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JMIR Medical Informatics

Clinical informatics, decision support for health professionals, electronic health records, and ehealth infrastructures.


Journal Description

JMIR Medical Informatics (JMI, ISSN 2291-9694) is a top-rated, tier A journal which focuses on clinical informatics, big data in health and health care, decision support for health professionals, electronic health records, ehealth infrastructures and implementation. It has a focus on applied, translational research, with a broad readership including clinicians, CIOs, engineers, industry and health informatics professionals.

Published by JMIR Publications, publisher of the Journal of Medical Internet Research (JMIR), the leading eHealth/mHealth journal (Impact Factor 2016: 5.175), JMIR Med Inform has a slightly different scope (emphasizing more on applications for clinicians and health professionals rather than consumers/citizens, which is the focus of JMIR), publishes even faster, and also allows papers which are more technical or more formative than what would be published in the Journal of Medical Internet Research.

JMIR Medical Informatics journal features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs (ready for deposit in PubMed Central/PubMed). The site is optimized for mobile and iPad use.

JMIR Medical Informatics adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics (


Recent Articles:

  • The DWISE mobile app (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Diabetes-Related Behavior Change Knowledge Transfer to Primary Care Practitioners and Patients: Implementation and Evaluation of a Digital Health Platform


    Background: Behavioral science is now being integrated into diabetes self-management interventions. However, the challenge that presents itself is how to translate these knowledge resources during care so that primary care practitioners can use them to offer evidence-informed behavior change support and diabetes management recommendations to patients with diabetes. Objective: The aim of this study was to develop and evaluate a computerized decision support platform called “Diabetes Web-Centric Information and Support Environment” (DWISE) that assists primary care practitioners in applying standardized behavior change strategies and clinical practice guidelines–based recommendations to an individual patient and empower the patient with the skills and knowledge required to self-manage their diabetes through planned, personalized, and pervasive behavior change strategies. Methods: A health care knowledge management approach is used to implement DWISE so that it features the following functionalities: (1) assessment of primary care practitioners’ readiness to administer validated behavior change interventions to patients with diabetes; (2) educational support for primary care practitioners to help them offer behavior change interventions to patients; (3) access to evidence-based material, such as the Canadian Diabetes Association’s (CDA) clinical practice guidelines, to primary care practitioners; (4) development of personalized patient self-management programs to help patients with diabetes achieve healthy behaviors to meet CDA targets for managing type 2 diabetes; (5) educational support for patients to help them achieve behavior change; and (6) monitoring of the patients’ progress to assess their adherence to the behavior change program and motivating them to ensure compliance with their program. DWISE offers these functionalities through an interactive Web-based interface to primary care practitioners, whereas the patient’s self-management program and associated behavior interventions are delivered through a mobile patient diary via mobile phones and tablets. DWISE has been tested for its usability, functionality, usefulness, and acceptance through a series of qualitative studies. Results: For the primary care practitioner tool, most usability problems were associated with the navigation of the tool and the presentation, formatting, understandability, and suitability of the content. For the patient tool, most issues were related to the tool’s screen layout, design features, understandability of the content, clarity of the labels used, and navigation across the tool. Facilitators and barriers to DWISE use in a shared decision-making environment have also been identified. Conclusions: This work has provided a unique electronic health solution to translate complex health care knowledge in terms of easy-to-use, evidence-informed, point-of-care decision aids for primary care practitioners. Patients’ feedback is now being used to make necessary modification to DWISE.

  • Source: Pixabay; Copyright: Free-Photos; URL:; License: Public Domain (CC0).

    Reasons For Physicians Not Adopting Clinical Decision Support Systems: Critical Analysis


    Background: Clinical decision support systems (CDSSs) are an integral component of today’s health information technologies. They assist with interpretation, diagnosis, and treatment. A CDSS can be embedded throughout the patient safety continuum providing reminders, recommendations, and alerts to health care providers. Although CDSSs have been shown to reduce medical errors and improve patient outcomes, they have fallen short of their full potential. User acceptance has been identified as one of the potential reasons for this shortfall. Objective: The purpose of this paper was to conduct a critical review and task analysis of CDSS research and to develop a new framework for CDSS design in order to achieve user acceptance. Methods: A critical review of CDSS papers was conducted with a focus on user acceptance. To gain a greater understanding of the problems associated with CDSS acceptance, we conducted a task analysis to identify and describe the goals, user input, system output, knowledge requirements, and constraints from two different perspectives: the machine (ie, the CDSS engine) and the user (ie, the physician). Results: Favorability of CDSSs was based on user acceptance of clinical guidelines, reminders, alerts, and diagnostic suggestions. We propose two models: (1) the user acceptance and system adaptation design model, which includes optimizing CDSS design based on user needs/expectations, and (2) the input-process-output-engagemodel, which reveals to users the processes that govern CDSS outputs. Conclusions: This research demonstrates that the incorporation of the proposed models will improve user acceptance to support the beneficial effects of CDSSs adoption. Ultimately, if a user does not accept technology, this not only poses a threat to the use of the technology but can also pose a threat to the health and well-being of patients.

