Methods to Evaluate the Effects of Internet-Based Digital Health Interventions for Citizens: Systematic Review of Reviews

Quality of the digital gp visits and characteristics of the users: retrospective observational study

OBJECTIVES

This study compares the demographics, diagnoses, re-admission rates, sick leaves, and prescribed medications of patients accessing digital general practitioner (GP) visits with those of patients opting for traditional face-to-face appointments in a primary health care setting.

DESIGN

The study adopted a retrospective analysis of patient record data collected in 2019, comparing visits to a digital primary health center with traditional health center visits.

SETTING

Primary health care.

PARTICIPANTS

The data encompassed patients who utilized the digital clinic and those who visited public health centers for primary health care services.

MAIN OUTCOME MEASURES

The study assessed demographics, health diagnoses, prescribed medications, sick leave recommendations, re-admission rates, and differences in costs between digital clinic and face-to-face visits. Secondary outcomes included a comparative analysis of medication categories, resolution rates for health problems, and potential impacts on health care utilization.

RESULTS

Digital clinic users were typically younger, more educated, and predominantly female compared with health centre users. Digital visits were well-suited for uncomplicated infections, while health centre appointments were associated with a higher prevalence of chronic conditions. Medication patterns differed between the two modalities, with digital clinic users receiving generic over-the-counter drugs and antibiotics, whereas health centre visits commonly involved cardiac and antihypertensive medications. Sick leave recommendations were slightly higher in the digital clinic, but the difference was not significant. Approximately 70% of health problems addressed in the digital clinic were successfully resolved, and the cost of digital visits was about 50,3% of face-to-face appointments.

CONCLUSION

Digital health care services offer a cost-efficient alternative for specific health problems, appealing to younger, educated individuals, when compared to the users of public health center, and may enable improvement of cost-effectiveness combined with acceptable demand management and patient segmentation practices. The results highlight the potential benefits of digital clinics, particularly for uncomplicated cases, while also emphasizing the importance of suitable referral mechanisms for in-person consultations.

Methods, Indicators, and End-User Involvement in the Evaluation of Digital Health Interventions for the Public: Scoping Review

BACKGROUND

Digital health interventions (DHIs) have the potential to enable public end users, such as citizens and patients, to manage and improve their health. Although the number of available DHIs is increasing, examples of successfully established DHIs in public health systems are limited. To counteract the nonuse of DHIs, they should be comprehensively evaluated while integrating end users. Unfortunately, there is a wide variability and heterogeneity according to the approaches of evaluation, which creates a methodological challenge.

OBJECTIVE

This scoping review aims to provide an overview of the current established processes for evaluating DHIs, including methods, indicators, and end-user involvement. The review is not limited to a specific medical field or type of DHI but offers a holistic overview.

METHODS

This scoping review was conducted following the JBI methodology for scoping reviews based on the framework by Arksey & O'Malley and complies with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Three scientific databases (PubMed, Scopus, and Science Direct) were searched in April 2023. English and German studies between 2008 and 2023 were considered when evaluating DHIs that explicitly address public end users. The process of study selection was carried out by several researchers to avoid reviewer bias.

RESULTS

The search strategy identified 9618 publications, of which 160 were included. Among these included articles, 200 evaluations were derived and analyzed. The results showed that there is neither a consensus on the methods to evaluate DHIs nor a commonly agreed definition or usage of the evaluated indicators, which results in a broad variety of evaluation practices. This aligns with observations of the existing literature. It was found that there is a lack of references to existing frameworks for the evaluation of DHIs. The majority of the included studies referred to user-centered approaches and involved end users in the evaluation process. As assistance for people developing and evaluating DHIs and as a basis for thinking about appropriate ways to evaluate DHIs, a results matrix was created where the findings were combined per DHI cluster. Additionally, general recommendations for the evaluators of DHIs were formulated.

CONCLUSIONS

The findings of this scoping review offer a holistic overview of the variety and heterogeneity according to the approaches of evaluation of DHIs for public end users. Evaluators of these DHIs should be encouraged to reference established frameworks or measurements for justification. This would ease the transferability of the results among similar evaluation studies within the digital health sector, thereby enhancing the coherence and comparability of research in this area.

The relationship between patient experience and real-world digital health access in primary care: A population-based cross-sectional study

Implementing digital health technologies in primary care is anticipated to improve patient experience. We examined the relationships between patient experience and digital health access in primary care settings in Ontario, Canada. We conducted a retrospective cross-sectional study using patient responses to the Health Care Experience Survey linked to health and administrative data between April 2019-February 2020. We measured patient experience by summarizing HCES questions. We used multivariable logistic regression stratified by the number of primary care visits to investigate associations between patient experience with digital health access and moderating variables. Our cohort included 2,692 Ontario adults, of which 63.0% accessed telehealth, 2.6% viewed medical records online, and 3.6% booked appointments online. Although patients reported overwhelmingly positive experiences, we found no consistent relationship with digital health access. Online appointment booking access was associated with lower odds of poor experience for patients with three or more primary care visits in the past 12 months (adjusted odds ratio 0.16, 95% CI 0.02-0.56). Younger age, tight financial circumstances, English as a second language, and knowing their primary care provider for fewer years had greater odds of poor patient experience. In 2019/2020, we found limited uptake of digital health in primary care and no clear association between real-world digital health adoption and patient experience in Ontario. Our findings provide an essential context for ensuing rapid shifts in digital health adoption during the COVID-19 pandemic, serving as a baseline to reexamine subsequent improvements in patient experience.

Impact of digital services on healthcare and social welfare: An umbrella review

BACKGROUND

Digital services can be effective and cost-efficient options for treating non-communicable diseases, but generalizability is limited due to heterogeneous treatment effects. This umbrella review aims to evaluate the impact of digital services on population health, costs, and patient and healthcare professional satisfaction, and to identify facilitators and barriers to using digital services in healthcare and social welfare.

METHODS

The protocol of the study was registered on the 4th of September 2022 to the International Prospective Register of Systematic Reviews, PROSPERO (CRD42022355635). The review was performed using the Centre for Reviews and Dissemination, Cochrane, Ovid Medline, Scopus, and Web of Science in June 2022. The methodological quality of the included reviews was assessed. The impact of digital services was categorized as no evidence, no dominance, and mixed and positive effect. Inductive content analysis was used to identify facilitators and barriers.

RESULTS

A total of 66 studies were included in the review, 64 % of which were evaluated as high quality. Studies on the impact of digital services in social welfare were not identified. Sixty-five percent of reviews evaluated the impact of digital services on population health with mixed effects; 21 % were on costs with mixed effects; 27 % were on patient satisfaction with positive effects; and 7.6 % were on healthcare professionals' satisfaction with mixed effects. Various features, allocation, end-user support, organized services, and service development facilitated the use of digital services. Correspondingly, barriers were related to service limitations, digital competency, funding- and service strategies, resources and change management.

CONCLUSIONS

Compared to usual care, digital services had a mixed impact on population health and costs with high satisfaction in patients. Mixed healthcare professionals' satisfaction was associated with the use of digital services, and it was less studied. To ensure successful implementation and sustainability of digital services, attention must be paid to address barriers and supporting facilitators at all levels.

