%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e150 %T Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study %+ Nuffield Department of Primary Care Health SciencesUniversity of OxfordRadcliffe Observatory QuarterOxford, OX2 6GGUnited Kingdom44 1865289293trish.greenhalgh@phc.ox.ac.uk  %A Greenhalgh,Trisha %A Shaw,Sara %A Wherton,Joseph %A Vijayaraghavan,Shanti %A Morris,Joanne %A Bhattacharya,Satya %A Hanson,Philippa %A Campbell-Richards,Desirée %A Ramoutar,Seendy %A Collard,Anna %A Hodkinson,Isabel %K remote consultations %K diabetes mellitus %K ethnography %K interviews %K organizational case studies %K health systems %D 2018 %7 17.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. Objective: The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model. Methods: A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). Results: When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Conclusions: Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity. %M 29625956 %R 10.2196/jmir.9897 %U http://www.jmir.org/2018/4/e150/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 2 %P e15 %T Patient Adherence to Scheduled Vital Sign Measurements During Home Telemonitoring: Analysis of the Intervention Arm in a Before and After Trial %+ Biomedical Systems Research LaboratoryUniversity of New South WalesBuilding G7Anzac ParadeSydney, New South Wales,Australia61 2 9385 074661 2 9385 5993b.celler@unsw.edu.au  %A Celler,Branko %A Argha,Ahmadreza %A Varnfield,Marlien %A Jayasena,Rajiv %K patient compliance %K vital signs %K telehealth %K telemonitoring %K clinical trial %K chronic disease %D 2018 %7 09.04.2018 %9 Original Paper %J JMIR Med Inform %G English %X 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; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364030&isReview=true (Archived by WebCite at http://www.webcitation.org/6xPOU3DpR). %M 29631991 %R 10.2196/medinform.9200 %U http://medinform.jmir.org/2018/2/e15/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e124 %T Optimizing Electronic Consultation Between Primary Care Providers and Psychiatrists: Mixed-Methods Study %+ Women's College Hospital Institute for Healthcare Solutions and Virtual CareWomen's College Hospital76 Grenville StToronto, ON, M5S 1B2Canada1 416 323 6230jennifer.hensel@wchospital.ca  %A Hensel,Jennifer M %A Yang,Rebecca %A Rai,Minnie %A Taylor,Valerie H %K eHealth %K psychiatry %K primary care %K consultation %K health services %D 2018 %7 06.04.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of electronic consultation (e-consult) between primary care providers (PCPs) and psychiatrists has potential, given the high prevalence of mental health issues in primary care and problematic access to specialist care. Utilization and uptake, however, appears to be lower than would be expected. Objective: This study aimed to examine actual utilization of e-consult between PCPs and psychiatrists and investigate the perceptions of PCPs about this form of psychiatric advice to inform how to optimize the utility and thereby the uptake of this service. Methods: In this mixed-methods study, we conducted a chart review of psychiatry e-consults (N=37) over 2 platforms during early implementation in Ontario, Canada, as well as 3 group interviews and 1 individual interview with PCPs (N=10) with variable experience levels and from a range of practice settings. The chart review assessed response times and referral content including the type of request, referral attachments, and consultant responses. Interviews explored the perceptions of the PCPs about the uses and barriers of psychiatry e-consult. Thematic content analysis of interview data identified common themes as well as themes unique to different provider profiles (eg, experienced PCPs vs new PCPs and rural vs urban practice). On the basis of interpretation of the quantitative and qualitative findings, we developed recommendations for the optimization of psychiatry e-consultation services. Results: During the study period, psychiatry e-consults comprised 3.66% (49/1339) of all e-consults submitted on the studied platforms. Among the e-consults reviewed, different psychiatric diagnoses were represented: 70% of requests (26/37) queried about medication safety or side effects, whereas 59% (22/37) asked about psychiatric symptom management. Moreover, 81% (30/37) of e-consults were answered within 24 hours, and 65% (24/37) were addressed in a single exchange. Themes from the interview data included psychiatry having a complexity that differentiates it from other specialties and may limit the utility of e-consult, other than for psychopharmacology advice. Variability in awareness exists in the way e-consultation could be used in psychiatry, with new PCPs feeling unsure about the appropriateness of a question. In general, new PCPs and PCPs practicing in rural areas were more receptive to psychiatry e-consult. PCPs viewed e-consult as an opportunity to collaborate and desired that it be integrated with other available services. Recommendations include the need for appropriate specialist staffing to address a wide range of requests, adequate education to referrers regarding the use of psychiatry e-consult, and the need to integrate psychiatry e-consult with other geographically relevant services, given the complexity of psychiatric issues. Conclusions: E-consult is a viable and timely way for PCPs to get much-needed psychiatric advice. For optimizing its utility and uptake, e-consult needs to be integrated into reliable care pathways with adequate referrer and consultant preparation. %M 29625949 %R 10.2196/jmir.8943 %U http://www.jmir.org/2018/4/e124/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 2 %P e18 %T Patient-Physician Communication in the Era of Mobile Phones and Social Media Apps: Cross-Sectional Observational Study on Lebanese Physicians’ Perceptions and Attitudes %+ Department of Internal MedicineAmerican University of Beirut Medical CenterAmerican University of BeirutHamra, Cairo StreetBeirut,Lebanon961 3614660961 1 370814fd21@aub.edu.lb  %A Daniel,Fady %A Jabak,Suha %A Sasso,Roula %A Chamoun,Yara %A Tamim,Hani %K social media %K communication %K patient-physician communication %K technology use %D 2018 %7 06.04.2018 %9 Original Paper %J JMIR Med Inform %G English %X 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. %M 29625955 %R 10.2196/medinform.8895 %U http://medinform.jmir.org/2018/2/e18/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e117 %T Use of Social Network Sites for Communication Among Health Professionals: Systematic Review %+ Centre for Gerontological NursingSchool of NursingThe Hong Kong Polytechnic UniversityRoom GH528, 5th Floor, Core G,The Hong Kong Polytechnic UniversityHung Hom, Kowloon,China (Hong Kong)852 27665587852 23649663angela.ym.leung@polyu.edu.hk  %A Chan,Windy SY %A Leung,Angela YM %K social networking %K social media %K health communication %K Facebook %K WhatsApp %K professional network %K health professionals %D 2018 %7 28.03.2018 %9 Review %J J Med Internet Res %G English %X Background: Although much research has been done investigating the roles of social network sites (SNSs) in linking patients and health professionals, there is a lack of information about their uses, benefits, and limitations in connecting health professions only for professional communication. Objective: This review aimed to examine the utilization of SNSs for communication among health professionals in (1) frontline clinical practice, (2) professional networks, and (3) education and training to identify areas for future health communication research. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A systematic search of the literature published in the last 10 years (January 1, 2007, to March 1, 2017) was performed in March 2017, using the following electronic databases: MEDLINE via OvidSP, EMBASE, CINAHL Complete, and InfoSci-Journals. The searches were conducted using the following defined search terms: “social media” OR “social network” OR “social network site” OR “Facebook” OR “Twitter” OR “Linkedin” OR “Instagram” OR “Weibo” OR “Whatsapp” OR “Telegram” OR “WeChat” AND “health” OR “health profession.” Results: Of the 6977 papers retrieved, a total of 33 studies were included in this review. They were exploratory in nature, and the majority used surveys (n=25) and interviews (n=6). All retrieved studies stated that SNSs enhanced effective communication and information sharing. SNSs were used for supporting delivering of clinical services, making referrals, and sharing information. They were beneficial to network building and professional collaboration. SNSs were novel tools to enhance educational interactions among peers, students, instructors, and preceptors. The application of SNSs came with restraints in technical knowledge, concerns on data protection, privacy and liability, issues in professionalism, and data protection. Conclusions: SNSs provide platforms facilitating efficient communication, interactions, and connections among health professionals in frontline clinical practice, professional networks, education, and training with limitations identified as technical knowledge, professionalism, and risks of data protection. The evolving use of SNSs necessitates robust research to explore the full potential and the relative effectiveness of SNSs in professional communication. %M 29592845 %R 10.2196/jmir.8382 %U http://www.jmir.org/2018/3/e117/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 3 %P e95 %T Total Knee Replacement and the Effect of Technology on Cocreation for Improved Outcomes and Delivery: Qualitative Multi-Stakeholder Study %+ Australian e-Health Research CentreHealth and BiosecurityCommonwealth Scientific and Industrial Research OrganizationGPO Box 76Epping, NSW, 1710Australia61 2 9372 417761 2 9372 4106sazzad.hussain@csiro.au  %A van Kasteren,Yasmin %A Freyne,Jill %A Hussain,M Sazzad %K arthroplasty %K replacement %K osteoarthritis %K patient participation %K consumer health informatics %K technology %K telemedicine %K rehabilitation %K self-care %K exercise therapy %K human computer interaction %K wearables %D 2018 %7 20.03.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The growth in patient-centered care delivery combined with the rising costs of health care have perhaps not unsurprisingly been matched by a proliferation of patient-centered technology. This paper takes a multistakeholder approach to explore how digital technology can support the cocreation of value between patients and their care teams in the delivery of total knee replacement (TKR) surgery, an increasingly common procedure to return mobility and relieve pain for people suffering from osteoarthritis. Objective: The aim of this study was to investigate communications and interactions between patients and care teams in the delivery of TKR to identify opportunities for digital technology to add value to TKR health care service by enhancing the cocreation of value. Methods: A multistakeholder qualitative study of user needs was conducted with Australian stakeholders (N=34): surgeons (n=12), physiotherapists (n=3), patients (n=11), and general practitioners (n=8). Data from focus groups and interviews were recorded, transcribed, and analyzed using thematic analysis. Results: Encounters between patients and their care teams are information-rich but time-poor. Results showed seven different stages of the TKR journey that starts with referral to a surgeon and ends with a postoperative review at 12 months. Each stage of the journey has different information and communication challenges that can be enhanced by digital technology. Opportunities for digital technology include improved waiting list management, supporting and reinforcing patient retention and recall of information, motivating and supporting rehabilitation, improving patient preparation for hospital stay, and reducing risks and anxiety associated with postoperative wound care. Conclusions: Digital technology can add value to patients’ care team communications by enhancing information flow, assisting patient recall and retention of information, improving accessibility and portability of information, tailoring information to individual needs, and by providing patients with tools to engage in their own health care management. For care teams, digital technology can add value through early detection of postoperative complications, proactive surveillance of health data for postoperative patients and patients on waiting lists, higher compliance with rehabilitation programs, and reduced length of stay. Digital technology has the potential to improve patient satisfaction and outcomes, as well as potentially reduce hospital length of stay and the burden of disease associated with postoperative morbidity. %M 29559424 %R 10.2196/jmir.7541 %U http://www.jmir.org/2018/3/e95/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 1 %P e16 %T Effect of Seasonal Variation on Clinical Outcome in Patients with Chronic Conditions: Analysis of the Commonwealth Scientific and Industrial Research Organization (CSIRO) National Telehealth Trial %+ Biomedical Systems Research LaboratoryUniversity of New South WalesElectrical Engineering and TelecommunicationsKensington, 2052Australia61 0418228297b.celler@unsw.edu.au  %A Argha,Ahmadreza %A Savkin,Andrey %A Liaw,Siaw-Teng %A Celler,Branko George %K telehealth %K telemonitoring %K seasonal variation %K clinical trial %K vital signs %K chronic disease %D 2018 %7 16.03.2018 %9 Original Paper %J JMIR Med Inform %G English %X 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; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364030&isReview=true (Archived by WebCite at http://www.webcitation.org/ 6xLPv9QDb) %M 29549068 %R 10.2196/medinform.9680 %U http://medinform.jmir.org/2018/1/e16/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 1 %P e13 %T Experiences of Indian Health Workers Using WhatsApp for Improving Aseptic Practices With Newborns: Exploratory Qualitative Study %+ EnCompass LLC5404 Wisconsin AveChevy Chase, MD, 20815United States1 6177849008ssmith@urc-chs.com  %A Pahwa,Parika %A Lunsford,Sarah %A Livesley,Nigel %K quality improvement %K mobile apps %K communication %K patient care team %D 2018 %7 01.03.2018 %9 Original Paper %J JMIR Med Inform %G English %X 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. %M 29496651 %R 10.2196/medinform.8154 %U http://medinform.jmir.org/2018/1/e13/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 1 %P e10 %T Patient and Health System Experience With Implementation of an Enterprise-Wide Telehealth Scheduled Video Visit Program: Mixed-Methods Study %+ Thomas Jefferson University1025 Walnut Street Suite 300Philadelphia, PA, 19107United States1 2155035591judd.hollander@jefferson.edu  %A Powell,Rhea E %A Stone,Danica %A Hollander,Judd E %K telemedicine %K video visit %K primary care %K specialty %K patient satisfaction %D 2018 %7 13.02.2018 %9 Original Paper %J JMIR Med Inform %G English %X Background: Real-time video visits are increasingly used to provide care in a number of settings because they increase access and convenience of care, yet there are few reports of health system experiences. Objective: The objective of this study is to report health system and patient experiences with implementation of a telehealth scheduled video visit program across a health system. Methods: This is a mixed methods study including (1) a retrospective descriptive report of implementation of a