  • Doctor accessing the AfyaEHMS project. Source: The Authors (eHealth Unit, Ministry of Health, Kenya) / Placeit; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study


    Background: The Kenyan government, working with international partners and local organizations, has developed an eHealth strategy, specified standards, and guidelines for electronic health record adoption in public hospitals and implemented two major health information technology projects: District Health Information Software Version 2, for collating national health care indicators and a rollout of the KenyaEMR and International Quality Care Health Management Information Systems, for managing 600 HIV clinics across the country. Following these projects, a modified version of the Open Medical Record System electronic health record was specified and developed to fulfill the clinical and administrative requirements of health care facilities operated by devolved counties in Kenya and to automate the process of collating health care indicators and entering them into the District Health Information Software Version 2 system. Objective: We aimed to present a descriptive case study of the implementation of an open source electronic health record system in public health care facilities in Kenya. Methods: We conducted a landscape review of existing literature concerning eHealth policies and electronic health record development in Kenya. Following initial discussions with the Ministry of Health, the World Health Organization, and implementing partners, we conducted a series of visits to implementing sites to conduct semistructured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation. Results: This case study describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital information technology infrastructure, training users, and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of sociotechnical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya. Conclusions: Implementing electronic health record systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing, but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. Strategies such as creating local support teams, using local development resources, ensuring end user buy-in, and rolling out in smaller facilities before larger hospitals are being incorporated into the project. These are positive developments to help maintain momentum as the project continues. Further integration with existing open source communities could help ongoing development and implementations of the project. We hope this case study will provide some lessons and guidance for other challenging implementations of electronic health record systems as they continue across Africa.

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

    Secure Logistic Regression Based on Homomorphic Encryption: Design and Evaluation


    Background: Learning a model without accessing raw data has been an intriguing idea to security and machine learning researchers for years. In an ideal setting, we want to encrypt sensitive data to store them on a commercial cloud and run certain analyses without ever decrypting the data to preserve privacy. Homomorphic encryption technique is a promising candidate for secure data outsourcing, but it is a very challenging task to support real-world machine learning tasks. Existing frameworks can only handle simplified cases with low-degree polynomials such as linear means classifier and linear discriminative analysis. Objective: The goal of this study is to provide a practical support to the mainstream learning models (eg, logistic regression). Methods: We adapted a novel homomorphic encryption scheme optimized for real numbers computation. We devised (1) the least squares approximation of the logistic function for accuracy and efficiency (ie, reduce computation cost) and (2) new packing and parallelization techniques. Results: Using real-world datasets, we evaluated the performance of our model and demonstrated its feasibility in speed and memory consumption. For example, it took approximately 116 minutes to obtain the training model from the homomorphically encrypted Edinburgh dataset. In addition, it gives fairly accurate predictions on the testing dataset. Conclusions: We present the first homomorphically encrypted logistic regression outsourcing model based on the critical observation that the precision loss of classification models is sufficiently small so that the decision plan stays still.

  • Viewing FitNesse test suite results on a workstation (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Agile Acceptance Test–Driven Development of Clinical Decision Support Advisories: Feasibility of Using Open Source Software


