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Background Clinical free-text data (eg, outpatient letters or nursing notes) represent a vast, untapped source of rich information that, if more accessible for research, would clarify and supplement information coded in structured data fields. Data usually need to be deidentified or anonymized before they can be reused for research, but there is a lack of established guidelines to govern effective deidentification and use of free-text information and avoid damaging data utility as a by-product. Objective This study aimed to develop recommendations for the creation of data governance standards to integrate with existing frameworks for personal data use, to enable free-text data to be used safely for research for patient and public benefit. Methods We outlined data protection legislation and regulations relating to the United Kingdom for context and conducted a rapid literature review and UK-based case studies to explore data governance models used in working with free-text data. We also engaged with stakeholders, including text-mining researchers and the general public, to explore perceived barriers and solutions in working with clinical free-text. Results We proposed a set of recommendations, including the need for authoritative guidance on data governance for the reuse of free-text data, to ensure public transparency in data flows and uses, to treat deidentified free-text data as potentially identifiable with use limited to accredited data safe havens, and to commit to a culture of continuous improvement to understand the relationships between the efficacy of deidentification and reidentification risks, so this can be communicated to all stakeholders. Conclusions By drawing together the findings of a combination of activities, we present a position paper to contribute to the development of data governance standards for the reuse of clinical free-text data for secondary purposes. While working in accordance with existing data governance frameworks, there is a need for further work to take forward the recommendations we have proposed, with commitment and investment, to assure and expand the safe reuse of clinical free-text data for public benefit.

Background Roadside observational studies play a fundamental role in designing evidence-informed strategies to address the pressing global health problem of road traffic injuries. Paper-based data collection has been the standard method for such studies, although digital methods are gaining popularity in all types of primary data collection. Objective This study aims to understand the reliability, productivity, and efficiency of paper vs digital data collection based on three different road user behaviors: helmet use, seatbelt use, and speeding. It also aims to understand the cost and time efficiency of each method and to evaluate potential trade-offs among reliability, productivity, and efficiency. Methods A total of 150 observational sessions were conducted simultaneously for each risk factor in Mumbai, India, across two rounds of data collection. We matched the simultaneous digital and paper observation periods by date, time, and location, and compared the reliability by subgroups and the productivity using Pearson correlations (r). We also conducted logistic regressions separately by method to understand how similar results of inferential analyses would be. The time to complete an observation and the time to obtain a complete dataset were also compared, as were the total costs in US dollars for fieldwork, data entry, management, and cleaning. Results Productivity was higher in paper than digital methods in each round for each risk factor. However, the sample sizes across both methods provided a precision of 0.7 percentage points or smaller. The gap between digital and paper data collection productivity narrowed across rounds, with correlations improving from r=0.27-0.49 to 0.89-0.96. Reliability in risk factor proportions was between 0.61 and 0.99, improving between the two rounds for each risk factor. The results of the logistic regressions were also largely comparable between the two methods. Differences in regression results were largely attributable to small sample sizes in some variable levels or random error in variables where the prevalence of the outcome was similar among variable levels. Although data collectors were able to complete an observation using paper more quickly, the digital dataset was available approximately 9 days sooner. Although fixed costs were higher for digital data collection, variable costs were much lower, resulting in a 7.73% (US $3011/38,947) lower overall cost. Conclusions Our study did not face trade-offs among time efficiency, cost efficiency, statistical reliability, and descriptive comparability when deciding between digital and paper, as digital data collection proved equivalent or superior on these domains in the context of our project. As trade-offs among cost, timeliness, and comparability—and the relative importance of each—could be unique to every data collection project, researchers should carefully consider the questionnaire complexity, target sample size, implementation plan, cost and logistical constraints, and geographical contexts when making the decision between digital and paper.

