasion of privacy. Objective:  The aim of the study was to elicit specific feedback from health professionals and laypeople about how they might use longitudinal health monitoring data for proactive health and well-being. Methods:  Interviews were conducted with 8 health professionals and 26 laypeople. Participants were asked to evaluate mock data visualization displays that could be generated by novel home monitoring systems. The mock displays were used to elicit reactions to longitudinal monitoring in the home setting as well as what behaviors, events, and physiological indicators people were interested in tracking. Results:  Based on the qualitative data provided by the interviews, lists of benefits of and concerns about health tracking from the perspectives of the practitioners and laypeople were compiled. Variables of particular interest to the interviewees, as well as their specific ideas for applications of collected data, were documented. Conclusions:  Based upon these interviews, we recommend that ubiquitous ``monitoring'' systems may be more readily adopted if they are developed as tools for personalized, longitudinal self-investigation that help end users learn about the conditions and variables that impact their social, cognitive, and physical health. ",
doi="10.2196/jmir.8.4.e29",
url="http://www.jmir.org/2006/4/e29/"
}


@Article{info:doi/10.2196/jmir.8.4.e25,
author="Kastner, Monika
and Wilczynski, L. Nancy
and Walker-Dilks, Cindy
and McKibbon, Ann Kathleen
and Haynes, Brian",
title="Age-Specific Search Strategies for Medline",
journal="J Med Internet Res",
year="2006",
month="Oct",
day="25",
volume="8",
number="4",
pages="e25",
keywords="Information storage and retrieval",
keywords="Medline",
keywords="medical subject headings",
abstract="Background:  Many clinicians and researchers are interested in patients of a specific age (childhood, geriatrics, and so on). Searching for age-specific publications in large bibliographic databases such as Medline is problematic because of inconsistencies in indexing, overlapping age categories, and the spread of the relevant literature over many journals. To our knowledge, no empirically tested age-specific search strategies exist for Medline. Objective:  We sought to determine the retrieval characteristics of age-specific terms in Medline for identifying studies relevant for five clinical specialties: adult medicine, geriatric medicine, pediatric medicine, neonatal medicine, and obstetrics. Methods:  We compared age-specific search terms and phrases for the retrieval of citations in Medline with a manual hand search of the literature for 161 core health care journals. Six experienced research assistants who were trained and intensively calibrated read all issues of 161 journals for the publishing year 2000. In addition to classifying all articles for purpose and quality, study participants' ages were also recorded. Outcome measures were sensitivity, specificity, precision, and accuracy of single and combination search terms. Results:  When maximizing sensitivity, the best sensitivity and specificity achieved with combination terms were 98\% and 81.2\%, respectively, for pediatric medicine, 96.4\% and 55.9\% for geriatric medicine, 95.3\% and 83.6\% for neonatal medicine, 94.9\% and 64.5\% for adult medicine, and 82\% and 97.1\% for obstetrics. When specificity was maximized, all disciplines had an expected decrease in sensitivity and an increase in precision. Highest values for optimizing best sensitivity and specificity were achieved in neonatal medicine, 92.5\% and 92.6\%, respectively. Conclusion:  Selected single terms and combinations of MeSH terms and textwords can reliably retrieve age-specific studies cited in Medline. ",
doi="10.2196/jmir.8.4.e25",
url="http://www.jmir.org/2006/4/e25/"
}


@Article{info:doi/10.2196/jmir.8.4.e27,
author="Norman, D. Cameron
and Skinner, A. Harvey",
title="eHEALS: The eHealth Literacy Scale",
journal="J Med Internet Res",
year="2006",
month="Nov",
day="14",
volume="8",
number="4",
pages="e27",
keywords="Internet",
keywords="literacy",
keywords="public health",
keywords="psychometrics",
keywords="quantitative evaluation",
abstract="Background:  Electronic health resources are helpful only when people are able to use them, yet there remain few tools available to assess consumers' capacity for engaging in eHealth. Over 40\% of US and Canadian adults have low basic literacy levels, suggesting that eHealth resources are likely to be inaccessible to large segments of the population. Using information technology for health requires eHealth literacy---the ability to read, use computers, search for information, understand health information, and put it into context. The eHealth Literacy Scale (eHEALS) was designed (1) to assess consumers' perceived skills at using information technology for health and (2) to aid in determining the fit between eHealth programs and consumers. Objectives:  The eHEALS is an 8-item measure of eHealth literacy developed to measure consumers' combined knowledge, comfort, and perceived skills at finding, evaluating, and applying electronic health information to health problems. The objective of the study was to psychometrically evaluate the properties of the eHEALS within a population context. A youth population was chosen as the focus for the initial development primarily because they have high levels of eHealth use and familiarity with information technology tools. Methods:  Data were collected at baseline, post-intervention, and 3- and 6-month follow-up using control group data as part of a single session, randomized intervention trial evaluating Web-based eHealth programs. Scale reliability was tested using item analysis for internal consistency (coefficient alpha) and test-retest reliability estimates. Principal components factor analysis was used to determine the theoretical fit of the measures with the data. Results:  A total of 664 participants (370 boys; 294 girls) aged 13 to 21 (mean = 14.95; SD = 1.24) completed the eHEALS at four time points over 6 months. Item analysis was performed on the 8-item scale at baseline, producing a tight fitting scale with $\alpha$ = .88. Item-scale correlations ranged from r = .51 to .76. Test-retest reliability showed modest stability over time from baseline to 6-month follow-up (r = .68 to .40). Principal components analysis produced a single factor solution (56\% of variance). Factor loadings ranged from .60 to .84 among the 8 items. Conclusions:  The eHEALS reliably and consistently captures the eHealth literacy concept in repeated administrations, showing promise as tool for assessing consumer comfort and skill in using information technology for health. Within a clinical environment, the eHEALS has the potential to serve as a means of identifying those who may or may not benefit from referrals to an eHealth intervention or resource. Further research needs to examine the applicability of the eHEALS to other populations and settings while exploring the relationship between eHealth literacy and health care outcomes. ",
doi="10.2196/jmir.8.4.e27",
url="http://www.jmir.org/2006/4/e27/"
}