    Background: Moving to electronic health records (EHRs) confers substantial benefits but risks unintended consequences. Modern EHRs consist of complex software code with extensive local configurability options, which can introduce defects. Defects in clinical decision support (CDS) tools are surprisingly common. Feasible approaches to prevent and detect defects in EHR configuration, including CDS tools, are needed. In complex software systems, use of test–driven development and automated regression testing promotes reliability. Test–driven development encourages modular, testable design and expanding regression test coverage. Automated regression test suites improve software quality, providing a “safety net” for future software modifications. Each automated acceptance test serves multiple purposes, as requirements (prior to build), acceptance testing (on completion of build), regression testing (once live), and “living” design documentation. Rapid-cycle development or “agile” methods are being successfully applied to CDS development. The agile practice of automated test–driven development is not widely adopted, perhaps because most EHR software code is vendor-developed. However, key CDS advisory configuration design decisions and rules stored in the EHR may prove amenable to automated testing as “executable requirements.” Objective: We aimed to establish feasibility of acceptance test–driven development of clinical decision support advisories in a commonly used EHR, using an open source automated acceptance testing framework (FitNesse). Methods: Acceptance tests were initially constructed as spreadsheet tables to facilitate clinical review. Each table specified one aspect of the CDS advisory’s expected behavior. Table contents were then imported into a test suite in FitNesse, which queried the EHR database to automate testing. Tests and corresponding CDS configuration were migrated together from the development environment to production, with tests becoming part of the production regression test suite. Results: We used test–driven development to construct a new CDS tool advising Emergency Department nurses to perform a swallowing assessment prior to administering oral medication to a patient with suspected stroke. Test tables specified desired behavior for (1) applicable clinical settings, (2) triggering action, (3) rule logic, (4) user interface, and (5) system actions in response to user input. Automated test suite results for the “executable requirements” are shown prior to building the CDS alert, during build, and after successful build. Conclusions: Automated acceptance test–driven development and continuous regression testing of CDS configuration in a commercial EHR proves feasible with open source software. Automated test–driven development offers one potential contribution to achieving high-reliability EHR configuration. Vetting acceptance tests with clinicians elicits their input on crucial configuration details early during initial CDS design and iteratively during rapid-cycle optimization.

  • Privacy-Preserving Patient Similarity Learning in a Federated Environment: Development and Analysis


    Background: There is an urgent need for the development of global analytic frameworks that can perform analyses in a privacy-preserving federated environment across multiple institutions without privacy leakage. A few studies on the topic of federated medical analysis have been conducted recently with the focus on several algorithms. However, none of them have solved similar patient matching, which is useful for applications such as cohort construction for cross-institution observational studies, disease surveillance, and clinical trials recruitment. Objective: The aim of this study was to present a privacy-preserving platform in a federated setting for patient similarity learning across institutions. Without sharing patient-level information, our model can find similar patients from one hospital to another. Methods: We proposed a federated patient hashing framework and developed a novel algorithm to learn context-specific hash codes to represent patients across institutions. The similarities between patients can be efficiently computed using the resulting hash codes of corresponding patients. To avoid security attack from reverse engineering on the model, we applied homomorphic encryption to patient similarity search in a federated setting. Results: We used sequential medical events extracted from the Multiparameter Intelligent Monitoring in Intensive Care-III database to evaluate the proposed algorithm in predicting the incidence of five diseases independently. Our algorithm achieved averaged area under the curves of 0.9154 and 0.8012 with balanced and imbalanced data, respectively, in κ-nearest neighbor with κ=3. We also confirmed privacy preservation in similarity search by using homomorphic encryption. Conclusions: The proposed algorithm can help search similar patients across institutions effectively to support federated data analysis in a privacy-preserving manner.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Patient Adherence to Scheduled Vital Sign Measurements During Home Telemonitoring: Analysis of the Intervention Arm in a Before and After Trial