Background The National Cancer Institute Informatics Technology for Cancer Research (ITCR) program provides a series of funding mechanisms to create an ecosystem of open-source software (OSS) that serves the needs of cancer research. As the ITCR ecosystem substantially grows, it faces the challenge of the long-term sustainability of the software being developed by ITCR grantees. To address this challenge, the ITCR sustainability and industry partnership working group (SIP-WG) was convened in 2019. Objective The charter of the SIP-WG is to investigate options to enhance the long-term sustainability of the OSS being developed by ITCR, in part by developing a collection of business model archetypes that can serve as sustainability plans for ITCR OSS development initiatives. The working group assembled models from the ITCR program, from other studies, and from the engagement of its extensive network of relationships with other organizations (eg, Chan Zuckerberg Initiative, Open Source Initiative, and Software Sustainability Institute) in support of this objective. Methods This paper reviews the existing sustainability models and describes 10 OSS use cases disseminated by the SIP-WG and others, including 3D Slicer, Bioconductor, Cytoscape, Globus, i2b2 (Informatics for Integrating Biology and the Bedside) and tranSMART, Insight Toolkit, Linux, Observational Health Data Sciences and Informatics tools, R, and REDCap (Research Electronic Data Capture), in 10 sustainability aspects: governance, documentation, code quality, support, ecosystem collaboration, security, legal, finance, marketing, and dependency hygiene. Results Information available to the public reveals that all 10 OSS have effective governance, comprehensive documentation, high code quality, reliable dependency hygiene, strong user and developer support, and active marketing. These OSS include a variety of licensing models (eg, general public license version 2, general public license version 3, Berkeley Software Distribution, and Apache 3) and financial models (eg, federal research funding, industry and membership support, and commercial support). However, detailed information on ecosystem collaboration and security is not publicly provided by most OSS. Conclusions We recommend 6 essential attributes for research software: alignment with unmet scientific needs, a dedicated development team, a vibrant user community, a feasible licensing model, a sustainable financial model, and effective product management. We also stress important actions to be considered in future ITCR activities that involve the discussion of the sustainability and licensing models for ITCR OSS, the establishment of a central library, the allocation of consulting resources to code quality control, ecosystem collaboration, security, and dependency hygiene.

Background High-frequency patient-reported outcome (PRO) assessments are used to measure patients' symptoms after surgery for surgical research; however, the quality of those longitudinal PRO data has seldom been discussed. Objective The aim of this study was to determine data quality-influencing factors and to profile error trajectories of data longitudinally collected via paper-and-pencil (P&P) or web-based assessment (electronic PRO [ePRO]) after thoracic surgery. Methods We extracted longitudinal PRO data with 678 patients scheduled for lung surgery from an observational study (n=512) and a randomized clinical trial (n=166) on the evaluation of different perioperative care strategies. PROs were assessed by the MD Anderson Symptom Inventory Lung Cancer Module and single-item Quality of Life Scale before surgery and then daily after surgery until discharge or up to 14 days of hospitalization. Patient compliance and data error were identified and compared between P&P and ePRO. Generalized estimating equations model and 2-piecewise model were used to describe trajectories of error incidence over time and to identify the risk factors. Results Among 678 patients, 629 with at least 2 PRO assessments, 440 completed 3347 P&P assessments and 189 completed 1291 ePRO assessments. In total, 49.4% of patients had at least one error, including (1) missing items (64.69%, 1070/1654), (2) modifications without signatures (27.99%, 463/1654), (3) selection of multiple options (3.02%, 50/1654), (4) missing patient signatures (2.54%, 42/1654), (5) missing researcher signatures (1.45%, 24/1654), and (6) missing completion dates (0.30%, 5/1654). Patients who completed ePRO had fewer errors than those who completed P&P assessments (ePRO: 30.2% [57/189] vs. P&P: 57.7% [254/440]; P Conclusions It is possible to improve data quality of longitudinally collected PRO through ePRO, compared with P&P. However, ePRO-related sampling bias needs to be considered when designing clinical research using longitudinal PROs as major outcomes.