telehealth scheduled visit program at one large urban academic-affiliated health system and (2) a survey of patients who participated in scheduled telehealth visits. Health system and patient-reported survey measures were aligned with the National Quality Forum telehealth measure reporting domains of access, experience, and effectiveness of care. Results: This study describes implementation of a scheduled synchronous video visit program over an 18-month period. A total of 3018 scheduled video visits were completed across multiple clinical departments. Patient experiences were captured in surveys of 764 patients who participated in telehealth visits. Among survey respondents, 91.6% (728/795) reported satisfaction with the scheduled visits and 82.7% (628/759) reported perceived quality similar to an in-person visit. A total of 86.0% (652/758) responded that use of the scheduled video visit made it easier to get care. Nearly half (46.7%, 346/740) of patients estimated saving 1 to 3 hours and 40.8% (302/740) reported saving more than 3 hours of time. The net promoter score, a measure of patient satisfaction, was very high at 52. Conclusions: A large urban multihospital health system implemented an enterprise-wide scheduled telehealth video visit program across a range of clinical specialties with a positive patient experience. Patients found use of scheduled video visits made it easier to get care and the majority perceived time saved, suggesting that use of telehealth for scheduled visits can improve potential access to care across a range of clinical scenarios with favorable patient experiences. %M 29439947 %R 10.2196/medinform.8479 %U http://medinform.jmir.org/2018/1/e10/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 1 %P e9 %T The Use of Communication Apps by Medical Staff in the Australian Health Care System: Survey Study on Prevalence and Use %+ General Surgery and Gastroenterology Clinical InstituteEpworth Healthcare89 Bridge RoadRichmond, 3121Australia61 294266666nikolicamanda@gmail.com  %A Nikolic,Amanda %A Wickramasinghe,Nilmini %A Claydon-Platt,Damian %A Balakrishnan,Vikram %A Smart,Philip %K mobile phone %K information science %K communications media %K privacy %K interdisciplinary communication %K hospital communication systems %K communication %D 2018 %7 09.02.2018 %9 Original Paper %J JMIR Med Inform %G English %X Background: The use of communication apps on mobile phones offers an efficient, unobtrusive, and portable mode of communication for medical staff. The potential enhancements in patient care and education appear significant, with clinical details able to be shared quickly within multidisciplinary teams, supporting rapid integration of disparate information, and more efficient patient care. However, sharing patient data in this way also raises legal and ethical issues. No data is currently available demonstrating how widespread the use of these apps are, doctor’s attitudes towards them, or what guides clinician choice of app. Objective: The objective of this study was to quantify and qualify the use of communication apps among medical staff in clinical situations, their role in patient care, and knowledge and attitudes towards safety, key benefits, potential disadvantages, and policy implications. Methods: Medical staff in hospitals across Victoria (Australia) were invited to participate in an anonymous 33-question survey. The survey collected data on respondent’s demographics, their use of communication apps in clinical settings, attitudes towards communication apps, perceptions of data “safety,” and why one communication app was chosen over others. Results: Communication apps in Victorian hospitals are in widespread use from students to consultants, with WhatsApp being the primary app used. The median number of messages shared per day was 12, encompassing a range of patient information. All respondents viewed these apps positively in quickly communicating patient information in a clinical setting; however, all had concerns about the privacy implications arising from sharing patient information in this way. In total, 67% (60/90) considered patient data “moderately safe” on these apps, and 50% (46/90) were concerned the use of these apps was inconsistent with current legislation and policy. Apps were more likely to be used if they were fast, easy to use, had an easy login process, and were already in widespread use. Conclusions: Communication app use by medical personnel in Victorian hospitals is pervasive. These apps contribute to enhanced communication between medical staff, but their use raises compliance issues, most notably with Australian privacy legislation. Development of privacy-compliant apps such as MedX needs to prioritize a user-friendly interface and market the product as a privacy-compliant comparator to apps previously adapted to health care settings. %M 29426813 %R 10.2196/medinform.9526 %U http://medinform.jmir.org/2018/1/e9/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e38 %T Remote Collaborative Depression Care Program for Adolescents in Araucanía Region, Chile: Randomized Controlled Trial %+ Departamento de Psiquiatría y Salud MentalHospital Clínico Universidad de ChileAv. La Paz 1003, RecoletaSantiago,Chile56 229788601graciela.rojas.castillo@gmail.com  %A Martínez,Vania %A Rojas,Graciela %A Martínez,Pablo %A Zitko,Pedro %A Irarrázaval,Matías %A Luttges,Carolina %A Araya,Ricardo %K primary health care %K depression %K adolescents %K Internet %K telemedicine %K medically underserved area %D 2018 %7 31.01.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite evidence on efficacious interventions, a great proportion of depressed adolescents do not receive evidence-based treatment and have no access to specialized mental health care. Remote collaborative depression care (RCDC) may help to reduce the gap between needs and specialized mental health services. Objective: The objective of this study was to assess the feasibility, acceptability, and effectiveness of an RCDC intervention for adolescents with major depressive disorder (MDD) living in the Araucanía Region, Chile. Methods: A cluster randomized, assessor-blind trial was carried out at 16 primary care centers in the Araucanía Region, Chile. Before randomization, all participating primary care teams were trained in clinical guidelines for the treatment of adolescent depression. Adolescents (N=143; 13-19 years) with MDD were recruited. The intervention group (RCDC, N=65) received a 3-month RCDC treatment that included continuous remote supervision by psychiatrists located in Santiago, Chile’s capital city, through shared electronic health records (SEHR) and phone patient monitoring. The control group (enhanced usual care or EUC; N=78) received EUC by clinicians who were encouraged to follow clinical guidelines. Recruitment and response rates and the use of the SEHR system were registered; patient adherence and satisfaction with the treatment and clinician satisfaction with RCDC were assessed at 12-week follow-up; and depressive symptoms and health-related quality of life (HRQoL) were evaluated at baseline and 12-weeks follow-up. Results: More than 60.3% (143/237) of the original estimated sample size was recruited, and a response rate of 90.9% (130/143) was achieved at 12-week follow-up. A mean (SD) of 3.5 (4.0) messages per patient were written on the SEHR system by primary care teams. A third of the patients showed an optimal adherence to psychopharmacological treatment, and adolescents in the RCDC intervention group were more satisfied with psychological assistance than those in EUC group. Primary care clinicians were satisfied with the RCDC intervention, valuing its usefulness. There were no significant differences in depressive symptoms or HRQoL between groups. Satisfaction with psychological care, in both groups, was related to a significant change in depressive symptomatology at 12-weeks follow-up (beta=−4.3, 95% CI −7.2 to −1.3). Conclusions: This is the first trial of its kind in Latin America that includes adolescents from vulnerable backgrounds, with an intervention that proved to be feasible and well accepted by both patients and primary care clinicians. Design and implementation issues may explain similar effectiveness across arms. The effectiveness of the intervention seems to be comparable with an already nationwide established treatment program that proved to be highly efficacious under controlled conditions. Trial Registration: ClinicalTrials.gov: NCT01860443; https://clinicaltrials.gov/ct2/show/NCT01860443 (Archived by WebCite at http://www.webcitation.org/6wafMKlTY) %M 29386172 %R 10.2196/jmir.8021 %U https://www.jmir.org/2018/1/e38/ %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 5 %N 1 %P e2 %T The Perceived Ease of Use and Usefulness of Loop: Evaluation and Content Analysis of a Web-Based Clinical Collaboration System %+ The Temmy Latner Centre for Palliative CareSinai Health System60 Murray Street, 4th Floor, Box 13Toronto, ON, M5T 3L9Canada1 416 586 4800 ext 78861 416 586 4804amna.husain@sinaihealthsystem.ca  %A Kurahashi,Allison M %A Stinson,Jennifer N %A van Wyk,Margaret %A Luca,Stephanie %A Jamieson,Trevor %A Weinstein,Peter %A Cafazzo,Joseph A %A Lokuge,Bhadra %A Cohen,Eyal %A Rapoport,Adam %A Husain,Amna %K patient-centered care %K patient participation %K chronic disease %K communication %K internet communication tools %K usability testing %K interdisciplinary communication %K health communication %K continuity of patient care %K patient care team %K inventions %D 2018 %7 09.01.2018 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Patients with complex health care needs require the expertise of many health care providers. Communication, collaboration, and patient-centered care positively impact care quality and patient outcomes. Few technologies exist that facilitate collaboration between providers across settings of care and also engage the patient. We developed a Web-based clinical collaboration system, Loop, to address this gap. The likelihood of a technological system’s uptake is associated with its perceived ease of use and perceived usefulness. We engaged stakeholders in the conceptualization and development of Loop in an effort to maximize its intuitiveness and utility. Objective: This study aimed to report end users’ perceptions about the ease of use and usefulness of Loop captured during usability tests of Loop. Methods: Participants represented three user types (patients, caregivers, and health care providers) recruited from three populations (adults with cancer, adolescents and young adults with cancer, and children with medical complexity). We conducted usability testing over three iterative cycles of testing and development in both laboratory-based and off-site environments. We performed a content analysis of usability testing transcripts to summarize and describe participant perceptions about the ease of use and usefulness of Loop. Results: Participants enjoyed testing Loop and were able to use the core functions—composing, posting, and reading messages—with little difficulty. They had difficulty interpreting certain visual cues and design elements or the purpose of some features. This difficulty negatively impacted perceived ease of use but was primarily limited to auxiliary features. Participants predicted that Loop could improve the efficiency and effectiveness of communication between care team members; however, this perceived usefulness could be compromised by disruptions to personal workflow such as additional time or task requirements. Conclusions: Loop was perceived to have value as a collaboration system; however, usability testing findings indicate that some design and functional elements need to be addressed to improve ease of use. Additionally, participant concerns highlight the need to consider how a system can be implemented so as to minimize impact on workflow and optimize usefulness. %M 29317386 %R 10.2196/humanfactors.7882 %U http://humanfactors.jmir.org/2018/1/e2/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e5 %T Digital Clinical Communication for Families and Caregivers of Children or Young People With Short- or Long-Term Conditions: Rapid Review %+ Warwick Medical SchoolUniversity of WarwickGibbet Hill RoadCoventry, CV4 7ALUnited Kingdom44 02476522534f.e.griffiths@warwick.ac.uk  %A Armoiry,Xavier %A Sturt,Jackie %A Phelps,Emma Elizabeth %A Walker,Clare-Louise %A Court,Rachel %A Taggart,Frances %A Sutcliffe,Paul %A Griffiths,Frances %A Atherton,Helen %K digital clinical communication %K professional-family relations %K family %K caregivers %K young adult %K children %K child health %D 2018 %7 05.01.2018 %9 Review %J J Med Internet Res %G English %X Background: The communication relationship between parents of children or young people with health conditions and health professionals is an important part of treatment, but it is unclear how far the use of digital clinical communication tools may affect this relationship. Objective: The objective of our study was to describe, assess the feasibility of, and explore the impact of digital clinical communication between families or caregivers and health professionals. Methods: We searched the literature using 5 electronic databases. We considered all types of study design published in the English language from January 2009 to August 2015. The population of interest included families and caregivers of children and young people aged less than 26 years with any type of health condition. The intervention was any technology permitting 2-way communication. Results: We included 31 articles. The main designs were randomized controlled trials (RCTs; n=10), cross-sectional studies (n=9), pre- and postintervention uncontrolled (pre/post) studies (n=7), and qualitative interview studies (n=2); 6 had mixed-methods designs. In the majority of cases, we considered the quality rating to be fair. Many different types of health condition were represented. A breadth of digital communication tools were included: videoconferencing or videoconsultation (n=14), and Web messaging or emails (n=12). Health care professionals were mainly therapists or cognitive behavioral therapists (n=10), physicians (n=8), and nurses (n=6). Studies were very heterogeneous in terms of outcomes. Interventions were mainly evaluated using satisfaction or acceptance, or outcomes relating to feasibility. Clinical outcomes were rarely used. The RCTs showed that digital clinical communication had no impact in comparison with standard care. Uncontrolled pre/post studies showed good rates of satisfaction or acceptance. Some economic studies suggested that digital clinical communication may save costs. Conclusions: This rapid review showed an emerging body of literature on the use of digital clinical communication to improve families’ and caregivers’ involvement in the health management of children or young people. Further research with appropriate study designs and longer-term outcome measures should be encouraged. Trial Registration: PROSPERO CRD42016035467; http://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD 42016 035467(Archived by WebCite at http://www.webcitation.org/6vpgZU1FU) %M 29305339 %R 10.2196/jmir.7999 %U http://www.jmir.org/2018/1/e5/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 12 %P e421 %T The Effect of Screen-to-Screen Versus Face-to-Face Consultation on Doctor-Patient Communication: An Experimental Study with Simulated Patients %+ Department of Communication and CognitionTilburg Center for Cognition and CommunicationTilburg UniversityWarandelaan 2Tilburg, 5037 ABNetherlands31 13 466 297131 13662892m.l.antheunis@uvt.nl  %A Tates,Kiek %A Antheunis,Marjolijn L %A Kanters,Saskia %A Nieboer,Theodoor E %A Gerritse,Maria BE %K teleconsultation %K communication quality %K patient satisfaction %K provider satisfaction %K information exchange %K interpersonal relationship building %K shared decision making %D 2017 %7 20.12.