    Background: In a home telemonitoring trial, patient adherence with scheduled vital signs measurements is an important aspect that has not been thoroughly studied and for which data in the literature are limited. Levels of adherence have been reported as varying from approximately 40% to 90%, and in most cases, the adherence rate usually dropped off steadily over time. This drop is more evident in the first few weeks or months after the start. Higher adherence rates have been reported for simple types of monitoring and for shorter periods of intervention. If patients do not follow the intended procedure, poorer results than expected may be achieved. Hence, analyzing factors that can influence patient adherence is of great importance. Objective: The goal of the research was to present findings on patient adherence with scheduled vital signs measurements in the recently completed Commonwealth Scientific and Industrial Research Organisation (CSIRO) national trial of home telemonitoring of patients (mean age 70.5 years, SD 9.3 years) with chronic conditions (chronic obstructive pulmonary disease, coronary artery disease, hypertensive diseases, congestive heart failure, diabetes, or asthma) carried out at 5 locations along the east coast of Australia. We investigated the ability of chronically ill patients to carry out a daily schedule of vital signs measurements as part of a chronic disease management care plan over periods exceeding 6 months (302 days, SD 135 days) and explored different levels of adherence for different measurements as a function of age, gender, and supervisory models. Methods: In this study, 113 patients forming the test arm of a Before and After Control Intervention (BACI) home telemonitoring trial were analyzed. Patients were required to monitor on a daily basis a range of vital signs determined by their chronic condition and comorbidities. Vital signs included noninvasive blood pressure, pulse oximetry, spirometry, electrocardiogram (ECG), blood glucose level, body temperature, and body weight. Adherence was calculated as the number of days during which at least 1 measurement was taken over all days where measurements were scheduled. Different levels of adherence for different measurements, as a function of age, gender, and supervisory models, were analyzed using linear regression and analysis of covariance for a period of 1 year after the intervention. Results: Patients were monitored on average for 302 (SD 135) days, although some continued beyond 12 months. The overall adherence rate for all measurements was 64.1% (range 59.4% to 68.8%). The adherence rates of patients monitored in hospital settings relative to those monitored in community settings were significantly higher for spirometry (69.3%, range 60.4% to 78.2%, versus 41.0%, range 33.1% to 49.0%, P<.001), body weight (64.5%, range 55.7% to 73.2%, versus 40.5%, range 32.3% to 48.7%, P<.001), and body temperature (66.8%, range 59.7% to 73.9%, versus 55.2%, range 48.4% to 61.9%, P=.03). Adherence with blood glucose measurements (58.1%, range 46.7% to 69.5%, versus 50.2%, range 42.8% to 57.6%, P=.24) was not significantly different overall. Adherence rates for blood pressure (68.5%, range 62.7% to 74.2%, versus 59.7%, range 52.1% to 67.3%, P=.04), ECG (65.6%, range 59.7% to 71.5%, versus 56.5%, range 48.7% to 64.4%, P=.047), and pulse oximetry (67.0%, range 61.4% to 72.7%, versus 56.4%, range 48.6% to 64.1%, P=.02) were significantly higher in males relative to female subjects. No statistical differences were observed between rates of adherence for the younger patient group (70 years and younger) and older patient group (older than 70 years). Conclusions: Patients with chronic conditions enrolled in the home telemonitoring trial were able to record their vital signs at home at least once every 2 days over prolonged periods of time. Male patients maintained a higher adherence than female patients over time, and patients supervised by hospital-based care coordinators reported higher levels of adherence with their measurement schedule relative to patients supervised in community settings. This was most noticeable for spirometry. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000635763; (Archived by WebCite at

  • The majority of physicians at the American University of Beirut Medical Center are reluctant to use virtual
communication technology as a form of patient communication (montage). Source: Facebook /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Patient-Physician Communication in the Era of Mobile Phones and Social Media Apps: Cross-Sectional Observational Study on Lebanese Physicians’ Perceptions...


    Background: The increased prevalence of virtual communication technology, particularly social media, has shifted the physician-patient relationship away from the well-established face-to-face interaction. The views and habits of physicians in Lebanon toward the use of online apps and social media as forms of patient communication have not been previously described. Objective: The aim of this study is to describe the views of Lebanese physicians toward the use of social media and other online apps as means of patient communication. Methods: This was a cross-sectional observational study using an online survey that addressed physicians’ perceptions on the use of virtual communication in their clinical practice. The study took place between April and June 2016, and was directed toward physicians at the American University of Beirut Medical Center. Results: A total of 834 doctors received the online survey, with 238 physicians completing the survey. Most of the participants were from medical specialties. Most responders were attending physicians. Less than half of the respondents believed that Web-based apps and social media could be a useful tool for communicating with patients. Email was the most common form of professional online app, followed by WhatsApp (an instant messaging service). The majority of participants felt that this mode of communication can result in medicolegal issues and that it was a breach of privacy. Participants strictly against the use of virtual forms of communication made up 47.5% (113/238) of the study sample. Conclusions: The majority of physicians at the American University of Beirut Medical Center are reluctant to use virtual communication technology as a form of patient communication. Appropriate policy making and strategies can allow both physicians and patients to communicate virtually in a more secure setting without fear of breaching privacy and confidentiality.

  • Source: Wikimedia Commons; Copyright: MC4 Army; URL:; License: Creative Commons Attribution (CC-BY).