Tanzania's and Germany's Digital Health Strategies and Their Consistency With the World Health Organization's Global Strategy on Digital Health 2020-2025: Comparative Policy Analysis

BACKGROUND

In recent years, the fast-paced adoption of digital health (DH) technologies has transformed health care delivery. However, this rapid evolution has also led to challenges such as uncoordinated development and information silos, impeding effective health care integration. Recognizing these challenges, nations have developed digital health strategies (DHSs), aligning with their national health priorities and guidance from global frameworks. The World Health Organization (WHO)'s Global Strategy on Digital Health 2020-2025 (GSDH) guides national DHSs.

OBJECTIVE

This study analyzes the DHSs of Tanzania and Germany as case studies and assesses their alignment with the GSDH and identifies strengths, shortcomings, and areas for improvement.

METHODS

A comparative policy analysis was conducted, focusing on the DHSs of Tanzania and Germany as case studies, selected for their contrasting health care systems and cooperative history. The analysis involved a three-step process: (1) assessing consistency with the GSDH, (2) comparing similarities and differences, and (3) evaluating the incorporation of emergent technologies. Primary data sources included national eHealth policy documents and related legislation.

RESULTS

Both Germany's and Tanzania's DHSs align significantly with the WHO's GSDH, incorporating most of its 35 elements, but each missing 5 distinct elements. Specifically, Tanzania's DHS lacks in areas such as knowledge management and capacity building for leaders, while Germany's strategy falls short in engaging health care service providers and beneficiaries in development phases and promoting health equity. Both countries, however, excel in other aspects like collaboration, knowledge transfer, and advancing national DHSs, reflecting their commitment to enhancing DH infrastructures. The high ratings of both countries on the Global Digital Health Monitor underscore their substantial progress in DH, although challenges persist in adopting the rapidly advancing technologies and in the need for more inclusive and comprehensive strategies.

CONCLUSIONS

This study reveals that both Tanzania and Germany have made significant strides in aligning their DHSs with the WHO's GSDH. However, the rapid evolution of technologies like artificial intelligence and machine learning presents challenges in keeping strategies up-to-date. This study recommends the development of more comprehensive, inclusive strategies and regular revisions to align with emerging technologies and needs. The research underscores the importance of context-specific adaptations in DHSs and highlights the need for broader, strategic guidelines to direct the future development of the DH ecosystem. The WHO's GSDH serves as a crucial blueprint for national DHSs. This comparative analysis demonstrates the value and challenges of aligning national strategies with global guidelines. Both Tanzania and Germany offer valuable insights into developing and implementing effective DHSs, highlighting the importance of continuous adaptation and context-specific considerations. Future policy assessments require in-depth knowledge of the country's health care needs and structure, supplemented by stakeholder input for a comprehensive evaluation.

Evaluation of Patient-Facing Mobile Apps to Support Physiotherapy Care: Systematic Review

BACKGROUND

Mobile health interventions delivered through mobile apps are increasingly used in physiotherapy care. This may be because of the potential of apps to facilitate changes in behavior, which is central to the aims of care delivered by physiotherapists. A benefit of using apps is their ability to incorporate behavior change techniques (BCTs) that can optimize the effectiveness of physiotherapeutic interventions. Research continues to suggest that despite their importance, behavior change strategies are often missing in patient management. Evaluating mobile apps that physiotherapists can use to drive behavior change may inform clinical practice and potentially improve patient outcomes. Examining the quality of apps and exploring their key features that can support behavior change and physiotherapy care are important aspects of such an evaluation.

OBJECTIVE

The primary aim of this study was to describe the range of mobile apps in app stores that are intended for use by patients to support physiotherapy care. The secondary aims were to assess app quality, BCTs, and their behavior change potential.

METHODS

A systematic review of mobile apps in app stores was undertaken. The Apple App Store and Google Play were searched using a 2-step search strategy, using terms relevant to the physiotherapy discipline. Strict inclusion and exclusion criteria were applied: apps had to be intended for use by patients and be self-contained (or stand-alone) without the requirement to be used in conjunction with a partner wearable device or another plugin. Included apps were coded for BCTs using the Behavior Change Technique Taxonomy version 1. App quality was assessed using the Mobile App Rating Scale, and the App Behavior Change Scale was used to assess the app's potential to change behavior.

RESULTS

In total, 1240 apps were screened, and 35 were included. Of these 35 apps, 22 (63%) were available on both the Apple App Store and Google Play platforms. In total, 24 (69%) were general in their focus (eg, not condition-specific), with the remaining 11 (31%) being more specific (eg, knee rehabilitation and pelvic floor training). The mean app quality score (Mobile App Rating Scale) was 3.7 (SD 0.4) of 5 (range 2.8-4.5). The mean number of BCTs identified per app was 8.5 (SD 3.6). BCTs most frequently included in the apps were instruction on how to perform a behavior (n=32), action planning (n=30), and self-monitoring of behavior (n=28). The mean behavior change potential score (App Behavior Change Scale) was 8.5 (SD 3.1) of 21 (range 3-15).

CONCLUSIONS

Mobile apps available to support patient care received from a physiotherapist are of variable quality. Although they contain some BCTs, the potential for behavior change varied widely across apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29047.

Digital intervention for public health: searching for implementing characteristics, concepts and recommendations: scoping review

Studying the impact of digital interventions on public health can help ensure that the offered services produce the desired results. In order to address these factors, the subsequent study uses a scope review to evaluate the state of the field while concentrating on ideas and suggestions that represent factors that have been crucial in the management of digital intervention for public health. To shed light on the traits, ideas and suggestions related to public health digital intervention, a scoping review was carried out. Five electronic databases were used to locate pertinent research that were published before February 2022. All texts were examined, and study abstracts were scrutinized to determine their eligibility. The last analysis of this study included fifteen publications; five reviews, four qualitative studies, two quantitative studies, one viewpoint study, one mixed-method study, one perspective study, and one interventional study. The key ideas for digital interventions in population management and health studies are presented in this overview. Many concepts, implementation characteristics and recommendations have been raised which highlight the future role of these interventions to enhance public engagement and health equity.

A Pilot Study to Examine the Feasibility and Acceptability of a Virtual Adaptation of an In-Person Adolescent Diabetes Prevention Program

BACKGROUND

Rates of prediabetes and type 2 diabetes are alarmingly high among racial/ethnic minority youth. The current study examines the virtual adaptation of an in-person peer-led youth diabetes prevention program.

METHODS

The initial phase involved the study team adapting workshop sessions from an in-person to a virtual format (Zoom). We conducted a 2-h feasibility pilot in December 2020 and implemented the full 12 session pilot program from June to September 2021 with 14 prediabetic adolescents recruited from our hospital-based general pediatric clinic. Weekly sessions were led by trained peer educators and focused on promoting healthy eating and physical activity using behavioral techniques (e.g., goal setting, brainstorming, and problem solving).

RESULTS

The virtual adaptation of our program was shown to be feasible and acceptable among our pilot participants. We were able to deliver the same workshop content and behavioral skills development as the in-person workshop using a variety of Zoom features.

CONCLUSIONS

Our peer-led youth diabetes prevention program was successfully adapted and implemented in a virtual format and was well accepted by at-risk youth. Future research is needed to examine the impact of virtual youth lifestyle interventions on behavioral and clinical outcomes such as weight and diabetes risk.