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the emergence of Web-based patient-provider contact, it is still unclear how the quality of Web-based doctor-patient interactions differs from face-to-face interactions. Objective: This study aimed to examine (1) the impact of a consultation medium on doctors’ and patients’ communicative behavior in terms of information exchange, interpersonal relationship building, and shared decision making and (2) the mediating role of doctors’ and patients’ communicative behavior on satisfaction with both types of consultation medium. Methods: Doctor-patient consultations on pelvic organ prolapse were simulated, both in a face-to-face and in a screen-to-screen (video) setting. Twelve medical interns and 6 simulated patients prepared 4 different written scenarios and were randomized to perform a total of 48 consultations. Effects of the consultations were measured by questionnaires that participants filled out directly after the consultation. Results: With respect to patient-related outcomes, satisfaction, perceived information exchange, interpersonal relationship building, and perceived shared decision making showed no significant differences between face-to-face and screen-to-screen consultations. Patients’ attitude toward Web-based communication (b=−.249, P=.02 and patients’ perceived time and attention (b=.271, P=.03) significantly predicted patients’ perceived interpersonal relationship building. Patients’ perceived shared decision making was positively related to their satisfaction with the consultation (b=.254, P=.005). Overall, patients experienced significantly greater shared decision making with a female doctor (mean 4.21, SD 0.49) than with a male doctor (mean 3.66 [SD 0.73]; b=.401, P=.009). Doctor-related outcomes showed no significant differences in satisfaction, perceived information exchange, interpersonal relationship building, and perceived shared decision making between the conditions. There was a positive relationship between perceived information exchange and doctors’ satisfaction with the consultation (b=.533, P<.001). Furthermore, doctors’ perceived interpersonal relationship building was positively related to doctors’ satisfaction with the consultation (b=.331, P=.003). Conclusions: In this study, the quality of doctor-patient communication, as indicated by information exchange, interpersonal relationship building, and shared decision making, did not differ significantly between Web-based and face-to-face consultations. Doctors and simulated patients were equally satisfied with both types of consultation medium, and no differences were found in the manner in which participants perceived communicative behavior during these consultations. The findings suggest that worries about a negative impact of Web-based video consultation on the quality of patient-provider consultations seem unwarranted as they offer the same interaction quality and satisfaction level as regular face-to-face consultations. %M 29263017 %R 10.2196/jmir.8033 %U http://www.jmir.org/2017/12/e421/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 4 %P e52 %T A Data Model for Teleconsultation in Managing High-Risk Pregnancies: Design and Preliminary Evaluation %+ Department of Medical InformaticsFaculty of MedicineMashhad University of Medical SciencesAzadi SquareMashhad,Islamic Republic Of Iran98 5138002429taram@mums.ac.ir  %A Deldar,Kolsoum %A Tara,Fatemeh %A Bahaadinbeigy,Kambiz %A Khajedaluee,Mohammad %A Tara,Mahmood %K remote consultation %K clinical archetype %K pregnancy %K clinical decision-making %D 2017 %7 14.12.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: Teleconsultation is a guarantor for virtual supervision of clinical professors on clinical decisions made by medical residents in teaching hospitals. Type, format, volume, and quality of exchanged information have a great influence on the quality of remote clinical decisions or tele-decisions. Thus, it is necessary to develop a reliable and standard model for these clinical relationships. Objective: The goal of this study was to design and evaluate a data model for teleconsultation in the management of high-risk pregnancies. Methods: This study was implemented in three phases. In the first phase, a systematic review, a qualitative study, and a Delphi approach were done in selected teaching hospitals. Systematic extraction and localization of diagnostic items to develop the tele-decision clinical archetypes were performed as the second phase. Finally, the developed model was evaluated using predefined consultation scenarios. Results: Our review study has shown that present medical consultations have no specific structure or template for patient information exchange. Furthermore, there are many challenges in the remote medical decision-making process, and some of them are related to the lack of the mentioned structure. The evaluation phase of our research has shown that data quality (P<.001), adequacy (P<.001), organization (P<.001), confidence (P<.001), and convenience (P<.001) had more scores in archetype-based consultation scenarios compared with routine-based ones. Conclusions: Our archetype-based model could acquire better and higher scores in the data quality, adequacy, organization, confidence, and convenience dimensions than ones with routine scenarios. It is probable that the suggested archetype-based teleconsultation model may improve the quality of physician-physician remote medical consultations. %M 29242181 %R 10.2196/medinform.8393 %U http://medinform.jmir.org/2017/4/e52/ %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 11 %P e175 %T Time Gain Needed for In-Ambulance Telemedicine: Cost-Utility Model %+ Interuniversity Center for Health Economics ResearchVrije Universiteit BrusselLaarbeeklaan 103Brussels,Belgium32 47 050 57 96alexis.valenzuela.espinoza@vub.be  %A Valenzuela Espinoza,Alexis %A Devos,Stefanie %A van Hooff,Robbert-Jan %A Fobelets,Maaike %A Dupont,Alain %A Moens,Maarten %A Hubloue,Ives %A Lauwaert,Door %A Cornu,Pieter %A Brouns,Raf %A Putman,Koen %K telemedicine %K prehospital %K stroke %K cost effectiveness %D 2017 %7 24.11.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Stroke is a very time-sensitive pathology, and many new solutions target the optimization of prehospital stroke care to improve the stroke management process. In-ambulance telemedicine, defined by live bidirectional audio-video between a patient and a neurologist in a moving ambulance and the automated transfer of vital parameters, is a promising new approach to speed up and improve the quality of acute stroke care. Currently, no evidence exists on the cost effectiveness of in-ambulance telemedicine. Objective: We aim to develop a first cost effectiveness model for in-ambulance telemedicine and use this model to estimate the time savings needed before in-ambulance telemedicine becomes cost effective. Methods: Current standard stroke care is compared with current standard stroke care supplemented with in-ambulance telemedicine using a cost-utility model measuring costs and quality-adjusted life-years (QALYs) from a health care perspective. We combine a decision tree with a Markov model. Data from the UZ Brussel Stroke Registry (2282 stroke patients) and linked hospital claims data at individual level are combined with literature data to populate the model. A 2-way sensitivity analysis varying both implementation costs and time gain is performed to map the different cost-effective combinations and identify the time gain needed for cost effectiveness and dominance. For several modeled time gains, the cost-effectiveness acceptability curve is calculated and mapped in 1 figure. Results: Under the base-case scenario (implementation cost of US $159,425) and taking a lifetime horizon into account, in-ambulance telemedicine is a cost-effective strategy compared to standard stroke care alone starting from a time gain of 6 minutes. After 12 minutes, in-ambulance telemedicine becomes dominant, and this results in a mean decrease of costs by US –$30 (95% CI –$32 to –$29) per patient with 0.00456 (95% CI 0.00448 to 0.00463) QALYs on average gained per patient. In over 82% of all probabilistic simulations, in-ambulance telemedicine remains under the cost-effectiveness threshold of US $47,747. Conclusions: Our model suggests that in-ambulance telemedicine can be cost effective starting from a time gain of 6 minutes and becomes a dominant strategy after approximately 15 minutes. This indicates that in-ambulance telemedicine has the potential to become a cost-effective intervention assuming time gains in clinical implementations are realized in the future. %M 29175808 %R 10.2196/mhealth.8288 %U http://mhealth.jmir.org/2017/11/e175/ %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 11 %P e165 %T Uses of Mobile Device Digital Photography of Dermatologic Conditions in Primary Care %+ Department of Family Medicine, Mayo Clinic200 1st Street SWRochester, MNUnited States1 5072840423pecina.jennifer@mayo.edu  %A Pecina,Jennifer L %A Wyatt,Kirk D %A Comfere,Nneka I %A Bernard,Matthew E %A North,Frederick %K telemedicine %K teledermatology %K mobile phone %K mobile applications %K primary health care %K smartphone %K remote consultation %D 2017 %7 08.11.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: PhotoExam is a mobile app that incorporates digital photographs into the electronic health record (EHR) using iPhone operating system (iOS, Apple Inc)–based mobile devices. Objective: The aim of this study was to describe usage patterns of PhotoExam in primary care and to assess clinician-level factors that influence the use of the PhotoExam app for teledermatology (TD) purposes. Methods: Retrospective record review of primary care patients who had one or more photos taken with the PhotoExam app between February 16, 2015 to February 29, 2016 were reviewed for 30-day outcomes for rates of dermatology consult request, mode of dermatology consultation (curbside phone consult, eConsult, and in-person consult), specialty and training level of clinician using the app, performance of skin biopsy, and final pathological diagnosis (benign vs malignant). Results: During the study period, there were 1139 photo sessions on 1059 unique patients. Of the 1139 sessions, 395 (34.68%) sessions documented dermatologist input in the EHR via dermatology curbside consultation, eConsult, and in-person dermatology consult. Clinicians utilized curbside phone consults preferentially over eConsults for TD. By clinician type, nurse practitioners (NPs) and physician assistants (PAs) were more likely to utilize the PhotoExam for TD as compared with physicians. By specialty type, pediatric clinicians were more likely to utilize the PhotoExam for TD as compared with family medicine and internal medicine clinicians. A total of 108 (9.5%) photo sessions had a biopsy performed of the photographed site. Of these, 46 biopsies (42.6%) were performed by a primary care clinician, and 27 (25.0%) biopsies were interpreted as a malignancy. Of the 27 biopsies that revealed malignant findings, 6 (22%) had a TD consultation before biopsy, and 10 (37%) of these biopsies were obtained by primary care clinicians. Conclusions: Clinicians primarily used the PhotoExam for non-TD purposes. Nurse practitioners and PAs utilized the app for TD purposes more than physicians. Primary care clinicians requested curbside dermatology consults more frequently than dermatology eConsults. %M 29117934 %R 10.2196/mhealth.8257 %U http://mhealth.jmir.org/2017/11/e165/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 4 %P e41 %T Adopting Telemedicine for the Self-Management of Hypertension: Systematic Review %+ School of Health AdministrationTexas State University601 University DriveSan Marcos, TX, 78666United States1 832 752 44191 512 245 8712mileski@txstate.edu  %A Mileski,Michael %A Kruse,Clemens Scott %A Catalani,Justin %A Haderer,Tara %K hypertension %K telemedicine %K eHealth %K mHealth %K disease management %D 2017 %7 24.10.2017 %9 Review %J JMIR Med Inform %G English %X Background: Hypertension is a chronic condition that affects adults of all ages. In the United States, 1 in 3 adults has hypertension, and about half of the hypertensive population is adequately controlled. This costs the nation US $46 billion each year in health care services and medications required for treatment and missed workdays. Finding easier ways of managing this condition is key to successful treatment. Objective: A solution to reduce visits to physicians for chronic conditions is to utilize telemedicine. Research is limited on the effects of utilizing telemedicine in health care facilities. There are potential benefits for implementing telemedicine programs with patients dealing with chronic conditions. The purpose of this review was to weigh the facilitators against the barriers for implementing telemedicine. Methods: Searches were methodically conducted in the Cumulative Index to Nursing and Allied Health Literature Complete (CINAHL Complete) via Elton B Stephens Company (EBSCO) and PubMed (which queries MEDLINE) to collect information about self-management of hypertension through the use of telemedicine. Results: Results identify facilitators and barriers corresponding to the implementation of self-management of hypertension using telemedicine. The most common facilitators include increased access, increase in health and quality, patient knowledge and involvement, technology growth with remote monitoring, cost-effectiveness, and increased convenience/ease. The most prevalent barriers include lack of evidence, self-management difficult to maintain, no long-term results/more areas to address, and long-term added workload commitment. Conclusions: This review guides health care professionals in incorporating new practices and identifying the best methods to introduce telemedicine into their practices. Understanding the facilitators and barriers to implementation is important, as is understanding how these factors will impact a successful implementation of telemedicine in the area of self-management of hypertension. %M 29066424 %R 10.2196/medinform.6603 %U http://medinform.jmir.org/2017/4/e41/ %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 9 %P e135 %T Atrial Fibrillation Screening in Nonmetropolitan Areas Using a Telehealth Surveillance System With an Embedded Cloud-Computing Algorithm: Prospective Pilot Study %+ Department of Internal MedicineNational Taiwan University HospitalNo.7, Chung Shan S. Rd.Taipei, 10002Taiwan886 2 2312 3456 ext 63651886 2 2353 9346ylho@ntu.edu.tw  %A Chen,Ying-Hsien %A Hung,Chi-Sheng %A Huang,Ching-Chang %A Hung,Yu-Chien %A Hwang,Juey-Jen %A Ho,Yi-Lwun %K atrial fibrillation %K screen %K cloud-computing algorithm %K electrocardiography %D 2017 %7 26.09.