    Assessing the Readability of Medical Documents: A Ranking Approach


    Background: The use of electronic health record (EHR) systems with patient engagement capabilities, including viewing, downloading, and transmitting health information, has recently grown tremendously. However, using these resources to engage patients in managing their own health remains challenging due to the complex and technical nature of the EHR narratives. Objective: Our objective was to develop a machine learning–based system to assess readability levels of complex documents such as EHR notes. Methods: We collected difficulty ratings of EHR notes and Wikipedia articles using crowdsourcing from 90 readers. We built a supervised model to assess readability based on relative orders of text difficulty using both surface text features and word embeddings. We evaluated system performance using the Kendall coefficient of concordance against human ratings. Results: Our system achieved significantly higher concordance (.734) with human annotators than did a baseline using the Flesch-Kincaid Grade Level, a widely adopted readability formula (.531). The improvement was also consistent across different disease topics. This method’s concordance with an individual human user’s ratings was also higher than the concordance between different human annotators (.658). Conclusions: We explored methods to automatically assess the readability levels of clinical narratives. Our ranking-based system using simple textual features and easy-to-learn word embeddings outperformed a widely used readability formula. Our ranking-based method can predict relative difficulties of medical documents. It is not constrained to a predefined set of readability levels, a common design in many machine learning–based systems. Furthermore, the feature set does not rely on complex processing of the documents. One potential application of our readability ranking is personalization, allowing patients to better accommodate their own background knowledge.

  • User engaged in at-home telemonitoring. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Effect of Seasonal Variation on Clinical Outcome in Patients with Chronic Conditions: Analysis of the Commonwealth Scientific and Industrial Research...


    Background: Seasonal variation has an impact on the hospitalization rate of patients with a range of cardiovascular diseases, including myocardial infarction and angina. This paper presents findings on the influence of seasonal variation on the results of a recently completed national trial of home telemonitoring of patients with chronic conditions, carried out at five locations along the east coast of Australia. Objective: The aim is to evaluate the effect of the seasonal timing of hospital admission and length of stay on clinical outcome of a home telemonitoring trial involving patients (age: mean 72.2, SD 9.4 years) with chronic conditions (chronic obstructive pulmonary disease coronary artery disease, hypertensive diseases, congestive heart failure, diabetes, or asthma) and to explore methods of minimizing the influence of seasonal variations in the analysis of the effect of at-home telemonitoring on the number of hospital admissions and length of stay (LOS). Methods: Patients were selected from a hospital list of eligible patients living with a range of chronic conditions. Each test patient was case matched with at least one control patient. A total of 114 test patients and 173 control patients were available in this trial. However, of the 287 patients, we only considered patients who had one or more admissions in the years from 2010 to 2012. Three different groups were analyzed separately because of substantially different climates: (1) Queensland, (2) Australian Capital Territory and Victoria, and (3) Tasmania. Time series data were analyzed using linear regression for a period of 3 years before the intervention to obtain an average seasonal variation pattern. A novel method that can reduce the impact of seasonal variation on the rate of hospitalization and LOS was used in the analysis of the outcome variables of the at-home telemonitoring trial. Results: Test patients were monitored for a mean 481 (SD 77) days with 87% (53/61) of patients monitored for more than 12 months. Trends in seasonal variations were obtained from 3 years’ of hospitalization data before intervention for the Queensland, Tasmania, and Australian Capital Territory and Victoria subgroups, respectively. The maximum deviation from baseline trends for LOS was 101.7% (SD 42.2%), 60.6% (SD 36.4%), and 158.3% (SD 68.1%). However, by synchronizing outcomes to the start date of intervention, the impact of seasonal variations was minimized to a maximum of 9.5% (SD 7.7%), thus improving the accuracy of the clinical outcomes reported. Conclusions: Seasonal variations have a significant effect on the rate of hospital admission and LOS in patients with chronic conditions. However, the impact of seasonal variation on clinical outcomes (rate of admissions, number of hospital admissions, and LOS) of at-home telemonitoring can be attenuated by synchronizing the analysis of outcomes to the commencement dates for the telemonitoring of vital signs. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12613000635763; (Archived by WebCite at 6xLPv9QDb)

  • Source: Freepik; Copyright: jannoon028; URL:; License: Licensed by JMIR.