Digital Patient Experience: Umbrella Systematic Review

BACKGROUND

The adoption and use of technology have significantly changed health care delivery. Patient experience has become a significant factor in the entire spectrum of patient-centered health care delivery. Digital health facilitates further improvement and empowerment of patient experiences. Therefore, the design of digital health is served by insights into the barriers to and facilitators of digital patient experience (PEx).

OBJECTIVE

This study aimed to systematically review the influencing factors and design considerations of PEx in digital health from the literature and generate design guidelines for further improvement of PEx in digital health.

METHODS

We performed an umbrella systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. We searched Scopus, PubMed, and Web of Science databases. Two rounds of small random sampling (20%) were independently reviewed by 2 reviewers who evaluated the eligibility of the articles against the selection criteria. Two-round interrater reliability was assessed using the Fleiss-Cohen coefficient (k1=0.88 and k2=0.80). Thematic analysis was applied to analyze the extracted data based on a small set of a priori categories.

RESULTS

The search yielded 173 records, of which 45 (26%) were selected for data analysis. Findings and conclusions showed a great diversity; most studies presented a set of themes (19/45, 42%) or descriptive information only (16/45, 36%). The digital PEx-related influencing factors were classified into 9 categories: patient capability, patient opportunity, patient motivation, intervention technology, intervention functionality, intervention interaction design, organizational environment, physical environment, and social environment. These can have three types of impacts: positive, negative, or double edged. We captured 4 design constructs (personalization, information, navigation, and visualization) and 3 design methods (human-centered or user-centered design, co-design or participatory design, and inclusive design) as design considerations.

CONCLUSIONS

We propose the following definition for digital PEx: "Digital patient experience is the sum of all interactions affected by a patient's behavioral determinants, framed by digital technologies, and shaped by organizational culture, that influence patient perceptions across the continuum of care channeling digital health." In this study, we constructed a design and evaluation framework that contains 4 phases-define design, define evaluation, design ideation, and design evaluation-and 9 design guidelines to help digital health designers and developers address digital PEx throughout the entire design process. Finally, our review suggests 6 directions for future digital PEx-related research.

Association of dental caries with use of internet and social media among 12 and 15-year-olds

OBJECTIVES

To investigate the association of dental caries with use of internet and social media to gain information on oral health and to evaluate the impact of this practice on oral health inequalities among 12 and 15-year-olds.

METHODS

Data from the Children's Dental Health Survey (CDHS) 2013, England Wales and Northern Ireland were used. The survey included sociodemographic, health behaviours, use of internet and social media, and clinical dental data. The association between the prevalence of caries experience (DMFT ≥ 1) and the number of untreated dental decay with use of internet and social media was assessed adjusting for age, gender, country, deprivation, toothbrushing, dental visits and consumption of sugary drinks and food.

RESULTS

A total of 4414 children were included in the analysis. Children who reported using internet and social media to gain information on oral health had significantly higher odds for caries experience (1.29, 95%CI: 1.03-1.62) in the model adjusting for age, gender and country. After adjusting for behavioural and socioeconomic factors the relationship remained positive, but not statistically significant. The use of internet and social media was not significantly associated with the number of untreated caries. Social gradients in oral health remained significant after adjusting for use of internet and social media.

CONCLUSIONS

The association between use of internet and social media, and dental caries could be mediated by health behaviours. Younger adults and children may be using the Internet and social media seeking information on dental caries, but longer online hours may also increase the caries risk. Internet-based health interventions should be supported by preventive strategies to promote effective and positive internet use.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

BACKGROUND

Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

AIMS

To describe the current landscape of digital health interventions in oncology in Africa.

METHODS

We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

RESULTS

The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

CONCLUSION

Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.

Introducing a digital portal that enables patients to access their health records

People manage many aspects of their lives online through digital devices such as smartphones. However, the ability for people to manage their healthcare digitally has not yet been fully realised. Patient portals are secure online links that offer patients convenient and constant access to their personal health records. Evidence has suggested that patient portals can enhance patients' engagement in their own care and support them to manage any long-term conditions. This article describes the introduction of a patient portal at Cambridge University Hospitals NHS Foundation Trust. The article outlines the process of implementation and discusses the lessons learned, which may be of value to other organisations.

Effects of Digital Technologies on Older People's Access to Health and Social Care: Umbrella Review

Background

The 2020 COVID-19 pandemic prompted the rapid implementation of new and existing digital technologies to facilitate access to health and care services during physical distancing. Older people may be disadvantaged in that regard if they are unable to use or have access to smartphones, tablets, computers, or other technologies.

Objective

In this study, we synthesized evidence on the impact of digital technologies on older adults’ access to health and social services.

Methods

We conducted an umbrella review of systematic reviews published from January 2000 to October 2019 using comprehensive searches of 6 databases. We looked for reviews in a population of adults aged ≥65 years in any setting, reporting outcomes related to the impact of technologies on access to health and social care services.

Results

A total of 7 systematic reviews met the inclusion criteria, providing data from 77 randomized controlled trials and 50 observational studies. All of them synthesized findings from low-quality primary studies, 2 of which used robust review methods. Most of the reviews focused on digital technologies to facilitate remote delivery of care, including consultations and therapy. No studies examined technologies used for first contact access to care, such as online appointment scheduling. Overall, we found no reviews of technology to facilitate first contact access to health and social care such as online appointment booking systems for older populations.

Conclusions

The impact of digital technologies on equitable access to services for older people is unclear. Research is urgently needed in order to understand the positive and negative consequences of digital technologies on health care access and to identify the groups most vulnerable to exclusion.

Supportive Care Interventions for People With Cancer Assisted by Digital Technology: Systematic Review

BACKGROUND

Although relatively new, digital health interventions are demonstrating rapid growth because of their ability to facilitate access and overcome issues of location, time, health status, and most recently, the impact of a major pandemic. With the increased uptake of digital technologies, digital health has the potential to improve the provision of supportive cancer care.

OBJECTIVE

This systematic review aims to evaluate digital health interventions for supportive cancer care.

METHODS

Published literature between 2000 and 2020 was systematically searched in MEDLINE, PubMed, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and Scopus. Eligible publications were randomized controlled trials of clinician-led digital health interventions to support adult cancer patients. The interventions included were determined by applying a digital health conceptual model. Studies were appraised for quality using the revised Cochrane risk of bias tool.

RESULTS

Twenty randomized controlled trials met the inclusion criteria for the analysis. Interventions varied by duration, frequency, degree of technology use, and applied outcome measures. Interventions targeting a single tumor stream, predominantly breast cancer, and studies involving the implementation of remote symptom monitoring have dominated the results. In most studies, digital intervention resulted in significant positive outcomes in patient-reported symptoms, levels of fatigue and pain, health-related quality of life, functional capacity, and depression levels compared with the control.

CONCLUSIONS

Digital health interventions are helpful and effective for supportive care of patients with cancer. There is a need for high-quality research. Future endeavors could focus on the use of valid, standardized outcome measures, maintenance of methodological rigor, and strategies to improve patient and health professional engagement in the design and delivery of supportive digital health interventions.

TRIAL REGISTRATION

PROSPERO CRD42020149730; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149730.

Consumer understanding of terms used in imaging reports requested for low back pain: a cross-sectional survey

OBJECTIVES

To investigate (1) self-reported societal comprehension of common and usually non-serious terms found in lumbar spine imaging reports and (2) its relationship to perceived seriousness, likely persistence of low back pain (LBP), fear of movement, back beliefs and history and intensity of LBP.