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Atrial fibrillation (AF) is a common form of arrhythmia that is associated with increased risk of stroke and mortality. Detecting AF before the first complication occurs is a recognized priority. No previous studies have examined the feasibility of undertaking AF screening using a telehealth surveillance system with an embedded cloud-computing algorithm; we address this issue in this study. Objective: The objective of this study was to evaluate the feasibility of AF screening in nonmetropolitan areas using a telehealth surveillance system with an embedded cloud-computing algorithm. Methods: We conducted a prospective AF screening study in a nonmetropolitan area using a single-lead electrocardiogram (ECG) recorder. All ECG measurements were reviewed on the telehealth surveillance system and interpreted by the cloud-computing algorithm and a cardiologist. The process of AF screening was evaluated with a satisfaction questionnaire. Results: Between March 11, 2016 and August 31, 2016, 967 ECGs were recorded from 922 residents in nonmetropolitan areas. A total of 22 (2.4%, 22/922) residents with AF were identified by the physician’s ECG interpretation, and only 0.2% (2/967) of ECGs contained significant artifacts. The novel cloud-computing algorithm for AF detection had a sensitivity of 95.5% (95% CI 77.2%-99.9%) and specificity of 97.7% (95% CI 96.5%-98.5%). The overall satisfaction score for the process of AF screening was 92.1%. Conclusions: AF screening in nonmetropolitan areas using a telehealth surveillance system with an embedded cloud-computing algorithm is feasible. %M 28951384 %R 10.2196/mhealth.8290 %U https://mhealth.jmir.org/2017/9/e135/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 3 %P e29 %T Impact of At-Home Telemonitoring on Health Services Expenditure and Hospital Admissions in Patients With Chronic Conditions: Before and After Control Intervention Analysis %+ Biomedical Systems Research LaboratoryUniversity of New South WalesBuilding G7Sydney, NSW, 2052Australia61 2 9385 074661 2 9385 5993b.celler@unsw.edu.au  %A Celler,Branko %A Varnfield,Marlien %A Nepal,Surya %A Sparks,Ross %A Li,Jane %A Jayasena,Rajiv %K telehealth %K telemonitoring %K chronic disease management %K healthcare outcomes %K BACI analysis %D 2017 %7 08.09.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: Telemonitoring is becoming increasingly important for the management of patients with chronic conditions, especially in countries with large distances such as Australia. However, despite large national investments in health information technology, little policy work has been undertaken in Australia in deploying telehealth in the home as a solution to the increasing demands and costs of managing chronic disease. Objective: The objective of this trial was to evaluate the impact of introducing at-home telemonitoring to patients living with chronic conditions on health care expenditure, number of admissions to hospital, and length of stay (LOS). Methods: A before and after control intervention analysis model was adopted whereby at each location patients were selected from a list of eligible patients living with a range of chronic conditions. Each test patient was case matched with at least one control patient. Test patients were supplied with a telehealth vital signs monitor and were remotely managed by a trained clinical care coordinator, while control patients continued to receive usual care. A total of 100 test patients and 137 control patients were analyzed. Primary health care benefits provided to Australian patients were investigated for the trial cohort. Time series data were analyzed using linear regression and analysis of covariance for a period of 3 years before the intervention and 1 year after. Results: There were no significant differences between test and control patients at baseline. Test patients were monitored for an average of 276 days with 75% of patients monitored for more than 6 months. Test patients 1 year after the start of their intervention showed a 46.3% reduction in rate of predicted medical expenditure, a 25.5% reduction in the rate of predicted pharmaceutical expenditure, a 53.2% reduction in the rate of predicted unscheduled admission to hospital, a 67.9% reduction in the predicted rate of LOS when admitted to hospital, and a reduction in mortality of between 41.3% and 44.5% relative to control patients. Control patients did not demonstrate any significant change in their predicted trajectory for any of the above variables. Conclusions: At-home telemonitoring of chronically ill patients showed a statistically robust positive impact increasing over time on health care expenditure, number of admissions to hospital, and LOS as well as a reduction in mortality. Trial Registration: Retrospectively registered with the Australian and New Zealand Clinical Trial Registry ACTRN12613000635763; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364030 (Archived by WebCite at http://www.webcitation.org/6sxqjkJHW) %M 28887294 %R 10.2196/medinform.7308 %U http://medinform.jmir.org/2017/3/e29/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 8 %P e279 %T Psychiatric Consultation at Your Fingertips: Descriptive Analysis of Electronic Consultation From Primary Care to Psychiatry %+ University of Pennsylvania Perelman School of MedicineNational Clinician Scholars ProgramBlockley Hall423 Guardian DrivePhiladelphia, PA,United States1 215 573 3977margaw@mail.med.upenn.edu  %A Lowenstein,Margaret %A Bamgbose,Olusinmi %A Gleason,Nathaniel %A Feldman,Mitchell D %K mental health %K primary care %K health care delivery %K teleconsultation %K telehealth %K Internet care delivery %D 2017 %7 04.08.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation. Objective: Our aim was to describe the implementation of eConsults for psychiatry in a large academic health system. Methods: We performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations. Results: Depression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time. Conclusions: For the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders. %M 28778852 %R 10.2196/jmir.7921 %U http://www.jmir.org/2017/8/e279/ %0 Journal Article %@ 1929-073X %I JMIR Publications %V 6 %N 2 %P e11 %T WhatsApp Messenger as an Adjunctive Tool for Telemedicine: An Overview %+ Department of OrthopedicsHospital Municipal Miguel CoutoR. Carlos Góis 375/203, LeblonRio de Janeiro, 22440-040Brazil55 2199751685955 21997516859v_giordano@me.com  %A Giordano,Vincenzo %A Koch,Hilton %A Godoy-Santos,Alexandre %A Dias Belangero,William %A Esteves Santos Pires,Robinson %A Labronici,Pedro %K whatsapp %K telemedicine %K smartphone %K mobile application %D 2017 %7 21.07.2017 %9 Original Paper %J Interact J Med Res %G English %X Background: The advent of telemedicine has allowed physicians to deliver medical treatment to patients from a distance. Mobile apps such as WhatsApp Messenger, an instant messaging service, came as a novel concept in all fields of social life, including medicine. The use of instant messaging services has been shown to improve communication within medical teams by providing means for quick teleconsultation, information sharing, and starting treatment as soon as possible. Objective: The aim of this study was to perform a comprehensive systematic review of present literature on the use of the WhatsApp Messenger app as an adjunctive health care tool for medical doctors. Methods: Searches were performed in PubMed, EMBASE, and the Cochrane Library using the term “whatsapp*” in articles published before January 2016. A bibliography of all relevant original articles that used the WhatsApp Messenger app was created. The level of evidence of each study was determined according to the Oxford Levels of Evidence ranking system produced by the Oxford Centre for Evidence-Based Medicine. The impact and the indications of WhatsApp Messenger are discussed in order to understand the extent to which this app currently functions as an adjunctive tool for telemedicine. Results: The database search identified a total of 30 studies in which the term “whatsapp*” was used. Each article’s list of references was evaluated item-by-item. After literature reviews, letters to the editor, and low-quality studies were excluded, a total of 10 studies were found to be eligible for inclusion. Of these studies, 9 had been published in the English language and 1 had been published in Spanish. Five were published by medical doctors. Conclusions: The pooled data presents compelling evidence that the WhatsApp Messenger app is a promising system, whether used as a communication tool between health care professionals, as a means of communication between health care professionals and the general public, or as a learning tool for providing health care information to professionals or to the general population. However, high-quality and properly evaluated research is needed, as are improvements in descriptions of the methodology and the study processes. These improvements will allow WhatsApp Messenger to be categorically defined as an effective telemedicine tool in many different fields of health care. %M 28733273 %R 10.2196/ijmr.6214 %U http://www.i-jmr.org/2017/2/e11/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 7 %P e219 %T My Team of Care Study: A Pilot Randomized Controlled Trial of a Web-Based Communication Tool for Collaborative Care in Patients With Advanced Cancer %+ Temmy Latner Centre for Palliative CareMount Sinai Hospital4th Floor, Box 1360 Murray StreetToronto, ON,Canada1 416 586 4800 ext 78841 416 586 4804amna.husain@tlcpc.org  %A Voruganti,Teja %A Grunfeld,Eva %A Jamieson,Trevor %A Kurahashi,Allison M %A Lokuge,Bhadra %A Krzyzanowska,Monika K %A Mamdani,Muhammad %A Moineddin,Rahim %A Husain,Amna %K MeSH: Internet %K professional-patient relations %K interdisciplinary communication %K neoplasms %K adult %K chronic disease %K continuity of patient care %K patient care team %K communication %K outcome assessment (health care) %D 2017 %7 18.07.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The management of patients with complex care needs requires the expertise of health care providers from multiple settings and specialties. As such, there is a need for cross-setting, cross-disciplinary solutions that address deficits in communication and continuity of care. We have developed a Web-based tool for clinical collaboration, called Loop, which assembles the patient and care team in a virtual space for the purpose of facilitating communication around care management. Objective: The objectives of this pilot study were to evaluate the feasibility of integrating a tool like Loop into current care practices and to capture preliminary measures of the effect of Loop on continuity of care, quality of care, symptom distress, and health care utilization. Methods: We conducted an open-label pilot cluster randomized controlled trial allocating patients with advanced cancer (defined as stage III or IV disease) with ≥3 months prognosis, their participating health care team and caregivers to receive either the Loop intervention or usual care. Outcome data were collected from patients on a monthly basis for 3 months. Trial feasibility was measured with rate of uptake, as well as recruitment and system usage. The Picker Continuity of Care subscale, Palliative care Outcomes Scale, Edmonton Symptom Assessment Scale, and Ambulatory and Home Care Record were patient self-reported measures of continuity of care, quality of care, symptom distress, and health services utilization, respectively. We conducted a content analysis of messages posted on Loop to understand how the system was used. Results: Nineteen physicians (oncologists or palliative care physicians) were randomized to the intervention or control arms. One hundred twenty-seven of their patients with advanced cancer were approached and 48 patients enrolled. Of 24 patients in the intervention arm, 20 (83.3%) registered onto Loop. In the intervention and control arms, 12 and 11 patients completed three months of follow-up, respectively. A mean of 1.2 (range: 0 to 4) additional healthcare providers with an average total of 3 healthcare providers participated per team. An unadjusted between-arm increase of +11.4 was observed on the Picker scale in favor of the intervention arm. Other measures showed negligible changes. Loop was primarily used for medical care management, symptom reporting, and appointment coordination. Conclusions: The results of this study show that implementation of Loop was feasible. It provides useful information for planning future studies further examining effectiveness and team collaboration. Numerically higher scores were observed for the Loop arm relative to the control arm with respect to continuity of care. Future work is required to understand the incentives and barriers to participation so that the implementation of tools like Loop can be optimized. Trial Registration: ClinicalTrials.gov NCT02372994; https://clinicaltrials.gov/ct2/show/NCT02372994 (Archived by WebCite at http://www.webcitation.org/6r00L4Skb). %M 28720558 %R 10.2196/jmir.7421 %U http://www.jmir.org/2017/7/e219/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 3 %P e13 %T The Rules of Engagement: Perspectives on Secure Messaging From Experienced Ambulatory Patient Portal Users %+ The Ohio State University College of Medicine2231 North High St277 Northwood-High BldgColumbus, OH, 43201United States1 614 366 02181 614 293 2715cynthia.sieck@osumc.edu  %A Sieck,Cynthia J %A Hefner,Jennifer L %A Schnierle,Jeanette %A Florian,Hannah %A Agarwal,Aradhna %A Rundell,Kristen %A McAlearney,Ann Scheck %K patient portals %K secure messaging %K patient-provider communication %K qualitative study %D 2017 %7 04.07.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: Patient portals have shown promise in engaging individuals in self-management of chronic conditions by allowing patients to input and track health information and exchange secure electronic messages with their providers. Past studies have identified patient barriers to portal use including usability issues, low health literacy, and concerns about loss of personal contact as well as provider concerns such as increased time spent responding to messages. However, to date, studies of both patient and provider perspectives on portal use have focused on the pre-implementation or initial implementation phases and do not consider how these issues may change as patients and providers gain greater experience with portals. Objective: Our study examined the following research question: Within primary care offices with high rates of patient-portal use, what do experienced physician and patient users of the ambulatory portal perceive as the benefits and challenges of portal use in general and secure messaging in particular? Methods: This qualitative study involved 42 interviews with experienced physician and patient users of an ambulatory patient portal, Epic’s MyChart. Participants were recruited from the Department of Family Medicine at a large Academic Medical Center (AMC) and included providers and their patients, who had been diagnosed with at least one chronic condition. A total of 29 patients and 13 primary care physicians participated in the interviews. All interviews were conducted by telephone and followed a semistructured interview guide. Interviews were transcribed verbatim to permit rigorous qualitative analysis. Both inductive and deductive methods were used to code and analyze the data iteratively, paying particular attention to themes involving secure messaging. Results: Experienced portal users discussed several emergent themes related to a need for greater clarity on when and how to use the secure messaging feature. Patient concerns included worry about imposing on their physician’s time, the lack of provider compensation for responding to secure messages, and uncertainty about when to use secure messaging to communicate with their providers. Similarly, providers articulated a lack of clarity as to the appropriate way to communicate via MyChart and suggested that additional training for both patients and providers might be important. Patient training could include orienting patients to the “rules of engagement” at portal sign-up, either in the office or through an online tutorial. Conclusions: As secure messaging through patient portals is increasingly being used as a method of physician-patient communication, both patients and providers are looking for guidance on how to appropriately engage with each other using this tool. Patients worry about whether their use is appropriate, and providers are concerned about the content of messages, which allow them to effectively manage patient questions. Our findings suggest that additional training may help address the concerns of both patients and providers, by providing “rules of engagement” for communication via patient portals. %M 28676467 %R 10.2196/medinform.7516 %U http://medinform.jmir.org/2017/3/e13/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 2 %P e16 %T Telemedicine Services for the Arctic: A Systematic Review %+ Department of Computer ScienceUniversity of Tromsø - The Arctic University of NorwayRealfagbygget Hansine Hansens vei 54 BreivikaTromsø, 9019Norway47 4868258147 776 44580ashenafi.z.woldaregay@uit.no  %A Woldaregay,Ashenafi Zebene %A Walderhaug,Ståle %A Hartvigsen,Gunnar %K telemedicine %K telehealth %K health services accessibility %K extreme cold %K arctic regions %K accidents %D 2017 %7 28.06.