    Secure and Efficient Regression Analysis Using a Hybrid Cryptographic Framework: Development and Evaluation


    Background: Machine learning is an effective data-driven tool that is being widely used to extract valuable patterns and insights from data. Specifically, predictive machine learning models are very important in health care for clinical data analysis. The machine learning algorithms that generate predictive models often require pooling data from different sources to discover statistical patterns or correlations among different attributes of the input data. The primary challenge is to fulfill one major objective: preserving the privacy of individuals while discovering knowledge from data. Objective: Our objective was to develop a hybrid cryptographic framework for performing regression analysis over distributed data in a secure and efficient way. Methods: Existing secure computation schemes are not suitable for processing the large-scale data that are used in cutting-edge machine learning applications. We designed, developed, and evaluated a hybrid cryptographic framework, which can securely perform regression analysis, a fundamental machine learning algorithm using somewhat homomorphic encryption and a newly introduced secure hardware component of Intel Software Guard Extensions (Intel SGX) to ensure both privacy and efficiency at the same time. Results: Experimental results demonstrate that our proposed method provides a better trade-off in terms of security and efficiency than solely secure hardware-based methods. Besides, there is no approximation error. Computed model parameters are exactly similar to plaintext results. Conclusions: To the best of our knowledge, this kind of secure computation model using a hybrid cryptographic framework, which leverages both somewhat homomorphic encryption and Intel SGX, is not proposed or evaluated to this date. Our proposed framework ensures data security and computational efficiency at the same time.

  • Improving aseptic practices with newborns in India. Source: Pixabay; Copyright: Engin Akyurt; URL:; License: Public Domain (CC0).

    Experiences of Indian Health Workers Using WhatsApp for Improving Aseptic Practices With Newborns: Exploratory Qualitative Study


    Background: Quality improvement (QI) involves the following 4 steps: (1) forming a team to work on a specific aim, (2) analyzing the reasons for current underperformance, (3) developing changes that could improve care and testing these changes using plan-do-study-act cycles (PDSA), and (4) implementing successful interventions to sustain improvements. Teamwork and group discussion are key for effective QI, but convening in-person meetings with all staff can be challenging due to workload and shift changes. Mobile technologies can support communication within a team when face-to-face meetings are not possible. WhatsApp, a mobile messaging platform, was implemented as a communication tool by a neonatal intensive care unit (NICU) team in an Indian tertiary hospital seeking to reduce nosocomial infections in newborns. Objective: This exploratory qualitative study aimed to examine experiences with WhatsApp as a communication tool among improvement team members and an external coach to improve adherence to aseptic protocols. Methods: Ten QI team members and the external coach were interviewed on communication processes and approaches and thematically analyzed. The WhatsApp transcript for the implementation period was also included in the analysis. Results: WhatsApp was effective for disseminating information, including guidance on QI and clinical practice, and data on performance indicators. It was not effective as a platform for group discussion to generate change ideas or analyze the performance indicator data. The decision of who to include in the WhatsApp group and how members engaged in the group may have reinforced existing hierarchies. Using WhatsApp created a work environment in which members were accessible all the time, breaking down barriers between personal and professional time. The continual influx of messages was distracting to some respondents, and how respondents managed these messages (eg, using the silent function) may have influenced their perceptions of WhatsApp. The coach used WhatsApp to share information, schedule site visits, and prompt action on behalf of the team. Conclusions: WhatsApp is a productive communication tool that can be used by teams and coaches to disseminate information and prompt action to improve the quality of care, but cannot replace in-person meetings.

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  • Development of an Educational Program to Increase Patient Involvement in a Healthcare Patient Portal: A Quality Improvement Project

    Date Submitted: Apr 20, 2018

    Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

    Background: Efforts in the United States to improve patient engagement and communication with health care providers have led to the creation of the meaningful use program. [1] The Centers for Medicare...

    Background: Efforts in the United States to improve patient engagement and communication with health care providers have led to the creation of the meaningful use program. [1] The Centers for Medicare and Medicaid Services have created a three-stage process to encourage the adoption and use of electronic health records (EHR). Benefits of EHR use include the ability to provide accurate, up-to-date, legible, and complete information about patients at the point of care. One important component of EHR is the patient portal. Patient portals provide 24-hour access to portions of a patient medical record as well as a secure pathway to send messages to providers, ask for refills of medications, and schedule appointments. Objective: To assess if patients who have not used the patient portal will engage in using the portal after an in-office orientation on how to access and the benefits of using the patient portal. Methods: A quality improvement project was performed using a convenience sample of 60 participants who were scheduled for an appointment in an outpatient cardiology office and had not accessed the patient portal in the past 12 months. The participants were given a survey regarding their computer and internet access as well as their level of comfort using a computer. Each participant was assisted in creating a username and password as well as a security question and answer. The participant then accessed the portal and navigated through the portal with the guidance of the nurse practitioner. They also sent a message via the portal to the provider they were assigned to that day. Each participant was given a pamphlet and a printed power point to reinforce what they had learned. After two months, the nurse practitioner accessed the portal to determine if the enrolled participants had accessed the portal. The reasons for access and frequency were recorded. If there was no access, the participant was called by the nurse practitioner to determine the reason they had not accessed the portal. Results: Of the 60 participants, 54% were women, 46% men, 93% were Caucasian. Fifty-six point seven accessed the portal from home. Reasons for access included: 85% reviewed labs, 53% reviewed messages sent to them from the office and 23% sent messages to the office. Twenty-four participants did not access the portal. Of those participants, 33% stated that they had no clear reason to access the portal, 25% stated that they forgot their login information and 17% stated they no interest in the portal. Conclusions: Patient portals are a useful tool for communication between patients and their providers. Providing an in-office orientation to the portal increased patient access to the portal.