DESIGN

Cross-sectional online survey of the general public.

SETTING

Five English-speaking countries: UK, USA, Canada, New Zealand and Australia.

PARTICIPANTS

Adults (age >18 years) with or without a history of LBP recruited in April 2019 with quotas for country, age and gender.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported understanding of 14 terms (annular fissure, disc bulge, disc degeneration, disc extrusion, disc height loss, disc protrusion, disc signal loss, facet joint degeneration, high intensity zone, mild canal stenosis, Modic changes, nerve root contact, spondylolisthesis and spondylosis) commonly found in lumbar spine imaging reports. For each term, we also elicited worry about its seriousness, and whether its presence would indicate pain persistence and prompt fear of movement.

RESULTS

From 774 responses, we included 677 (87.5%) with complete and valid responses. 577 (85%) participants had a current or past history of LBP of whom 251 (44%) had received lumbar spine imaging. Self-reported understanding of all terms was poor. At best, 235 (35%) reported understanding the term 'disc degeneration', while only 71 (10.5%) reported understanding the term 'Modic changes'. For all terms, a moderate to large proportion of participants (range 59%-71%), considered they indicated a serious back problem, that pain might persist (range 52%-71%) and they would be fearful of movement (range 42%-57%).

CONCLUSION

Common and usually non-serious terms in lumbar spine imaging reports are poorly understood by the general population and may contribute to the burden of LBP.

TRIAL REGISTRATION NUMBER

ACTRN12619000545167.

Introducing a digital portal that enables patients to access their health records

People manage many aspects of their lives online through digital devices such as smartphones. However, the ability for people to manage their healthcare digitally has not yet been fully realised. Patient portals are secure online links that offer patients convenient and constant access to their personal health records. Evidence has suggested that patient portals can enhance patients' engagement in their own care and support them to manage any long-term conditions. This article describes the introduction of a patient portal at Cambridge University Hospitals NHS Foundation Trust. The article outlines the process of implementation and discusses the lessons learned, which may be of value to other organisations.

Sensor-based platforms for remote management of chronic diseases in developing regions: A qualitative approach examining the perspectives of healthcare professionals

The continuous monitoring of chronic diseases serves as one of the cornerstones in the efforts to improve the quality of life of patients and maintain the healthcare services provided to them. This study aims to provide an in-depth understanding of the perspectives of healthcare professionals on using sensor-based networks (SBN) used for remote and continuous monitoring of patients with chronic illness in Kosovo, a developing country. A qualitative research method was used to interview 26 healthcare professionals. The study results demonstrate the positive attitudes of participants to using SBN, and considers their concerns on the impact of these platforms on the patient's life, the number of visits in the medical centre, data privacy concerning interactions between patients and their medical personnel and the costs of the platform. Further to that, the study makes an important contribution to knowledge by identifying the challenges and drawbacks of these platforms and provides recommendations for system designers.

Digital Health Interventions in Physiotherapy: Development of Client and Health Care Provider Survey Instruments

BACKGROUND

The advancement of digital health has widened the scope of technology use across multiple frontiers of health care services, including personalized therapeutics, mobile health, eHealth record management, and telehealth consultations. The World Health Organization (WHO) responded to this in 2018 by publishing an inaugural broad classification framework of digital health interventions (DHIs) used to address contemporary health system needs.

OBJECTIVE

This study aims to describe the systematic development of dual survey instruments (clinician and patient) to support data collection, administered in a physiotherapy setting, about perceptions toward DHIs. This is achieved by adapting the WHO framework classification for DHIs for application in real-world research.

METHODS

Using a qualitative item review approach, WHO DHI descriptors were adapted and refined systematically to be used in a survey form. This approach was designed to align with the processes of delivering and receiving care in clinical practice, using musculoskeletal physiotherapy as a practical case scenario.

RESULTS

Complementary survey instruments (for health care providers and clients) were developed by adapting descriptor items. These instruments will be used in a larger study exploring the willingness of physiotherapists and patients to use digital technologies in the management of musculoskeletal conditions.

CONCLUSIONS

This study builds on the WHO-standardized DHI framework. We developed dual novel survey instruments by adapting and refining the functions of DHIs. These may be deployed to explore the perceived usefulness and application of DHIs for different clinical care functions. Researchers may wish to use these survey instruments to examine digital health use systematically in a variety of clinical fields or technology scenarios in a way that is standardized and generalizable.

Digital Health Interventions: New opportunities for health science librarians

This article acquaints health science librarians with digital health interventions (DHIs) and suggests ways they can become involved with initiatives in their own organisations. Examples of DHIs are provided and the risks and benefits of these applications are examined, including increasing accuracy of diagnosis & treatment, and health care efficiencies within legal and ethical frameworks. The WHO Guideline on digital interventions for health system strengthening is a useful resource which highlights ways that countries can use digital health technology to improve people's health and essential services. JM proposes the creation of a road map to assist health science librarians in becoming involved in digital health, providing practical suggestions to inform the development of action plans within your local service provision. J.M.

Adult patient access to electronic health records

BACKGROUND

To support patient-centred care, healthcare organisations increasingly offer patients access to data stored in the institutional electronic health record (EHR).

OBJECTIVES

Primary objective 1. To assess the effects of providing adult patients with access to electronic health records (EHRs) alone or with additional functionalities on a range of patient, patient-provider, and health resource consumption outcomes, including patient knowledge and understanding, patient empowerment, patient adherence, patient satisfaction with care, adverse events, health-related quality of life, health-related outcomes, psychosocial health outcomes, health resource consumption, and patient-provider communication. Secondary objective 1. To assess whether effects of providing adult patients with EHR access alone versus EHR access with additional functionalities differ among patient groups according to age, educational level, or different status of disease (chronic or acute).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Scopus in June 2017 and in April 2020.