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: Telemedicine services have been successfully used in areas where there are adequate infrastructures such as reliable power and communication lines. However, despite the increasing number of merchants and seafarers, maritime and Arctic telemedicine have had limited success. This might be linked with various factors such as lack of good infrastructure, lack of trained onboard personnel, lack of Arctic-enhanced telemedicine equipment, extreme weather conditions, remoteness, and other geographical challenges. Objective: The purpose of this review was to assess and analyze the current status of telemedicine services in the context of maritime conditions, extreme weather (ie, Arctic weather), and remote accidents and emergencies. Moreover, the paper aimed to identify successfully implemented telemedicine services in the Arctic region and in maritime settings and remote emergency situations and present state of the art systems for these areas. Finally, we identified the status quo of telemedicine services in the context of search and rescue (SAR) scenarios in these extreme conditions. Methods: A rigorous literature search was conducted between September 7 and October 28, 2015, through various online databases. Peer reviewed journals and articles were considered. Relevant articles were first identified by reviewing the title, keywords, and abstract for a preliminary filter with our selection criteria, and then we reviewed full-text articles that seemed relevant. Information from the selected literature was extracted based on some predefined categories, which were defined based on previous research and further elaborated upon via iterative brainstorming. Results: The initial hits were vetted using the title, abstract, and keywords, and we retrieved a total of 471 papers. After removing duplicates from the list, 422 records remained. Then, we did an independent assessment of the articles and screening based on the inclusion and exclusion criteria, which eliminated another 219 papers, leaving 203 relevant papers. After a full-text assessment, 36 articles were left, which were critically analyzed. The inter-rater agreement was measured using Cohen Kappa test, and disagreements were resolved through discussion. Conclusions: Despite the increasing number of fishermen and other seafarers, Arctic and maritime working conditions are mainly characterized by an absence of access to health care facilities. The condition is further aggravated for fishermen and seafarers who are working in the Arctic regions. In spite of the existing barriers and challenges, some telemedicine services have recently been successfully delivered in these areas. These services include teleconsultation (9/37, 24%), teleradiology (8/37, 22%), teledermatology and tele-education (3/37, 8%), telemonitoring and telecardiology (telesonography) (1/37, 3%), and others (10/37, 27%). However, the use of telemedicine in relation to search and rescue (SAR) services is not yet fully exploited. Therefore, we foresee that these implemented and evaluated telemedicine services will serve as underlying models for the successful implementation of future search and rescue (SAR) services. %M 28659257 %R 10.2196/medinform.6323 %U http://medinform.jmir.org/2017/2/e16/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 6 %P e221 %T The Effectiveness of Information Technology-Supported Shared Care for Patients With Chronic Disease: A Systematic Review %+ The Netherlands Cancer InstituteDivision of Psychosocial Research and EpidemiologyPlesmanlaan 121Amsterdam, 1066CXNetherlands31 88 005 7531 51 223 22w.v.harten@nki.nl  %A Kooij,Laura %A Groen,Wim G %A van Harten,Wim H %K review %K integrated healthcare systems %K health information systems %K chronic disease %D 2017 %7 22.06.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: In patients with chronic disease, many health care professionals are involved during treatment and follow-up. This leads to fragmentation that in turn may lead to suboptimal care. Shared care is a means to improve the integration of care delivered by various providers, specifically primary care physicians (PCPs) and specialty care professionals, for patients with chronic disease. The use of information technology (IT) in this field seems promising. Objective: Our aim was to systematically review the literature regarding the effectiveness of IT-supported shared care interventions in chronic disease in terms of provider or professional, process, health or clinical and financial outcomes. Additionally, our aim was to provide an inventory of the IT applications' characteristics that support such interventions. Methods: PubMed, Scopus, and EMBASE were searched from 2006 to 2015 to identify relevant studies using search terms related to shared care, chronic disease, and IT. Eligible studies were in the English language, and the randomized controlled trials (RCTs), controlled trials, or single group pre-post studies used reported on the effects of IT-supported shared care in patients with chronic disease and cancer. The interventions had to involve providers from both primary and specialty health care. Intervention and IT characteristics and effectiveness—in terms of provider or professional (proximal), process (intermediate), health or clinical and financial (distal) outcomes—were extracted. Risk of bias of (cluster) RCTs was assessed using the Cochrane tool. Results: The initial search yielded 4167 results. Thirteen publications were used, including 11 (cluster) RCTs, a controlled trial, and a pre-post feasibility study. Four main categories of IT applications were identified: (1) electronic decision support tools, (2) electronic platform with a call-center, (3) electronic health records, and (4) electronic communication applications. Positive effects were found for decision support-based interventions on financial and health outcomes, such as physical activity. Electronic health record use improved PCP visits and reduced rehospitalization. Electronic platform use resulted in fewer readmissions and better clinical outcomes—for example, in terms of body mass index (BMI) and dyspnea. The use of electronic communication applications using text-based information transfer between professionals had a positive effect on the number of PCPs contacting hospitals, PCPs’ satisfaction, and confidence. Conclusions: IT-supported shared care can improve proximal outcomes, such as confidence and satisfaction of PCPs, especially in using electronic communication applications. Positive effects on intermediate and distal outcomes were also reported but were mixed. Surprisingly, few studies were found that substantiated these anticipated benefits. Studies showed a large heterogeneity in the included populations, outcome measures, and IT applications used. Therefore, a firm conclusion cannot be drawn. As IT applications are developed and implemented rapidly, evidence is needed to test the specific added value of IT in shared care interventions. This is expected to require innovative research methods. %M 28642218 %R 10.2196/jmir.7405 %U http://www.jmir.org/2017/6/e221/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e177 %T Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study %+ Centre for Health Services and Policy Research201-2206 East MallVancouver, BC, V6T 1Z3Canada1 778 998 38211 604 822 5690kim.mcgrail@ubc.ca  %A McGrail,Kimberlyn Marie %A Ahuja,Megan Alyssa %A Leaver,Chad Andrew %K virtual visits %K telehealth %K primary care delivery %K patient-centered care %D 2017 %7 26.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual visits are clinical interactions in health care that do not involve the patient and provider being in the same room at the same time. The use of virtual visits is growing rapidly in health care. Some health systems are integrating virtual visits into primary care as a complement to existing modes of care, in part reflecting a growing focus on patient-centered care. There is, however, limited empirical evidence about how patients view this new form of care and how it affects overall health system use. Objective: Descriptive objectives were to assess users and providers of virtual visits, including the reasons patients give for use. The analytic objective was to assess empirically the influence of virtual visits on overall primary care use and costs, including whether virtual care is with a known or a new primary care physician. Methods: The study took place in British Columbia, Canada, where virtual visits have been publicly funded since October 2012. A survey of patients who used virtual visits and an observational study of users and nonusers of virtual visits were conducted. Comparison groups included two groups: (1) all other BC residents, and (2) a group matched (3:1) to the cohort. The first virtual visit was used as the intervention and the main outcome measures were total primary care visits and costs. Results: During 2013-2014, there were 7286 virtual visit encounters, involving 5441 patients and 144 physicians. Younger patients and physicians were more likely to use and provide virtual visits (P<.001), with no differences by sex. Older and sicker patients were more likely to see a known provider, whereas the lowest socioeconomic groups were the least likely (P<.001). The survey of 399 virtual visit patients indicated that virtual visits were liked by patients, with 372 (93.2%) of respondents saying their virtual visit was of high quality and 364 (91.2%) reporting their virtual visit was “very” or “somewhat” helpful to resolve their health issue. Segmented regression analysis and the corresponding regression parameter estimates suggested virtual visits appear to have the potential to decrease primary care costs by approximately Can $4 per quarter (Can –$3.79, P=.12), but that benefit is most associated with seeing a known provider (Can –$8.68, P<.001). Conclusions: Virtual visits may be one means of making the health system more patient-centered, but careful attention needs to be paid to how these services are integrated into existing health care delivery systems. %M 28550006 %R 10.2196/jmir.7374 %U http://www.jmir.org/2017/5/e177/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 1 %P e8 %T Does Telehealth Monitoring Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data %+ School of Nursing and Allied HealthLiverpool John Moores UniversityTithebarn Building79 Tithebarn StreetLiverpool, L2 2ERUnited Kingdom44 151 231 587244 151 231 5872D.A.Fitzsimmons@ljmu.ac.uk  %A Kargiannakis,Melissa %A Fitzsimmons,Deborah A %A Bentley,Claire L %A Mountain,Gail A %K information systems %K telemedicine %K pulmonary disease %K chronic obstructive %K triggers and rules %K information integration %K decision support systems %K information retrieval %D 2017 %7 22.03.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: The increasing prevalence and associated cost of treating chronic obstructive pulmonary disease (COPD) is unsustainable. Health care organizations are focusing on ways to support self-management and prevent hospital admissions, including telehealth-monitoring services capturing physiological and health status data. This paper reports on data captured during a pilot randomized controlled trial of telehealth-supported care within a community-based service for patients discharged from hospital following an exacerbation of their COPD. Objective: The aim was to undertake the first analysis of system data to determine whether telehealth monitoring can identify an exacerbation of COPD, providing clinicians with an opportunity to intervene with timely treatment and prevent hospital readmission. Methods: A total of 23 participants received a telehealth-supported intervention. This paper reports on the analysis of data from a telehealth monitoring system that captured data from two sources: (1) data uploaded both manually and using Bluetooth peripheral devices by the 23 participants and (2) clinical records entered as nursing notes by the clinicians. Rules embedded in the telehealth monitoring system triggered system alerts to be reviewed by remote clinicians who determined whether clinical intervention was required. We also analyzed data on the frequency and length (bed days) of hospital admissions, frequency of hospital Accident and Emergency visits that did not lead to hospital admission, and frequency and type of community health care service contacts—other than the COPD discharge service—for all participants for the duration of the intervention and 6 months postintervention. Results: Patients generated 512 alerts, 451 of which occurred during the first 42 days that all participants used the equipment. Patients generated fewer alerts over time with typically seven alerts per day within the first 10 days and four alerts per day thereafter. They also had three times more days without alerts than with alerts. Alerts were most commonly triggered by reports of being more tired, having difficulty with self-care, and blood pressure being out of range. During the 8-week intervention, and for 6-month follow-up, eight of the 23 patients were hospitalized. Hospital readmission rates (2/23, 9%) in the first 28 days of service were lower than the 20% UK norm. Conclusions: It seems that the clinical team can identify exacerbations based on both an increase in alerts and the types of system-generated alerts as evidenced by their efforts to provided treatment interventions. There was some indication that telehealth monitoring potentially delayed hospitalizations until after patients had been discharged from the service. We suggest that telehealth-supported care can fulfill an important role in enabling patients with COPD to better manage their condition and remain out of hospital, but adequate resourcing and timely response to alerts is a critical factor in supporting patients to remain at home. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 68856013; http://www.isrctn.com/ISRCTN68856013 (Archived by WebCite at http://www.webcitation.org/6ofApNB2e) %M 28330829 %R 10.2196/medinform.6359 %U http://medinform.jmir.org/2017/1/e8/ %0 Journal Article %@ 2369-6893 %I JMIR Publications %V 2 %N 1 %P e22 %T Enhancing Video Chat Applications for Home Health Care %+ Radio Robots, LLCPO Box 783Sudbury, MA, 01776United States1 617 901 34901 617 682 0442stutman@alum.mit.edu  %A Stutman,Steve %K video chat %K patient-physician interaction %K age in place %D 2016 %7 29.12.2016 %9 Poster %J iproc %G English %X Background: Estimates show that up to 87% of seniors would like to “age in place.” Often, such people are remote from their families and health care providers. Acquisition and telemetry of data and bio-signals from personal health care instrumentation is of great value, but we feel that this does not tell the complete story, because we are dealing with humans. A brief video chat, via personal computer, can usually provide a great deal of information concerning a person’s well-being. An individual’s mood, physical status, and energy level and the state of their surroundings can frequently be determined in a one-minute video chat. While these evaluations are qualitative, they can be very useful in answering the simple, important question “Is this person OK?” A video chat can also help build constructive social bonds between patients and providers because the telecommunication is no longer “faceless.” People who are aging in place are generally not the best computer users. Even if a person is proficient with the use of computers, issues with vision and manual dexterity can present obstacles to the use of video chat applications such as Skype. We have designed and implemented a low-cost system, comprised of a small “helper” program and a wired keypad, which operates with a personal computer and obviates the difficulties experienced by many less experienced and older users. Very simply, this system makes it easier for many people to communicate with their families and healthcare providers. Objective: Our goal was to simplify the use of video chat applications. A conventional desktop is often visually cluttered or has one application window obscuring another. Navigation with a mouse or other pointing device can be difficult for people with impaired vision and those with tremors, arthritis, or other dexterity limiting factors. We designed and built a “helper” program that, in conjunction with a dedicated large symbol keypad, lets a user initiate a video chat just by pressing a couple of buttons. Methods: At present we have conducted a small pilot study (N=8) with naïve computer users who want to video chat with family members. Participants in the study were chosen because they had difficulty initiating video chats. We asked this group to use our system and measured time required to initiate a video chat. Results: All subjects were able to initiate video chats in <30 seconds. The users were all able to terminate the chats when desired. In simple terms, the naïve users were able to start and end calls when they wanted to. Users expressed satisfaction at being able to control this aspect of their computers without technical support from others and enjoyed chat interactions. Conclusions: Video chat applications can be made simpler and easier to use, empowering a person who is aging in place to engage with family and healthcare providers. %R 10.2196/iproc.6246 %U http://www.iproc.org/2016/1/e22/ %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 3 %N 2 %P e29 %T Impact of Structured Rounding Tools on Time Allocation During Multidisciplinary Rounds: An Observational Study %+ Department of Biomedical and Health Information SciencesUniversity of Illinois at Chicago1919 W Taylor Street, Room 204Chicago, IL, 30047United States1 31241346231 312996 8342abrahamj@uic.edu  %A Abraham,Joanna %A Kannampallil,Thomas G %A Patel,Vimla L %A Patel,Bela %A Almoosa,Khalid F %K teaching rounds %K communication %K intensive care units %D 2016 %7 09.12.2016 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Recent research has shown evidence of disproportionate time allocation for patient communication during multidisciplinary rounds (MDRs). Studies have shown that patients discussed later during rounds receive lesser time. Objective: The aim of our study was to investigate whether disproportionate time allocation effects persist with the use of structured rounding tools. Methods: Using audio recordings of rounds (N=82 patients), we compared time allocation and communication breakdowns between a problem-based Subjective, Objective, Assessment, and Plan (SOAP) and a system-based Handoff Intervention Tool (HAND-IT) rounding tools. Results: We found no significant linear dependence of the order of patient presentation on the time spent or on communication breakdowns for both structured tools. However, for the problem-based tool, there was a significant linear relationship between the time spent on discussing a patient and the number of communication breakdowns (P<.05)––with an average of 1.04 additional breakdowns with every 120 seconds in discussion. Conclusions: The use of structured rounding tools potentially mitigates disproportionate time allocation and communication breakdowns during rounds, with the more structured HAND-IT, almost completely eliminating such effects. These results have potential implications for planning, prioritization, and training for time management during MDRs. %M 27940423 %R 10.2196/humanfactors.6642 %U http://humanfactors.jmir.org/2016/2/e29/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 11 %P e304 %T How Professionals Share an E-Care Plan for the Elderly in Primary Care: Evaluating the Use of an E-Communication Tool by Different Combinations of Professionals %+ Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtPostbus 85500Huispostnr STR 6.131Utrecht, 3508 GANetherlands31 62390838731 887568099cjong8@umcutrecht.nl  %A de Jong,Catharina C %A Ros,Wynand JG %A van Leeuwen,Mia %A Schrijvers,Guus %K eHealth %K primary care %K elderly %K email %K nurses %K general practitioners %K medical informatics %K Internet %D 2016 %7 24.11.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Home-dwelling elderly patients with multimorbidity are at risk of fragmentation of care because of the many different professionals involved and a potentially unclear level of communication. Multidisciplinary communication seems to occur incidentally. Mutual feedback is needed for a professional team to provide consistent care and adequate support to the patient system. eHealth technology can improve outcomes. Objective: The aim of this study was to evaluate the use of a tool, Congredi, for electronic communication by professionals for the care of home-dwelling elderly patients. Methods: The research group was recruited through general practices and home care organizations. Congredi, a tool designed for multidisciplinary communication, was made available for professionals in primary care. It consists of a care plan and a communication channel (secure emailing). Professionals opened Congredi records for elderly patients who had 2 or more professionals involved. The records were the unit of analysis. Data were gathered from the Congredi system over a period of 42 weeks. Results: An inclusion rate of 21.4% (203/950) was achieved; nearly half of the participants were nurses. During the study, professionals were active in 448 patient records; female professionals were prevalent. In the patient records, 3 types of actions (care activities, emailing, and process activities) were registered. Most activities occurred in the multidisciplinary records (mean 12.2), which had twice the number of activities of monodisciplinary records (6.35), and solo records had a mean of 3.43 activities. Most activities were care activities (mean 9.14), emailing had a mean of 0.89 activities, and process activities had a mean of 0.29. Conclusions: An e-communication tool (Congredi) was usable for improving multidisciplinary communication among professionals. It even seemed to yield results for 40% of the professionals who used the e-care plan on their own. The content of the tool provided an active communication practice, with significant increases observed in the actions that must be shared for the effective coordination of care. %M 27884811 %R 10.2196/jmir.6332 %U http://www.jmir.org/2016/11/e304/ %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 4 %N 3 %P e26 %T Satisfaction Levels and Factors Influencing Satisfaction With Use of a Social App for Neonatal and Pediatric Patient Transfer Information Systems: A Questionnaire Study Among Doctors %+ Research Institute of Clinical Medicine of Chonbuk National UniversityBiomedical Research Institute of Chonbuk National University HospitalDepartment of PediatricsChonbuk National University Hospital20, Gunjiro, DuckjinkuJeonju, Korea, 561-712Republic Of Korea82 63 250 146082 63 250 1464kyunim99@gmail.com  %A Choi,Iee %A Kim,Jin Kyu %A Kim,Sun Jun %A Cho,Soo Chul %A Kim,Il Nyeo %K social media %K personal satisfaction %K information systems %K patient transfer %D 2016 %7 04.08.2016 %9 Original Paper %J JMIR Med Inform %G English %X Background: The treatment of neonatal and pediatric patients is limited to certain medical institutions depending on treatment difficulty. Effective patient transfers are necessary in situations where there are limited medical resources. In South Korea, the government has made a considerable effort to establish patient transfer systems using various means, such as websites, telephone, and so forth. However, in reality, the effort has not yet been effective. Objective: In this study, we ran a patient transfer information system using a social app for effective patient transfer. We analyzed the results, satisfaction levels, and the factors influencing satisfaction. Methods: Naver Band is a social app and mobile community application which in Korea is more popular than Facebook. It facilitates group communication. Using Naver Band, two systems were created: one by the Neonatal Intensive Care Unit and the other by the Department of Pediatrics at Chonbuk National University Children's Hospital, South Korea. The information necessary for patient transfers was provided to participating obstetricians (n=51) and pediatricians (n=90). We conducted a survey to evaluate the systems and reviewed the results retrospectively. Results: The number of patients transferred was reported to increase by 65% (26/40) obstetricians and 40% (23/57) pediatricians. The time taken for transfers was reported to decrease by 72% (29/40) obstetricians and 59% (34/57) pediatricians. Satisfaction was indicated by 83% (33/40) obstetricians and 89% (51/57) pediatricians. Regarding factors influencing satisfaction, the obstetricians reported communication with doctors in charge (P=.03) and time reduction during transfers (P=.02), whereas the pediatricians indicated review of the diagnosis and treatment of transferred patients (P=.01) and the time reduction during transfers (P=.007). Conclusions: The users were highly satisfied and different users indicated different factors of satisfaction. This finding implies that users’ requirements should be accommodated in future developments of patient transfer information systems. %M 27492978 %R 10.2196/medinform.5984 %U http://medinform.jmir.org/2016/3/e26/ %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 7 %P e193 %T Telemedical Education: Training Digital Natives in Telemedicine %+ Partners HealthCare Connected Health25 New Chardon St.Boston, MA, 02114United States1 61772427241 6177242724kjethwani@partners.org  %A Pathipati,Akhilesh S %A Azad,Tej D %A Jethwani,Kamal %K telemedicine %K medical education %K medical school %K curriculum reform %D 2016 %7 12.07.2016 %9 Viewpoint %J J Med Internet Res %G English %X Telemedicine plays an important role in the delivery of medical care, and will become increasingly prominent going forward. Current medical students are among the first generation of “digital natives” who are well versed in the incorporation of technology into social interaction. These students are well positioned to apply advances in communications to patient care. Even so, providers require training to effectively leverage these opportunities. Therefore, we recommend introducing telemedicine training into medical school curricula and propose a model for incorporation. %M 27405323 %R 10.2196/jmir.5534 %U http://www.jmir.org/2016/7/e193/ %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 2 %N 2 %P e11 %T Considerations for the Telehealth Systems of Tomorrow: An Analysis of Student Perceptions of Telehealth Technologies %+ University of Central FloridaDepartment of PsychologyCollege of Sciences4000 Central Florida Blvd.Orlando, FL, 32816United States1 (407)823 09201 (407)823 0920dewar@knights.ucf.edu  %A Bull,Tyler Preston %A Dewar,Alexis Roxanne %A Malvey,Donna M %A Szalma,James Leo %K telehealth systems %K younger adults %K telehealth advantages %K telehealth disadvantages %K thematic analysis %D 2016 %7 08.07.2016 %9 Original Paper %J JMIR Med Educ %G English %X Background: While much is known about factors that facilitate telehealth adoption, less is known about why adoption does or does not occur in specific populations, such as students. Objective: This study aims to examine the perceptions of telehealth systems within a large student sample. Methods: Undergraduate students (N=315) participated in a survey of the perceived advantages and disadvantages of telehealth technologies. The responses to the survey were analyzed using thematic analysis. Results: We found that students were likely to adopt telehealth systems for the following reasons: (1) the system worked efficiently, (2) the convenience of telehealth, and (3) to gain access to health services. Students also perceived several disadvantages to telehealth systems, such as issues of trust (ie, security, privacy), the impersonal nature of telehealth systems, and they were concerned about the potential for major system errors. Conclusion: By understanding the current barriers to telehealth adoption in a cohort of students, we can not only better anticipate the future needs of this group, but also incorporate such needs into the design of future telehealth systems. %M 27731865 %R 10.2196/mededu.5392 %U http://mededu.jmir.org/2016/2/e11/ %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e43 %T Use of iPhones by Nurses in an Acute Care Setting to Improve Communication and Decision-Making Processes: Qualitative Analysis of Nurses’ Perspectives on iPhone Use %+ University of MelbourneParkvilleVictoria, 3010Australia61 3 9035 ext 551161 3 9035maureen.farrell@unimelb.edu.au  %A Farrell,Maureen %K acute care %K clinical decision making %K communication %K iPhones %K nursing %D 2016 %7 31.05.