@Article{info:doi/10.2196/jmir.8.4.e26,
author="Adler, G. Kenneth",
title="Web Portals in Primary Care: An Evaluation of Patient Readiness and Willingness to Pay for Online Services",
journal="J Med Internet Res",
year="2006",
month="Oct",
day="26",
volume="8",
number="4",
pages="e26",
keywords="Internet",
keywords="communication",
keywords="primary health care",
keywords="electronic mail",
keywords="patient access to records",
keywords="Web-based services",
keywords="payment schemes",
abstract="Background:  Online Web communication between physician and patient has been proposed by leading primary care organizations as a way to enhance physician-patient communication, but lack of payment for this service has acted as a significant barrier to implementation. Objective:  This study evaluates current patient readiness and willingness to pay for online services in a fairly typical urban family medicine practice. Methods:  All patients that visited the author for medical care during a one-month period in the spring of 2006 were anonymously surveyed with a one-page survey instrument that inquired about demographics, willingness to pay a small annual fee for online services, the greatest fee they were willing to pay, and their most desired service. Results:  A total of 346 patients out of 2380 active patients in the study practice (14.5\%) were surveyed. The valid survey response rate was 95.1\% (329/346.) Three quarters, or 75.4\%, of patients had Internet access. The group with the highest access were 18- to 29-year-olds (97\%), and the group with the least access were those 70 years and up (56\%) (P < .001). Categorized by employment, students and employed patients had the best access at 92\% and 87\%, respectively, and retirees and disabled patients had the worst access at 66\% and 42\%, respectively (P < .001). Of all patients with Internet access, 74.6\% (n = 185) were willing to pay a small annual fee for one or more of the following online services: viewing of parts of their medical record, messaging with their physician, medication refills, appointment requests, and billing inquiries. Willingness to pay did not vary significantly by age (P = .06). Of all respondents, regardless of Internet access, 47.1\% (n = 155) were willing to pay US \$10 or more per year, with the median amount being US \$20. Of those with Internet access (n = 248), 60.1\% (n = 149) were willing to pay US \$10 or more per year, and 31\% were willing to pay US \$50 or more per year. The three most important services to patients with Internet access (n = 248), in order of importance, were emailing with their physician (34\%), Internet viewing of their medical record (22\%), and medication refills (11\%) (P < .001). Conclusions:  This study suggests that patients of all ages are currently ready and willing to pay a small annual fee for online services with their primary care physician's office. If 47.1\% of a practice of 2500 patients each paid US \$10 per year for online services, the annual revenue generated would be US \$11775. Not only does this study support the economic feasibility of patient Web portals, but it suggests that online services could form a new line of revenue for primary care physicians. ",
doi="10.2196/jmir.8.4.e26",
url="http://www.jmir.org/2006/4/e26/"
}


@Article{info:doi/10.2196/jmir.8.4.e28,
author="El Emam, Khaled
and Jabbouri, Sam
and Sams, Scott
and Drouet, Youenn
and Power, Michael",
title="Evaluating Common De-Identification Heuristics for Personal Health Information",
journal="J Med Internet Res",
year="2006",
month="Nov",
day="21",
volume="8",
number="4",
pages="e28",
keywords="Privacy",
keywords="confidentiality",
keywords="HIPAA",
keywords="security",
keywords="data disclosure",
keywords="ethics",
abstract="Background:  With the growing adoption of electronic medical records, there are increasing demands for the use of this electronic clinical data in observational research. A frequent ethics board requirement for such secondary use of personal health information in observational research is that the data be de-identified. De-identification heuristics are provided in the Health Insurance Portability and Accountability Act Privacy Rule, funding agency and professional association privacy guidelines, and common practice. Objective:  The aim of the study was to evaluate whether the re-identification risks due to record linkage are sufficiently low when following common de-identification heuristics and whether the risk is stable across sample sizes and data sets. Methods:  Two methods were followed to construct identification data sets. Re-identification attacks were simulated on these. For each data set we varied the sample size down to 30 individuals, and for each sample size evaluated the risk of re-identification for all combinations of quasi-identifiers. The combinations of quasi-identifiers that were low risk more than 50\% of the time were considered stable. Results:  The identification data sets we were able to construct were the list of all physicians and the list of all lawyers registered in Ontario, using 1\% sampling fractions. The quasi-identifiers of region, gender, and year of birth were found to be low risk more than 50\% of the time across both data sets. The combination of gender and region was also found to be low risk more than 50\% of the time. We were not able to create an identification data set for the whole population. Conclusions:  Existing Canadian federal and provincial privacy laws help explain why it is difficult to create an identification data set for the whole population. That such examples of high re-identification risk exist for mainstream professions makes a strong case for not disclosing the high-risk variables and their combinations identified here. For professional subpopulations with published membership lists, many variables often needed by researchers would have to be excluded or generalized to ensure consistently low re-identification risk. Data custodians and researchers need to consider other statistical disclosure techniques for protecting privacy. ",
doi="10.2196/jmir.8.4.e28",
url="http://www.jmir.org/2006/4/e28/"
}