SELECTION CRITERIA

Randomised controlled trials and cluster-randomised trials of EHR access with or without additional functionalities for adults with any medical condition.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 10 studies with 78 to 4500 participants and follow-up from 3 to 24 months. Nine studies assessed the effects of EHR with additional functionalities, each addressing a subset of outcomes sought by this review. Five studies focused on patients with diabetes mellitus, four on patients with specific diseases, and one on all patients. All studies compared EHR access alone or with additional functionalities plus usual care versus usual care only. No studies assessing the effects of EHR access alone versus EHR access with additional functionalities were identified. Interventions required a variety of data within the EHR, such as patient history, problem list, medication, allergies, and lab results. In addition to EHR access, eight studies allowed patients to share self-documented data, seven offered individualised disease management functions, seven offered educational disease-related information, six supported secure communication, and one offered preventive reminders. Only two studies were at low or unclear risk of bias across domains. Meta-analysis could not be performed, as participants, interventions, and outcomes were too heterogeneous, and most studies presented results based on different adjustment methods or variables. The quality of evidence was rated as low or very low across outcomes. Overall differences between intervention and control groups, if any, were small. The relevance of any small effects remains unclear for most outcomes because in most cases, trial authors did not define a minimal clinically important difference. Overall, results suggest that the effects of EHR access alone and with additional functionalities are mostly uncertain when compared with usual care. Patient knowledge and understanding: very low-quality evidence is available from one study, so we are uncertain about effects of the intervention on patient knowledge about diabetes and blood glucose testing. Patient empowerment: low-quality evidence from three studies suggests that the intervention may have little or no effect on patient empowerment measures. Patient adherence: low-quality evidence from two studies suggests that the intervention may slightly improve adherence to the process of monitoring risk factors and preventive services. Effects on medication adherence are conflicting in two studies; this may or may not improve to a clinically relevant degree. Patient satisfaction with care: low-quality evidence from three studies suggests that the intervention may have little or no effect on patient satisfaction, with conflicting results. Adverse events: two small studies reported on mortality; one of these also reported on serious and other adverse events, but sample sizes were too small for small differences to be detected. Therefore, low-quality evidence suggests that the intervention may have little to no effect on mortality and other adverse events. Health-related quality of life: only very low-quality evidence from one study is available. We are uncertain whether the intervention improves disease-specific quality of life of patients with asthma. Health-related outcomes: low-quality evidence from eight studies suggests that the intervention may have little to no effect on asthma control, glycosylated haemoglobin (HbA1c) levels, blood pressure, low-density lipoprotein or total cholesterol levels, body mass index or weight, or 10-year Framingham risk scores. Low-quality evidence from one study suggests that the composite scores of risk factors for diabetes mellitus may improve slightly with the intervention, but there is uncertainty about effects on ophthalmic medications or intraocular pressure. Psychosocial health outcomes: no study investigated psychosocial health outcomes in a more than anecdotal way. Health resource consumption: low-quality evidence for adult patients in three studies suggests that there may be little to no effect of the intervention on different measures of healthcare use. Patient-provider communication: very low-quality evidence is available from a single small study, and we are uncertain whether the intervention improves communication measures, such as the number of messages sent.

AUTHORS' CONCLUSIONS

The effects of EHR access with additional functionalities in comparison with usual care for the most part are uncertain. Only adherence to the process of monitoring risk factors and providing preventive services as well as a composite score of risk factors for diabetes mellitus may improve slightly with EHR access with additional functionalities. Due to inconsistent terminology in this area, our search may have missed relevant studies. As the overall quality of evidence is very low to low, future research is likely to change these results. Further trials should investigate the impact of EHR access in a broader range of countries and clinical settings, including more patients over a longer period of follow-up, as this may increase the likelihood of detecting effects of the intervention, should these exist. More studies should focus on assessing outcomes such as patient empowerment and behavioural outcomes, rather than concentrating on health-related outcomes alone. Future studies should distinguish between effects of EHR access only and effects of additional functionalities, and investigate the impact of mobile EHR tools. Future studies should include information on usage patterns, and consider the potential for widening health inequalities with implementation of EHR access. A taxonomy for EHR access and additional functionalities should be developed to promote consistency and comparability of outcome measures, and facilitate future reviews by better enabling cross-study comparisons.

ReMindCare, an app for daily clinical practice in patients with first episode psychosis: A pragmatic real-world study protocol

AIM

Despite the potential benefits of e-health interventions for patients with psychosis, the integration of these applications into the clinical workflow and analysis of their long-term effects still face significant challenges. To address these issues, we developed the ReMindCare app. This app aims to improve the treatment quality for patients with psychosis. We chose to study the app in real world and pragmatic manner to ensure results will be generalizable.

METHODS

This is a naturalistic empirical study of patients in a first episode of psychosis programme. The app was purpose-designed based on two previous studies, and it offers the following assessments: (a) three daily questions regarding anxiety, sadness and irritability; and (b) 18 weekly questions about medication adherence, medication side effects, medication attitudes and prodromal symptoms. The app offers preset alerts, reminders and the ability for patients to reach out to their clinicians. Data captured by the app are linked to the electronic medical record of the patient. Patients will use the app as part of their ongoing care for a maximum period of 5 years, and assessments will occur at baseline and at the end of the first, second and fifth years of app use.

RESULTS

Recruitment started in October 2018 and is still ongoing.

CONCLUSIONS

The ReMindCare app represents early real-world use of digital mental health tools that offer direct integration into clinical care. High retention and compliance rates are expected, and this will in turn lead to improved quality of assessments and communication between patients and clinicians.

Barriers to Creating Scalable Business Models for Digital Health Innovation in Public Systems: Qualitative Case Study

Background

Health systems are increasingly looking toward the private sector to provide digital solutions to address health care demands. Innovation in digital health is largely driven by small- and medium-sized enterprises (SMEs), yet these companies experience significant barriers to entry, especially in public health systems. Complex and fragmented care models, alongside a myriad of relevant stakeholders (eg, purchasers, providers, and producers of health care products), make developing value propositions for digital solutions highly challenging.

Objective

This study aims to identify areas for health system improvement to promote the integration of innovative digital health technologies developed by SMEs.

Methods

This paper qualitatively analyzes a series of case studies to identify health system barriers faced by SMEs developing digital health technologies in Canada and proposed solutions to encourage a more innovative ecosystem. The Women’s College Hospital Institute for Health System Solutions and Virtual Care established a consultation program for SMEs to help them increase their innovation capacity and take their ideas to market. The consultation involved the SME filling out an onboarding form and review of this information by an expert advisory committee using guided considerations, leading to a recommendation report provided to the SME. This paper reports on the characteristics of 25 SMEs who completed the program and qualitatively analyzed their recommendation reports to identify common barriers to digital health innovation.

Results

A total of 2 central themes were identified, each with 3 subthemes. First, a common barrier to system integration was the lack of formal evaluation, with SMEs having limited resources and opportunities to conduct such an evaluation. Second, the health system’s current structure does not create incentives for clinicians to use digital technologies, which threatens the sustainability of SMEs’ business models. SMEs faced significant challenges in engaging users and payers from the public system due to perverse economic incentives. Physicians are compensated by in-person visits, which actively works against the goals of many digital health solutions of keeping patients out of clinics and hospitals.

Conclusions

There is a significant disconnect between the economic incentives that drive clinical behaviors and the use of digital technologies that would benefit patients’ well-being. To encourage the use of digital health technologies, publicly funded health systems need to dedicate funding for the evaluation of digital solutions and streamlined pathways for clinical integration.

Opportunities and challenges of delivering digital clinical trials: lessons learned from a randomised controlled trial of an online behavioural intervention for children and young people

BACKGROUND

Despite being the gold standard of research to determine effectiveness, randomised controlled trials (RCTs) often struggle with participant recruitment, engagement and retention. These issues may be exacerbated when recruiting vulnerable populations, such as participants with mental health issues. We aimed to update understanding of the scope of these problems in trials of health technology and identify possible solutions through reflecting on experiences from an exemplar trial (Online Remote Behavioural Intervention for Tics; ORBIT).

METHOD

We extracted anonymised data on recruitment, retention and requests for more funding and time from trials funded by the largest funder of health technology trials in the UK (the National Institute of Health Research Health Technology Assessment) between 2010 and 2020, and compared these with data from a recent, successful trial (ORBIT). ORBIT aimed to assess the clinical- and cost-effectiveness of blended online and human behavioural therapy for tics in young people. Many of the trial procedures, including recruitment, the intervention and data collection, were undertaken online.