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Smartphones and other mobile devices are having and will continue to have an impact on health care delivery in acute settings in Australia and overseas. Nurses, unlike physicians, have been slow to adopt these technologies and the reasons for this may relate to the status of both these professions within the hospital setting. Objective: To explore nurses’ perspectives on iPhone use within an acute care unit. We examined their experiences and views on how this device may improve communication and decision-making processes at the point of care. Methods: Two focus group discussions, using a semistructured interview, were conducted over the trial period. The discussions focused on the nurses’ experiences regarding ease of use, features, and capabilities of the device. The focus groups were recorded, transcribed, and analyzed using semistructured interview questions as a guide. Results: The positive findings indicated that the iPhones were accessible and portable at point of care with patients, enhanced communication in the workplace, particularly among the nurses, and that this technology would evolve and be embraced by all nurses in the future. The negatives were the small screen size when undertaking bedside education for the patient and the invasive nature of the device. Another issue was the perception of being viewed as unprofessional when using the device in real time with the patients and their family. Conclusions: The use of iPhones by nurses in acute care settings has the potential to enhance patient care, especially through more effective communication among nurses, and other health care professionals. To ensure that the benefits of this technology is woven into the everyday practice of the nurse, it is important that leaders in these organizations develop the agenda or policy to ensure that this occurs. %M 27246197 %R 10.2196/mhealth.5071 %U http://mhealth.jmir.org/2016/2/e43/ %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 4 %P e79 %T Interprofessional Communication of Clinicians Using a Mobile Phone App: A Randomized Crossover Trial Using Simulated Patients %+ Department of Surgery and CancerSt Mary's CampusImperial College LondonQEQM BuildingLondon, W2 1NYUnited Kingdom44 0 207 594 79244 0 0 7594 3137bhavesh.patel07@imperial.ac.uk  %A Patel,Bhavesh %A Johnston,Maximilian %A Cookson,Natalie %A King,Dominic %A Arora,Sonal %A Darzi,Ara %K communication %K mobile phone %K pager %K applications %K apps %K escalation of care %K simulation %D 2016 %7 06.04.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Most hospitals use paging systems as the principal communication system, despite general dissatisfaction by end users. To this end, we developed an app-based communication system (called Hark) to facilitate and improve the quality of interpersonal communication. Objective: The objectives of our study were (1) to assess the quality of information transfer using pager- and app-based (Hark) communication systems, (2) to determine whether using mobile phone apps for escalation of care results in additional delays in communication, and (3) to determine how end users perceive mobile phone apps as an alternative to pagers. Methods: We recruited junior (postgraduate year 1 and 2) doctors and nurses from a range of specialties and randomly assigned them to 2 groups who used either a pager device or the mobile phone-based Hark app. We asked nurses to hand off simulated patients while doctors were asked to receive handoff information using these devices. The quality of information transfer, time taken to respond to messages, and users’ satisfaction with each device was recorded. Each participant used both devices with a 2-week washout period in between uses. Results: We recruited 22 participants (13 nurses, 9 doctors). The quality of the referrals made by nurses was significantly better when using Hark (Hark median 118, range 100–121 versus pager median 77, range 39–104; P=.001). Doctors responded to messages using Hark more quickly than when responding to pagers, although this difference was not statistically significant (Hark mean 86.6 seconds, SD 96.2 versus pager mean 136.5 seconds, SD 201.0; P=.12). Users rated Hark as significantly better on 11 of the 18 criteria of an information transfer device (P<.05) These included “enhances interprofessional efficiency,” “results in less disturbance,” “performed desired functions reliably,” and “allows me to clearly transfer information.” Conclusions: Hark improved the quality of transfer of information about simulated patients and was rated by users as more effective and efficient, and less distracting than pagers. Using this device did not result in delay in patient care. %M 27052694 %R 10.2196/jmir.4854 %U http://www.jmir.org/2016/4/e79/ %0 Journal Article %@ 2291-9694 %I Gunther Eysenbach %V 4 %N 1 %P e3 %T Early Indication of Decompensated Heart Failure in Patients on Home-Telemonitoring: A Comparison of Prediction Algorithms Based on Daily Weight and Noninvasive Transthoracic Bio-impedance %+ Personal Health SolutionsPhilips Research5.007High Tech Campus 34Eindhoven, 5656AENetherlands31 63192693031 40274276illapha@gmail.com  %A Cuba Gyllensten,Illapha %A Bonomi,Alberto G %A Goode,Kevin M %A Reiter,Harald %A Habetha,Joerg %A Amft,Oliver %A Cleland,John GF %K Heart failure %K telemonitoring %K deterioration detection %K alert algorithms %K ambulatory monitoring %K impedance %D 2016 %7 18.02.2016 %9 Original Paper %J JMIR Med Inform %G English %X Background: Heart Failure (HF) is a common reason for hospitalization. Admissions might be prevented by early detection of and intervention for decompensation. Conventionally, changes in weight, a possible measure of fluid accumulation, have been used to detect deterioration. Transthoracic impedance may be a more sensitive and accurate measure of fluid accumulation. Objective: In this study, we review previously proposed predictive algorithms using body weight and noninvasive transthoracic bio-impedance (NITTI) to predict HF decompensations. Methods: We monitored 91 patients with chronic HF for an average of 10 months using a weight scale and a wearable bio-impedance vest. Three algorithms were tested using either simple rule-of-thumb differences (RoT), moving averages (MACD), or cumulative sums (CUSUM). Results: Algorithms using NITTI in the 2 weeks preceding decompensation predicted events (P<.001); however, using weight alone did not. Cross-validation showed that NITTI improved sensitivity of all algorithms tested and that trend algorithms provided the best performance for either measurement (Weight-MACD: 33%, NITTI-CUSUM: 60%) in contrast to the simpler rules-of-thumb (Weight-RoT: 20%, NITTI-RoT: 33%) as proposed in HF guidelines. Conclusions: NITTI measurements decrease before decompensations, and combined with trend algorithms, improve the detection of HF decompensation over current guideline rules; however, many alerts are not associated with clinically overt decompensation. %M 26892844 %R 10.2196/medinform.4842 %U http://medinform.jmir.org/2016/1/e3/ %0 Journal Article %@ 2291-9694 %I Gunther Eysenbach %V 4 %N 1 %P e6 %T Disruptive Innovation: Implementation of Electronic Consultations in a Veterans Affairs Health Care System %+ School of Public HealthDepartment of Health Policy and ManagementBoston UniversityRoom 264715 Albany StreetBoston, MA, 02118United States1 617 414 14261 617 638 5374gourig@bu.edu  %A Gupte,Gouri %A Vimalananda,Varsha %A Simon,Steven R %A DeVito,Katerina %A Clark,Justice %A Orlander,Jay D %K remote consultations %K clinical communication %K electronic consultation %K telehealth %K clinical information %K decision making, telemonitoring %K eHealth infrastructures %D 2016 %7 12.02.2016 %9 Original Paper %J JMIR Med Inform %G English %X Background: Electronic consultations (e-consults) offer rapid access to specialist input without the need for a patient visit. E-consult implementation began in 2011 at VA Boston Healthcare System (VABHS). By early 2013, e-consults were available for all clinical services. In this implementation, the requesting clinician selects the desired consultation within the electronic health record (EHR) ordering menu, which creates an electronic form that is pre-populated with patient demographic information and allows free-text entry of the reason for consult. This triggers a message to the requesting clinician and requested specialty, thereby enabling bidirectional clinician-clinician communication. Objective: The aim of this study is to examine the utilization of e-consults in a large Veterans Affairs (VA) health care system. Methods: Data from the electronic health record was used to measure frequency of e-consult use by provider type (physician or nurse practitioner (NP) and/or physician assistant), and by the requesting and responding specialty from January 2012 to December 2013. We conducted chart reviews for a purposive sample of e-consults and semi-structured interviews with a purposive sample of clinicians and hospital leaders to better characterize the process, challenges, and usability of e-consults. Results: A total of 7097 e-consults were identified, 1998 from 2012 and 5099 from 2013. More than one quarter (27.56%, 1956/7097) of the e-consult requests originated from VA facilities in New England other than VABHS and were excluded from subsequent analysis. Within the VABHS e-consults (72.44%, 5141/7097), variability in frequency and use of e-consults across provider types and specialties was found. A total of 64 NPs requested 2407 e-consults (median 12.5, range 1-415). In contrast, 448 physicians (including residents and fellows) requested 2349 e-consults (median 2, range 1-116). More than one third (37.35%, 1920/5141) of e-consults were sent from primary care to specialists. While most e-consults reflected a request for specialist input to a generalist’s question in diagnosis or management in the ambulatory setting, we identified creative uses of e-consults, including requests for face-to-face appointments and documentation of pre-operative chart reviews; moreover, 7.00% (360/5141) of the e-consults originated from our sub-acute and chronic care inpatient units. In interviews, requesting providers reported high utility and usability. Specialists recognized the value of e-consults but expressed concerns about additional workload. Conclusions: The e-consult mechanism is frequently utilized for its initial intended purpose. It has also been adopted for unexpected clinical and administrative uses, developing into a “disruptive innovation” and highlighting existing gaps in mechanisms for provider communication. Further investigation is needed to characterize optimal utilization of e-consults within specialty and the medical center, and what features of the e-consult program, other than volume, represent valid measures of access and quality care. %M 26872820 %R 10.2196/medinform.4801 %U http://medinform.jmir.org/2016/1/e6/ %0 Journal Article %@ 2291-9694 %I Gunther Eysenbach %V 3 %N 4 %P e37 %T Resident Use of Text Messaging for Patient Care: Ease of Use or Breach of Privacy? %+ Section of Hospital MedicineDepartment of MedicineUniversity of Chicago5841 South Maryland AvenueMC 5000Chicago, IL, 60637United States1 773 702 69881 773 759 7398mprochas@medicine.bsd.uchicago.edu  %A Prochaska,Micah T %A Bird,Amber-Nicole %A Chadaga,Amar %A Arora,Vineet M %K in-hospital communication %K SMS text messaging %K mobile technology %D 2015 %7 26.11.2015 %9 Short Paper %J JMIR Med Inform %G English %X Background: Short message service (SMS) text messaging is an efficient form of communication and pervasive in health care, but may not securely protect patient information. It is unclear if resident providers are aware of the security concerns of SMS text messaging when communicating about patient care. Objective: We sought to compare residents’ preferences for SMS text messaging compared with other forms of in-hospital communication when considering security versus ease of use. Methods: This study was a cross-sectional multi-institutional survey of internal medicine residents. Residents ranked different communication modalities based on efficiency, ease of use, and security using a Likert scale. Communication options included telephone, email, hospital paging, and SMS text messaging. Respondents also reported whether they had received confidential patient identifiers through any of these modalities. Results: SMS text messaging was preferred by 71.7% (94/131) of respondents because of its efficiency and by 79.8% (103/129) of respondents because of its ease of use. For security, 82.5% (104/126) of respondents preferred the hospital paging system, whereas only 20.6% (26/126) of respondents preferred SMS text messaging for secure communication. In all, 70.9% (93/131) of respondents reported having received patient identifiers (first and/or last name), 81.7% (107/131) reported receiving patient initials, and 50.4% (66/131) reported receiving a patient’s medical record number through SMS text messages. Conclusions: Residents prefer in-hospital communication through SMS text messaging because of its ease of use and efficiency. Despite security concerns, the majority of residents reported receiving confidential patient information through SMS text messaging. For providers, it is possible that the benefits of improved in-hospital communication with SMS text messaging and the presumed improvement in the coordination and delivery of patient care outweigh security concerns they may have. The tension between the security and convenience of SMS text messaging may represent an educational opportunity to ensure the compliance of mobile technology in the health care setting. %R 10.2196/medinform.4797 %U http://medinform.jmir.org/2015/4/e37/ %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 2 %P e72 %T The Effect of Health Information Technology on Health Care Provider Communication: A Mixed-Method Protocol %+ University of MichiganSchool of Nursing400 N. Ingalls, room 4306Ann Arbor, MI, 48109United States1 734 936 30551 734 647 2416mmanojlo@umich.edu  %A Manojlovich,Milisa %A Adler-Milstein,Julia %A Harrod,Molly %A Sales,Anne %A Hofer,Timothy P %A Saint,Sanjay %A Krein,Sarah L %K interdisciplinary communication %K health information technology %K computer communication networks %K hospital communication systems %D 2015 %7 11.06.