  • Integrated decision support software and data feedback can improve sexual orientation recording, comprehensive sexual health testing and detection of infections among gay and bisexual men attending general practice

    Date Submitted: Apr 17, 2018

    Open Peer Review Period: Apr 18, 2018 - Jun 13, 2018

    Background: Gay and bisexual men are disproportionately affected by HIV and other sexually transmissible infections (STIs) yet opportunities for STI testing of this population are often missed or inco...

    Background: Gay and bisexual men are disproportionately affected by HIV and other sexually transmissible infections (STIs) yet opportunities for STI testing of this population are often missed or incomplete in general practice settings. Strategies are needed for improving the uptake and completeness of sexual health testing in this setting. Objective: We evaluated an intervention centred around integrated decision support software and routine data feedback to improve the collection of sexual orientation data and increase sexual health screening among gay and bisexual men attending general practice. Methods: A study using before/after and case/comparison methods was undertaken to assess the interventions impact in seven Australian general practice clinics. The software was introduced in 2012 and used patient records to prompt clinicians to record sexual orientation and, along with pathology testing history, generated prompts when sexual health testing was overdue or incomplete. It also facilitated the routine extraction of clinical data, which was regularly reported to clinicians. We calculated summary rate ratios (SRRs) based on quarterly trends in the 12-month before and 24-month intervention periods and compared those to four comparison clinics that did not receive the intervention. Results: Among 32,276 attending male patients, sexual orientation recording increased 19% (from 47% to 56%) during the intervention period (SRR=1.10, P<0.001). Comprehensive STI testing increased by 89% during the intervention (26-49%; SRR=1.38, P<0.001). While comprehensive testing increased slightly in comparison sites, the increase was comparatively greater in intervention sites (SRR=1.12, P<0.001). There was also an increase in detection of chlamydia and gonorrhoea after the intervention’s introduction, which was not observed in the comparison sites. Conclusions: Integrated decision support software and data feedback were associated with modest increases in sexual orientation recording, comprehensive screening among gay and bisexual men, and the detection of STIs. Decision support software can be utilised to enhance the delivery of sexual health care in general practice. Clinical Trial: N/A

  • Is Adherence to Cancer Screening Associated with Knowledge of Screening Guidelines? A Feasibility Study of Linking Self-reported Survey Data with Medical Records

    Date Submitted: Mar 28, 2018

    Open Peer Review Period: Mar 31, 2018 - May 26, 2018

    Background: It is feasible that patients who are more aware of cancer screening guidelines may be more likely to adhere to them. Objective: In this study, we aimed to determine if screening knowledge...

    Background: It is feasible that patients who are more aware of cancer screening guidelines may be more likely to adhere to them. Objective: In this study, we aimed to determine if screening knowledge was associated with documented screening participation. We also assessed the feasibility and acceptability of linking electronic survey data with clinical data in the primary care setting. Methods: An electronic survey was conducted at two sites in Toronto, Canada. At one site, eligible patients were approached in the waiting room to complete the survey; at the second site, eligible patients were sent an email inviting them to participate. Participants were asked to consent to linkage of their survey results with their electronic medical record. Results: Overall, 1683 participants responded to the survey: 1436 responded via email (response rate 24.8%) whereas 247 responded to the survey in the waiting room (response rate 67.5%). The majority of patients consented to linking their survey data to their medical record. Knowledge of cancer screening guidelines was generally low. Although the majority of participants were able to identify the recommended tests for breast and cervical screening, very few participants correctly identified the recommended age and frequency of screening, with a maximum of 22% of screen-eligible women answering all three questions correctly for breast cancer screening. However, this low level of knowledge among patients was not significantly associated with screening uptake, particularly after adjustment for sociodemographic characteristics. Conclusions: Although knowledge of screening guidelines was low among patients in our study, this was not associated with screening participation. Participants were willing to link self-reported data with their medical record data, which has significant implications for future research.