RESULTS

Data were extracted on 51 trials conducted between 2010 and 2020. Sixty per cent of trials failed to reach their original recruitment target and only 44% achieved their follow-up in the specified time frame. In contrast, ORBIT recruited to target and achieved 90% follow-up. We posit that these achievements are related to (a) judicious use of digital technology for trial procedures and (b) adequate numbers of highly trained and motivated trial staff. We provide details of both these to help other research teams plan and cost for successful trials.

CONCLUSION

An approach combining human and online methods may be advantageous in facilitating trial delivery, particularly in paediatric mental health services. Given the importance of successful clinical trials in advancing healthcare delivery and the waste of human and economic resources associated with unsuccessfully delivered trials, it is imperative that trials are appropriately costed and future research focusses on improving trial design and delivery.

TRIAL REGISTRATION

The ORBIT trial is registered with ISRTCN ( ISRCTN70758207 ) Registered on March 20, 2018. and ClinicalTrials.gov ( NCT03483493 ). Registered on March 30, 2018.

Capturing the Impact of Patient Portals Based on the Quadruple Aim and Benefits Evaluation Frameworks: Scoping Review

Background

Despite extensive and continuing research in the area of patient portals, measuring the impact of patient portals remains a convoluted process.

Objective

This study aims to explore what is known about patient portal evaluations and to provide recommendations for future endeavors. The focus is on mapping the measures used to assess the impact of patient portals on the dimensions of the Quadruple Aim (QA) framework and the Canada Health Infoway’s Benefits Evaluation (BE) framework.

Methods

A scoping review was conducted using the methodological framework of Arksey and O’Malley. Reporting was guided by the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) extension for scoping reviews. A systematic and comprehensive search was conducted using the Ovid platform, and the following databases were searched: Ovid MEDLINE (R) ALL (including epub ahead of print, in-process, and other nonindexed citations), EMBASE, and PsycINFO. CINAHL on the EBSCO platform and Web of Science were searched for studies published between March 2015 and June 2020. A systematic gray literature search was conducted using the Google search engine. Extracted data were tabulated based on a coding template developed to categorize the literature into themes and areas of interest.

Results

A total of 96 studies were included for data extraction. The studies were categorized based on the QA dimensions, with strict adherence to the definitions for each dimension. From the patients’ perspective, it was determined that most evaluations focused on benefits and barriers to access, access to test results, medication adherence, condition management, medical notes, and secure messaging. From the population perspective, the evaluations focused on the increase in population outreach, decrease in disparities related to access to care services, and improvement in quality of care. From the health care workforce perspective, the evaluations focused on the impact of patients accessing medical records, impact on workflow, impact of bidirectional secure messaging, and virtual care. From the health system perspective, the evaluations focused on decreases in no-show appointments, impact on office visits and telephone calls, impact on admission and readmission rates and emergency department visits, and impact on health care use. Overall, 77 peer-reviewed studies were mapped on the expanded version of the BE framework. The mapping was performed using subdimensions to create a more precise representation of the areas that are currently explored when studying patient portals. Most of the studies evaluated more than one subdimension.

Conclusions

The QA and BE frameworks provide guidance in identifying gaps in the current literature by providing a way to show how an impact was assessed. This study highlights the need to appropriately plan how the impact will be assessed and how the findings will be translated into effective adaptations.

The State of Evidence in Patient Portals: Umbrella Review

Background

Patient portals have emerged as a recognized digital health strategy. To date, research on patient portals has grown rapidly. However, there has been limited evaluation of the growing body of evidence on portal availability, use, clinical or health behavior and outcomes, and portal adoption over time.

Objective

This paper aims to comprehensively consolidate the current state of evidence on patient portals using the umbrella review methodology, introduce our approach for evaluating evidence for quantitative and qualitative findings presented in included systematic reviews, and present a knowledge translation tool that can be used to inform all stages of patient portal adoption.

Methods

For this study, a modified version of the Joanna Briggs Institute umbrella review method was used. Multiple databases were searched for systematic reviews focused on patient portals, and the final sample included 14 reviews. We conducted a meta-level synthesis of findings from quantitative, qualitative, and mixed methods primary studies reported in systematic reviews. We organized the umbrella review findings according to the Clinical Adoption Meta-Model (CAMM). Vote-counting, GRADE (Grading of Recommendations, Assessment, Development, and Evaluations), and CERQual (Confidence in the Evidence from Review of Qualitative Research) were used to assess the umbrella review evidence.

Results

Our knowledge translation tool summarizes the findings in the form of an evidence map. Organized by the CAMM categories, the map describes the following factors that influence portal adoption and effects over time: patient contexts, patient's interest and satisfaction, portal design, facilitators and barriers, providers' attitudes, service utilization, behavioral effects, clinical outcomes, and patient-reported outcomes. The map lists the theories and mechanisms recognized in the included portal research while identifying the need for business models and organizational theories that can inform all stages of portal adoption. Our GRADE and CERQual umbrella review evaluation resulted in the majority of evidence being rated as moderate to low, which reflects methodological issues in portal research, insufficient number of studies, or mixed results in specific focus areas. The 2 findings with a high rating of evidence were patients' interest in using portals for communication and the importance of a simple display of information in the portals. Over 40 portal features were identified in the umbrella review, with communication through secure messaging and appointment booking mentioned in all systematic reviews.

Conclusions

Our umbrella review provides a meta-level synthesis to make sense of the evidence on patient portals from published systematic reviews. Unsystematic and variable reporting of portal features undermines the ability to evaluate and compare portal effects and overlooks the specific context of portal use. Research designs sensitive to the social, organizational, policy, and temporal dimensions are needed to better understand the underlying mechanisms and context that leverage the identified factors to improve portal use and effects.

Mobile Applications for Caregivers of Individuals with Chronic Conditions and/or Diseases: Quantitative Content Analysis

BACKGROUND

Mobile health applications can help empowering caregivers and promote their wellbeing and their quality of life.

OBJECTIVE

To analyze the technical and functional characteristics of mobile health applications designed for caregivers of individuals with chronic conditions and/or diseases.

MATERIALS AND METHODS

Systematic search of mobile health applications for smartphones (apps) based on the PRISMA standard for systematic reviews on the App Store and Google Play store during May and June 2018. A second search was carried out on the Pubmed and Google Scholar database to determine whether the applications had been tested or evaluated with results published in scientific journals and then a third search was performed on the Spanish health apps catalogs to evaluate the quality and security of the selected apps.

RESULTS

746 available health apps were identified and 43 were included in this paper. 67% (n = 29) of the apps were aimed exclusively at informal caregivers, 51% (n = 22) were designed to support caregivers and only 21% (n = 9) of them provided any sort of social or emotional support. The screening in Pubmed and Google Scholar determined that the apps analyzed lacked published papers and most of the apps (84%; n = 36) lacked approval from official agencies supporting their usage.

DISCUSSION

The apps available on the market that meet the actual needs of caregivers are limited. Most of the apps were aimed at improving the care of the individual with a chronic illness.

CONCLUSION

Despite the remarkable benefits of mHealth regarding the care of chronic diseases, a relatively poor contribution has been made to support caregivers. Customized apps, interventions assessing their effectiveness and adequate evidence are needed to understand the impact of this digital tool on caregivers' health.

Citizen-Patient Involvement in the Development of mHealth Technology: Protocol for a Systematic Scoping Review

Background

The development of mobile technology for information retrieval and communication, both at individual and health organizational levels, has been extensive over the last decade. Mobile health (mHealth) technology is rapidly adapting to the health care service contexts to improve treatment, care, and effectiveness in health care services.