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Communication failures between physicians and nurses are one of the most common causes of adverse events for hospitalized patients, as well as a major root cause of all sentinel events. Communication technology (ie, the electronic medical record, computerized provider order entry, email, and pagers), which is a component of health information technology (HIT), may help reduce some communication failures but increase others because of an inadequate understanding of how communication technology is used. Increasing use of health information and communication technologies is likely to affect communication between nurses and physicians. Objective: The purpose of this study is to describe, in detail, how health information and communication technologies facilitate or hinder communication between nurses and physicians with the ultimate goal of identifying how we can optimize the use of these technologies to support effective communication. Effective communication is the process of developing shared understanding between communicators by establishing, testing, and maintaining relationships. Our theoretical model, based in communication and sociology theories, describes how health information and communication technologies affect communication through communication practices (ie, use of rich media; the location and availability of computers) and work relationships (ie, hierarchies and team stability). Therefore we seek to (1) identify the range of health information and communication technologies used in a national sample of medical-surgical acute care units, (2) describe communication practices and work relationships that may be influenced by health information and communication technologies in these same settings, and (3) explore how differences in health information and communication technologies, communication practices, and work relationships between physicians and nurses influence communication. Methods: This 4-year study uses a sequential mixed-methods design, beginning with a quantitative survey followed by a two-part qualitative phase. Survey results from aim 1 will provide a detailed assessment of health information and communication technologies in use and help identify sites with variation in health information and communication technologies for the qualitative phase of the study. In aim 2, we will conduct telephone interviews with hospital personnel in up to 8 hospitals to gather in-depth information about communication practices and work relationships on medical-surgical units. In aim 3, we will collect data in 4 hospitals (selected from telephone interview results) via observation, shadowing, focus groups, and artifacts to learn how health information and communication technologies, communication practices, and work relationships affect communication. Results: Results from aim 1 will be published in 2016. Results from aims 2 and 3 will be published in subsequent years. Conclusions: As the majority of US hospitals do not yet have HIT fully implemented, results from our study will inform future development and implementation of health information and communication technologies to support effective communication between nurses and physicians. %M 26068442 %R 10.2196/resprot.4463 %U http://www.researchprotocols.org/2015/2/e72/ %0 Journal Article %@ 2291-9694 %I Gunther Eysenbach %V 3 %N 2 %P e21 %T A Telesurveillance System With Automatic Electrocardiogram Interpretation Based on Support Vector Machine and Rule-Based Processing %+ National Taiwan UniversityGraduate Institute of Communication EngineeringNo. 1, Section 4, Roosevelt RoadTaipei, 10617Taiwan886 233669652886 233663662jjding@ntu.edu.tw  %A Ho,Te-Wei %A Huang,Chen-Wei %A Lin,Ching-Miao %A Lai,Feipei %A Ding,Jian-Jiun %A Ho,Yi-Lwun %A Hung,Chi-Sheng %K telehealth care %K telesurveillance system %K electrocardiogram %K ECG classification %K support vector machine %D 2015 %7 07.05.2015 %9 Original Paper %J JMIR Med Inform %G English %X Background: Telehealth care is a global trend affecting clinical practice around the world. To mitigate the workload of health professionals and provide ubiquitous health care, a comprehensive surveillance system with value-added services based on information technologies must be established. Objective: We conducted this study to describe our proposed telesurveillance system designed for monitoring and classifying electrocardiogram (ECG) signals and to evaluate the performance of ECG classification. Methods: We established a telesurveillance system with an automatic ECG interpretation mechanism. The system included: (1) automatic ECG signal transmission via telecommunication, (2) ECG signal processing, including noise elimination, peak estimation, and feature extraction, (3) automatic ECG interpretation based on the support vector machine (SVM) classifier and rule-based processing, and (4) display of ECG signals and their analyzed results. We analyzed 213,420 ECG signals that were diagnosed by cardiologists as the gold standard to verify the classification performance. Results: In the clinical ECG database from the Telehealth Center of the National Taiwan University Hospital (NTUH), the experimental results showed that the ECG classifier yielded a specificity value of 96.66% for normal rhythm detection, a sensitivity value of 98.50% for disease recognition, and an accuracy value of 81.17% for noise detection. For the detection performance of specific diseases, the recognition model mainly generated sensitivity values of 92.70% for atrial fibrillation, 89.10% for pacemaker rhythm, 88.60% for atrial premature contraction, 72.98% for T-wave inversion, 62.21% for atrial flutter, and 62.57% for first-degree atrioventricular block. Conclusions: Through connected telehealth care devices, the telesurveillance system, and the automatic ECG interpretation system, this mechanism was intentionally designed for continuous decision-making support and is reliable enough to reduce the need for face-to-face diagnosis. With this value-added service, the system could widely assist physicians and other health professionals with decision making in clinical practice. The system will be very helpful for the patient who suffers from cardiac disease, but for whom it is inconvenient to go to the hospital very often. %M 25953306 %R 10.2196/medinform.4397 %U http://medinform.jmir.org/2015/2/e21/ %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 3 %P e63 %T Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews %+ College of Applied Health SciencesDepartment of Biomedical and Health Information SciencesUniversity of Illinois at Chicago1919 West Taylor Street (AHSB)Chicago, IL, 60612United States1 31235535191 3129968342skitsiou@uic.edu  %A Kitsiou,Spyros %A Paré,Guy %A Jaana,Mirou %K home telemonitoring %K telemedicine %K telehealth %K remote monitoring %K remote consultation %K heart failure %K chronic diseases %K continuity of patient care %K physiologic monitoring %K ambulatory monitoring %K home care services %K review %K umbrella review %K systematic review %K meta-analysis %D 2015 %7 12.03.2015 %9 Review %J J Med Internet Res %G English %X Background: Growing interest on the effects of home telemonitoring on patients with chronic heart failure (HF) has led to a rise in the number of systematic reviews addressing the same or very similar research questions with a concomitant increase in discordant findings. Differences in the scope, methods of analysis, and methodological quality of systematic reviews can cause great confusion and make it difficult for policy makers and clinicians to access and interpret the available evidence and for researchers to know where knowledge gaps in the extant literature exist. Objective: This overview aims to collect, appraise, and synthesize existing evidence from multiple systematic reviews on the effectiveness of home telemonitoring interventions for patients with chronic heart failure (HF) to inform policy makers, practitioners, and researchers. Methods: A comprehensive literature search was performed on MEDLINE, EMBASE, CINAHL, and the Cochrane Library to identify all relevant, peer-reviewed systematic reviews published between January 1996 and December 2013. Reviews were searched and screened using explicit keywords and inclusion criteria. Standardized forms were used to extract data and the methodological quality of included reviews was appraised using the AMSTAR (assessing methodological quality of systematic reviews) instrument. Summary of findings tables were constructed for all primary outcomes of interest, and quality of evidence was graded by outcome using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system. Post-hoc analysis and subgroup meta-analyses were conducted to gain further insights into the various types of home telemonitoring technologies included in the systematic reviews and the impact of these technologies on clinical outcomes. Results: A total of 15 reviews published between 2003 and 2013 were selected for meta-level synthesis. Evidence from high-quality reviews with meta-analysis indicated that taken collectively, home telemonitoring interventions reduce the relative risk of all-cause mortality (0.60 to 0.85) and heart failure-related hospitalizations (0.64 to 0.86) compared with usual care. Absolute risk reductions ranged from 1.4%-6.5% and 3.7%-8.2%, respectively. Improvements in HF-related hospitalizations appeared to be more pronounced in patients with stable HF: hazard ratio (HR) 0.70 (95% credible interval [Crl] 0.34-1.5]). Risk reductions in mortality and all-cause hospitalizations appeared to be greater in patients who had been recently discharged (≤28 days) from an acute care setting after a recent HF exacerbation: HR 0.62 (95% CrI 0.42-0.89) and HR 0.67 (95% CrI 0.42-0.97), respectively. However, quality of evidence for these outcomes ranged from moderate to low suggesting that further research is very likely to have an important impact on our confidence in the observed estimates of effect and may change these estimates. The post-hoc analysis identified five main types of non-invasive telemonitoring technologies included in the systematic reviews: (1) video-consultation, with or without transmission of vital signs, (2) mobile telemonitoring, (3) automated device-based telemonitoring, (4) interactive voice response, and (5) Web-based telemonitoring. Of these, only automated device-based telemonitoring and mobile telemonitoring were effective in reducing the risk of all-cause mortality and HF-related hospitalizations. More research data are required for interactive voice response systems, video-consultation, and Web-based telemonitoring to provide robust conclusions about their effectiveness. Conclusions: Future research should focus on understanding the process by which home telemonitoring works in terms of improving outcomes, identify optimal strategies and the duration of follow-up for which it confers benefits, and further investigate whether there is differential effectiveness between chronic HF patient groups and types of home telemonitoring technologies. %M 25768664 %R 10.2196/jmir.4174 %U http://www.jmir.org/2015/3/e63/ %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 1 %P e8 %T Optimizing Inter-Professional Communications in Surgery: Protocol for a Mixed-Methods Exploratory Study %+ Sunnybrook Health Sciences CentreDivision of General Surgery2075 Bayview Avenue, T-wingToronto, ON, M4N 3M5Canada1 416 480 61061 416 480 6002natalie.coburn@sunnybrook.ca  %A Hallet,Julie %A Wallace,David %A El-Sedfy,Abraham %A Hall,Trevor NT %A Ahmed,Najma %A Bridge,Jennifer %A Taggar,Ru %A Smith,Andy J %A Nathens,Avery B %A Coburn,Natalie G %A Gotlib-Conn,Lesley %K communication %K interprofessional %K pager %K resident %K nurse %K education %K patient safety %D 2015 %7 05.03.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Effective nurse-physician communication is critical to delivering high quality patient care. Interprofessional communication between surgical nurses and surgeons, often through the use of pagers, is currently characterized by information gaps and interprofessional tensions, both sources of workflow interruption, potential medical error, impaired educational experience, and job satisfaction. Objective: This study aims to define current patterns of, and understand enablers and barriers to interprofessional communication in general surgery, in order to optimize the use of communication technologies, teamwork, provider satisfaction, and quality and safety of patient care. Methods: We will use a mixed-methods multiphasic approach. In phase 1, a quantitative and content analysis of alpha-numeric pages (ANP) received by general surgery residents will be conducted to develop a paging taxonomy. Frequency, timing (on-call vs regular duty hours), and interval between pages will be described using a 4-week sample of pages. Results will be compared between pages sent to junior and senior residents. Finally, using an inductive analysis, two independent assessors will classify ANP thematically. In Phase 2, a qualitative constructivist approach will explore stakeholders’ experiences with interprofessional communication, including paging, through interviews and shadowing of 40 residents and 40 nurses at two institutions. Finally, a survey will be developed, tested, and administered to all general surgery nurses and residents at the same two institutions, to evaluate their attitudes about the effectiveness and quality of interprofessional communication, and assess their satisfaction. Results: Describing the profile of current pages is the first step towards identifying areas and root causes of IPC inefficiency. This study will identify key contextual barriers to surgical nurse-house staff communication, and existing interprofessional knowledge and practice gaps. Conclusions: Our findings will inform the design of a guideline and tailored intervention to improve IPC in order to ensure high quality patient care, optimal educational experience, and provider satisfaction. %M 25745882 %R 10.2196/resprot.3623 %U http://www.researchprotocols.org/2015/1/e8/ %0 Journal Article %@ 2291-9694 %I Gunther Eysenbach %V 3 %N 1 %P e5 %T Veteran, Primary Care Provider, and Specialist Satisfaction With Electronic Consultation %+ VA Pittsburgh Healthcare SystemCenter for Health Equity Research and PromotionBuilding 30University Drive C (151C)Pittsburgh, PA, 15240-1001United States1 412 360 22371 412 360 2285keri.rodriguez@va.gov  %A Rodriguez,Keri L %A Burkitt,Kelly H %A Bayliss,Nichole K %A Skoko,Jennifer E %A Switzer,Galen E %A Zickmund,Susan L %A Fine,Michael J %A Macpherson,David S %K access %K rural health %K referral and consultation %K patient satisfaction %K veterans %D 2015 %7 14.01.2015 %9 Original Paper %J JMIR Med Inform %G English %X Background: Access to specialty care is challenging for veterans in rural locations. To address this challenge, in December 2009, the Veterans Affairs (VA) Pittsburgh Healthcare System (VAPHS) implemented an electronic consultation (e-consult) program to provide primary care providers (PCPs) and patients with enhanced specialty care access. Objective: The aim of this quality improvement (QI) project evaluation was to: (1) assess satisfaction with the e-consult process, and (2) identify perceived facilitators and barriers to using the e-consult program. Methods: We conducted semistructured telephone interviews with veteran patients (N=15), Community Based Outpatient Clinic (CBOC) PCPs (N=15), and VA Pittsburgh specialty physicians (N=4) who used the e-consult program between December 2009 to August 2010. Participants answered questions regarding satisfaction in eight domains and identified factors contributing to their responses. Results: Most participants were white (patients=87%; PCPs=80%; specialists=75%) and male (patients=93%; PCPs=67%; specialists=75%). On average, patients had one e-consult (SD 0), PCPs initiated 6 e-consults (SD 6), and VAPHS specialists performed 17 e-consults (SD 11). Patients, PCPs, and specialty physicians were satisfied with e-consults median (range) of 5.0 (4-5) on 1-5 Likert-scale, 4.0 (3-5), and 3.5 (3-5) respectively. The most common reason why patients and specialists reported increased overall satisfaction with e-consults was improved communication, whereas improved timeliness of care was the most common reason for PCPs. Communication was the most reported perceived barrier and facilitator to e-consult use. Conclusions: Veterans and VA health care providers were satisfied with the e-consult process. Our findings suggest that while the reasons for satisfaction with e-consult differ somewhat for patients and physicians, e-consult may be a useful tool to improve VA health care system access for rural patients. %M 25589233 %R 10.2196/medinform.3725 %U http://medinform.jmir.org/2015/1/e5/