  • EHR Model for India: To address challenges in quality Healthcare

    Date Submitted: Mar 27, 2018

    Open Peer Review Period: Mar 29, 2018 - May 24, 2018

    Abstract: In this paper there is a discussion on providing a standard system for health care service providers and patients. We have carried out the detailed study of guidelines provided by ministry o...

    Abstract: In this paper there is a discussion on providing a standard system for health care service providers and patients. We have carried out the detailed study of guidelines provided by ministry of health and family welfare to adopt the electronic health record system. The major aim is to eliminate the conventional health record system. The major focus in this research is to propose the interoperable electronic health Record system (IEHR), and test the feasibility and acceptance of the EHR. Further there is a scope to promote the services in select locations such as hospitals and primary health centres. Medical centres can store patient’s health information with minimal efforts.

  • The Wearable Smart Blanket System Model for Monitoring the Vital Signs of Patients in Ambulance

    Date Submitted: Mar 17, 2018

    Open Peer Review Period: Mar 18, 2018 - May 13, 2018

    Objective: The timely and managed intervention reduces the consequences due to disease and sudden death of patients in emergency conditions. Monitoring and caring for the patients in emergency conditi...

    Objective: The timely and managed intervention reduces the consequences due to disease and sudden death of patients in emergency conditions. Monitoring and caring for the patients in emergency conditions requires the rapid and correct decisions to maintain their lives. The present study aimed at modeling the wearable smart blanket system for monitoring the patients in the emergency conditions of ambulance. Method: The present study was applied and descriptive-developmental. Firstly, the requirements and features of wearable smart blanket system were elicited and secondly a smart blanket system was modeled by using the UML charts and elicited requirements. Finally, the designed architecture was evaluated by using ARID scenario-based method. Results: The functional requirements of wearable smart blanket system with its data elements and physical-structural features of this system as well as non-functional requirements were elicited. Based on the requirements and data elements elicited from the questionnaire, class diagram, activity, use case diagram, sequence, deployment, and component were drawn. Then, the ARID scenario-based evaluation method was used to show that the designed architecture can provide the expected scenarios from the proposed system by using the UML and the relationships between components, systems, and users from the structural and behavioral perspectives. Conclusion: wearable smart blanket system collects the data related to medical signals by the sensors installed on the blanket and such data are processed by the smart system. The obtained data about the conditions of patient help the physician in ambulance to intervene timely and rapidly without any delay.

  • Impact of electronic versus paper vital sign observations on length-of-stay in trauma patients: a stepped-wedge cluster randomised study

    Date Submitted: Feb 26, 2018

    Open Peer Review Period: Feb 27, 2018 - Apr 24, 2018

    Background: Electronic recording of vital sign observations (e-Obs) has become increasingly prevalent in hospital care. The evidence of clinical impact for these systems is mixed. Objective: To assess...

    Background: Electronic recording of vital sign observations (e-Obs) has become increasingly prevalent in hospital care. The evidence of clinical impact for these systems is mixed. Objective: To assess the effect of e-Obs versus paper documentation (paper) on length of stay (time between trauma unit admission and ‘fit to discharge’) for trauma patients. Methods: A single centre randomised stepped-wedge study of e-Obs against paper in two 26-bed trauma wards at a medium-sized UK teaching hospital. Randomisation of the phased intervention order to the 12 study areas was computer-generated. The primary outcome was length of stay. Results: 1232 patient episodes were randomised (paper: 628, e-Obs: 604). There were 37 deaths in hospital, 21 in the Paper arm and 16 in the e-Obs arm. For discharged patients the median length of stay was 5.4 days (range: 0.2 to 79.0) on paper and 5.6 days (range: 0.1 to 236.7) on e-Obs arm. Competing risks regression analysis for time to discharge showed no difference between the treatment arms, subhazard ratio: 1.05 (0.82, 1.35) P=.68. More patient episodes contained an EWS≥3 using the e-Obs system than paper, subhazard ratio 1.63 (95% CI 1.28, 2.09 P<0.001). However, there was no difference in the time to the subsequent observation (‘escalation time’) hazard ratio 1.05 (95% CI 0.80, 1.38 P=.70). Conclusions: The phased introduction of an e-Obs documentation system was not associated with a change in length of stay. More patient episodes contained an EWS≥3 using the e-Obs system, but this was not associated with a change in ‘escalation time’. Clinical Trial: ISRCTN91040762