Objective

The overall aim of this scoping review is to explore the role of citizen-patient involvement in the development of mHealth technology in order to inform future interventions. By identifying key characteristics of citizen-patient involvement in system development, we aim to improve digital communication and collaboration between health care providers and citizen-patients, including sharing of health care data.

Methods

The systematic scoping review will follow the Joanna Briggs Institute methodology for scoping reviews by searching literature in 3 steps. We will include literature reporting on the public, citizens, and patients participating in the development of mobile technology for health care purposes in MEDLINE, CINAHL, Scopus, EMBASE, and ProQuest Dissertations and Theses. A preliminary search was completed in MEDLINE and Scopus. The screening process will be conducted by 2 of the authors. Data will be extracted using a data extraction tool prepared for the study.

Results

The study is expected to identify research gaps that will inform and motivate the development of mHealth technology. The final report is planned for submission to an indexed journal in November 2020.

Conclusions

To our knowledge, this review will be the first review to provide knowledge about how citizen-patients participate in system developments for mHealth tools and the value that such involvement adds to the system development process.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16781

Evaluating Smart Assistant Responses for Accuracy and Misinformation Regarding Human Papillomavirus Vaccination: Content Analysis Study

Background

Almost half (46%) of Americans have used a smart assistant of some kind (eg, Apple Siri), and 25% have used a stand-alone smart assistant (eg, Amazon Echo). This positions smart assistants as potentially useful modalities for retrieving health-related information; however, the accuracy of smart assistant responses lacks rigorous evaluation.

Objective

This study aimed to evaluate the levels of accuracy, misinformation, and sentiment in smart assistant responses to human papillomavirus (HPV) vaccination–related questions.

Methods

We systematically examined responses to questions about the HPV vaccine from the following four most popular smart assistants: Apple Siri, Google Assistant, Amazon Alexa, and Microsoft Cortana. One team member posed 10 questions to each smart assistant and recorded all queries and responses. Two raters independently coded all responses (κ=0.85). We then assessed differences among the smart assistants in terms of response accuracy, presence of misinformation, and sentiment regarding the HPV vaccine.

Results

A total of 103 responses were obtained from the 10 questions posed across the smart assistants. Google Assistant data were excluded owing to nonresponse. Over half (n=63, 61%) of the responses of the remaining three smart assistants were accurate. We found statistically significant differences across the smart assistants (N=103, χ²₂=7.807, P=.02), with Cortana yielding the greatest proportion of misinformation. Siri yielded the greatest proportion of accurate responses (n=26, 72%), whereas Cortana yielded the lowest proportion of accurate responses (n=33, 54%). Most response sentiments across smart assistants were positive (n=65, 64%) or neutral (n=18, 18%), but Cortana’s responses yielded the largest proportion of negative sentiment (n=7, 12%).

Conclusions

Smart assistants appear to be average-quality sources for HPV vaccination information, with Alexa responding most reliably. Cortana returned the largest proportion of inaccurate responses, the most misinformation, and the greatest proportion of results with negative sentiments. More collaboration between technology companies and public health entities is necessary to improve the retrieval of accurate health information via smart assistants.

[Implementation and participatory design of digital health interventions]

There are dynamic interactions between (digital) technologies and society. Digital technologies have a (re-)structuring effect on social relationships and social innovations in a variety of ways. Because of these characteristics, technological innovations affect our individual lifestyles and living environments. In particular, the development and implementation of interventions with digital (health) technologies is attracting increasing national and international attention (e.g. telematics GP consultations and app-supported patient education programs).Digital health technologies enable new forms of interaction and knowledge-based reproduction in the field of health. The integration of potential users in the development process of digital health technologies and interventions requires the discussion of new research approaches. The interests, needs, and requirements of users may influence the nonuse of digital health technologies. It is above all the successful implementation, involving potential users, that can have an influence on acceptance and integrative use in the later course of care. The discourse on the participatory development and implementation of interventions with digital health technologies in the field of digital public health presents itself as a complex process characterized by various theoretical approaches and methodological procedures and requiring representation, evaluation, and classification.

Patient Use and Experience With Online Access to Electronic Health Records in Norway: Results From an Online Survey

Background

The electronic health record (EHR) has been fully established in all Norwegian hospitals. Patient-accessible electronic health records (PAEHRs) are available to citizens aged 16 years and older through the national health portal Helsenorge.

Objective

This study aimed at understanding how patients use PAEHRs. Three research questions were addressed in order to explore (1) characteristics of users, (2) patients’ use of the service, and (3) patient experience with the service.

Methods

We conducted an online survey of users who had accessed their EHR online at least once through the national health portal. Patients from two of the four health regions in Norway were invited to participate. Quantitative data were supplemented by qualitative information.

Results

A total of 1037 respondents participated in the survey, most of whom used the PAEHR regularly (305/1037, 29.4%) or when necessary (303/1037, 29.2%). Service utilization was associated with self-reported health, age, gender, education, and health care professional background. Patients found the service useful to look up health information (687/778, 88.3%), keep track of their treatment (684/778, 87.9%), prepare for a hospital appointment (498/778, 64.0%), and share documents with their general practitioner (292/778, 37.5%) or family (194/778, 24.9%). Most users found it easy to access their EHR online (965/1037, 93.1%) and did not encounter technical challenges. The vast majority of respondents (643/755, 85.2%) understood the content, despite over half of them acknowledging some difficulties with medical terms or phrases. The overall satisfaction with the service was very high (700/755, 92.7%). Clinical advantages to the patients included enhanced knowledge of their health condition (565/691, 81.8%), easier control over their health status (685/740, 92.6%), better self-care (571/653, 87.4%), greater empowerment (493/674, 73.1%), easier communication with health care providers (493/618, 79.8%), and increased security (655/730, 89.7%). Patients with complex, long-term or chronic conditions seemed to benefit the most. PAEHRs were described as useful, informative, effective, helpful, easy, practical, and safe.

Conclusions

PAEHRs in Norway are becoming a mature service and are perceived as useful by patients. Future studies should include experimental designs focused on specific populations or chronic conditions that are more likely to achieve clinically meaningful benefits. Continuous evaluation programs should be conducted to assess implementation and changes of wide-scale routine services over time.

Trends and Visibility of "Digital Health" as a Keyword in Articles by JMIR Publications in the New Millennium: Bibliographic-Bibliometric Analysis

Background

Digital health has become an advancing phenomenon in the health care systems of modern societies. Over the past two decades, various digital health options, technologies, and innovations have been introduced; many of them are still being investigated and evaluated by researchers all around the globe. However, the actual trends and visibility of peer-reviewed publications using “digital health” as a keyword to reflect the topic, published by major relevant journals, still remain to be quantified.

Objective

This study aimed to conduct a bibliographic-bibliometric analysis on articles published in JMIR Publications journals that used “digital health” as a keyword. We evaluated the trends, topics, and citations of these research publications to identify the important share and contribution of JMIR Publications journals in publishing articles on digital health.

Methods

All JMIR Publications journals were searched to find articles in English, published between January 2000 and August 2019, in which the authors focused on, utilized, or discussed digital health in their study and used “digital health” as a keyword. In addition, a bibliographic-bibliometric analysis was conducted using the freely available Profiles Research Networking Software by the Harvard Clinical and Translational Science Center.

Results

Out of 1797 articles having “digital health” as a keyword, published mostly between 2016 and 2019, 277 articles (32.3%) were published by JMIR Publications journals, mainly in the Journal of Medical Internet Research. The most frequently used keyword for the topic was “mHealth.” The average number of times an article had been cited, including self-citations, was above 2.8.

Conclusions

The reflection of “digital health” as a keyword in JMIR Publications journals has increased noticeably over the past few years. To maintain this momentum, more regular bibliographic and bibliometric analyses will be needed. This would encourage authors to consider publishing their articles in relevant, high-visibility journals and help these journals expand their supportive publication policies and become more inclusive of digital health.

Is research on patient portals attuned to health equity? A scoping review

OBJECTIVE

Our scoping review examined how research on patient portals addresses health equity. Questions guiding our review were: 1) What health equity concepts are addressed in patient portal research-both explicitly and implicitly? 2) What are the gaps? 3) Is the potential for ehealth-related health inequities explicitly acknowledged in studies on patient portals? 4) What novel approaches and interventions to reduce health inequities are tested in patient portal research?

MATERIALS AND METHODS

We searched 4 databases. Search terms included "patient portal" in combination with a comprehensive list of health equity terms relevant in ehealth context. Authors independently reviewed the papers during initial screening and full-text review. We applied the eHealth Equity Framework to develop search terms and analyze the included studies.

RESULTS

Based on eHealth Equity Framework categories, the main findings generated from 65 reviewed papers were governance structures, ehealth policies, and cultural and societal values may further inequities; social position of providers and patients introduces differential preferences in portal use; equitable portal implementation can be supported through diverse user-centered design; and intermediary strategies are typically recommended to encourage portal use across populations.

DISCUSSION

The predominant focus on barriers in portal use may be inadvertently placing individual responsibility in addressing these barriers on patients already experiencing the greatest health disparities. This approach may mask the impact of the socio-technical-economic-political context on outcomes for different populations.

CONCLUSION

To support equitable health outcomes related to patient portals we need to look beyond intermediary initiatives and develop equitable strategies across policy, practice, research, and implementation.

Learning From eHealth Implementations Through "Implementomics": A Multidimensional Annotation Model Applied to eHealth Projects of the RAFT Network

The implementation of digital health technologies has increased globally, producing substantial amounts of information and knowledge. While there are still areas in digital health that are understudied, concurrently there is an exponential increase in published articles, guidelines, methods, projects, and experiences, many of which fail to reach critical mass (pilotitis). Semantically describing and documenting this implementation knowledge and the effectiveness of these tools will help to avoid the duplication of efforts, to reduce preventable implementation obstacles, and to assure that investments are targeted to the most important technological innovations. The RAFT annotation model, presented in this paper, enables to semantically describe all elements of various outputs and implementation projects that were developed, are used, or are part of the RAFT network. This model was initially developed to annotate various implementations and outputs of the RAFT network to facilitate knowledge documentation and sharing, and to be used as a proof of concept for the Implementome. The Implementome will be an interconnected knowledge system that enables the user to navigate on multiple dimensions through metadata annotated projects, people, and information, and can serve as base for consensus building, best practices and guidelines. The RAFT annotation model can be further developed to enable the annotation of outputs, implementations, people, initiatives, and projects of the digital health domain in general.

Optimising patient active role with a user-centred eHealth platform (CONCERTO+) in chronic diseases management: a study protocol for a pilot cluster randomised controlled trial

INTRODUCTION

Multimorbidity increases care needs and primary care use among people with chronic diseases. The Concerto Health Program (CHP) has been developed to optimise chronic disease management in primary care services. However, in its current version, the CHP primarily targets clinicians and does not aim to answer directly patients' and their informal caregivers' needs for chronic disease management. Various studies have shown that interventions that increase patient activation level are associated with better health outcomes. Furthermore, educational tools must be adapted to patients and caregivers in terms of health literacy and usability. This project aims to develop, implement and evaluate a user-centred, multifunctional and personalised eHealth platform (CONCERTO+) to promote a more active patient role in chronic disease management and decision-making.

METHODS AND ANALYSIS

This project uses a collaborative research approach, aiming at the personalisation of CHP through three phases: (1) the development of one module of an eHealth platform based on scientific evidence and user-centred design; (2) a feasibility study of CONCERTO+ through a pilot cluster randomised controlled trial where patients with chronic diseases from a primary healthcare practice will receive CONCERTO+ during 6 months and be compared to patients from a control practice receiving usual care and (3) an analysis of CONCERTO+ potential for scaling up. To do so, we will conduct two focus groups with patients and informal caregivers and individual interviews with health professionals at the two study sites, as well as health care managers, information officers and representatives of the Ministry of Health.

ETHICS AND DISSEMINATION

This study received ethical approval from Ethics Committee of Université Laval. The findings will be used to inform the effectiveness of CONCERTO+ to improve management care in chronic diseases. We will disseminate findings through presentations in scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03628963; Pre-results.

Use of the Principles of Design Thinking to Address Limitations of Digital Mental Health Interventions for Youth: Viewpoint

Numerous reviews and meta-analyses have indicated the enormous potential of technology to improve the appeal, effectiveness, cost, and reach of mental health interventions. However, the promise of digital mental health interventions for youth has not yet been realized. Significant challenges have been repeatedly identified, including engagement, fidelity, and the lack of personalization. We introduce the main tenets of design thinking and explain how they can specifically address these challenges, with an entirely new toolbox of mindsets and practices. In addition, we provide examples of a new wave of digital interventions to demonstrate the applicability of design thinking to a wide range of intervention goals. In the future, it will be critical for scientists and clinicians to implement their scientific standards, methods, and review outlets to evaluate the contribution of design thinking to the next iteration of digital mental health interventions for youth.

Perspectives of New Zealand patients and GPs at the beginning of patient portal implementation

ABSTRACT INTRODUCTIONNew Zealand health policy encourages patient access to their electronic medical records via portals. AIMTo discover patient and general practitioner (GP) perspectives of access to electronic medical records and e-messaging in the early portal implementation phase. METHODSIn 2014, Auckland primary health organisations and an Accident & Medical organisation were asked to invite their GPs to complete an online survey and consent for a researcher to attend their waiting room and invite patients to complete a survey. RESULTSIn total, 421 patients (13% Māori, 18% Pacific, 7% Asian, 53% NZ European/Other) participated from 13 general practices. Most (77%) knew they were entitled to see their medical records and 90% were interested in viewing them. Over two-thirds thought that viewing their records online and e-messaging their practice was a good idea. Over 80% disagreed that they would be worried, confused or embarrassed by seeing their records, with 59% expecting portals to facilitate understanding of their medical conditions. Internet security and privacy concerned 40% of patients. Among 83 GPs who completed the survey, six (7%) had already implemented portals. Few were comfortable to open up the whole health record, especially visit notes. While GPs thought that portal access may help patients better understand their plan of care, their main concerns related to causing confusion and worry. Portal implementation was expected to change GP documentation and increase practice workload and costs without demonstrable benefit to practices. DISCUSSIONAt the beginning of portal adoption, patients were interested. GPs were more reticent, unsure whether the benefits would outweigh the downsides for their patients and practice workload.