Background: Rapid advances in mobile technologies and applications and the continued growth in digital network coverage have the potential to transform data collection in low- and middle-income countries. A common perception is that digital data collection (DDC) is faster and quickly adaptable. Objective: The objective of this study was to test whether DDC is faster and more adaptable in a roadside environment. We conducted a reliability study comparing digital versus paper data collection in 3 cities in Ghana, Vietnam, and Indonesia observing road safety risk factors in real time. Methods: Roadside observation of helmet use among motorcycle passengers, seat belt use among 4-wheeler passengers, and speeding was conducted in Accra, Ghana; Ho Chi Minh City (HCMC), Vietnam; and Bandung, Indonesia. Two independent data collection teams were deployed to the same sites on the same dates and times, one using a paper-based data collection tool and the other using a digital tool. All research assistants were trained on paper-based data collection and DDC. A head-to-head analysis was conducted to compare the volume of observations, as well as the prevalence of each risk factor. Correlations (r) for continuous variables and kappa for categorical variables are reported with their level of statistical significance. Results: In Accra, there were 119 observation periods (90-min each) identical by date, time, and location during the helmet and seat belt use risk factor data collection and 118 identical periods observing speeding prevalence. In Bandung, there were 150 observation periods common to digital and paper data collection methods, whereas in HCMC, there were 77 matching observation periods for helmet use, 82 for seat belt use, and 84 for speeding. Data collectors using paper tools were more productive than their DDC counterparts during the study. The highest mean volume per session was recorded for speeding, with Bandung recording over 1000 vehicles on paper (paper: mean 1092 [SD 435]; digital: mean 807 [SD 261]); whereas the lowest volume per session was from HCMC for seat belts (paper: mean 52 [SD 28]; digital: mean 62 [SD 30]). Accra and Bandung showed good-to-high correlation for all 3 risk factors (r=0.52 to 0.96), with higher reliability in speeding and helmet use over seat belt use; HCMC showed high reliability for speeding (r=0.99) but lower reliability for helmet and seat belt use (r=0.08 to 0.32). The reported prevalence of risk factors was comparable in all cities regardless of the data collection method. Conclusions: DDC was convenient and reliable during roadside observational data collection. There was some site-related variability in implementing DDC methods, and generally the productivity was higher using the more familiar paper-based method. Even with low correlations between digital and paper data collection methods, the overall reported population prevalence was similar for all risk factors.

Background: There is increasing use of online surveys to improve data quality and timeliness and reduce costs. While there have been numerous cross-sectional studies comparing responses to online or paper surveys, there is little research from a longitudinal perspective. Objective: In the context of the well-established Australian Longitudinal Study on Women’s Health, we examined the patterns of responses to online or paper surveys across the first two waves of the study in which both modes were offered. We compared the following: differences between women born between 1946 and 1951 and between 1973 and 1978; types of device used for online completion; sociodemographic, behavioral, and health characteristics of women who responded online or using mailed paper surveys; and associations between mode of completion in the first survey and participation and mode of completion in the second survey. Methods: Participants in this study, who had responded to regular mailed surveys since 1996, were offered a choice of completing surveys using paper questionnaires or Web-based electronic questionnaires starting in 2012. Two groups of women were involved: an older cohort born between 1946 and 1951 aged in their 60s and a younger cohort born between 1973 and 1978 aged in their 30s when the online surveys were first introduced. We compared women who responded online on both occasions, women who responded online at the first survey and used the paper version of the second survey, women who changed from paper to online, and those who used paper for both surveys. Results: Of the 9663 women in their 60s who responded to one or both surveys, more than 50% preferred paper surveys (5290/9663, 54.74%, on the first survey and 5373/8621, 62.32%, on the second survey). If they chose the online version, most used computers. In contrast, of the 8628 women in their 30s, 56.04% (4835/8628) chose the online version at the first survey. While most favored computers to phones or tablets, many did try these alternatives on the subsequent survey. Many women who completed the survey online the first time preferred the paper version on the subsequent survey. In fact, for women in their 60s, the number who went from online to paper (1151/3851, 29.89%) exceeded the number who went from paper to online (734/5290, 13.88%). The online option was more likely to be chosen by better educated and healthier women. In both cohorts, women who completed paper surveys were more likely than online completers to become nonrespondents on the next survey. Due to the large sample size, almost all differences were statistically significant, with P

Background Colorectal cancer screening by fecal occult blood testing has been an important public health test and shown to reduce colorectal cancer–related mortality. However, the low participation rate in colorectal cancer screening by the general public remains a problematic public health issue. This fact could be attributed to the complex and unpleasant operation of the screening tool. Objective This study aimed to validate a novel toilet paper–based point-of-care test (ie, JustWipe) as a public health instrument to detect fecal occult blood and provide detailed results from the evaluation of the analytic characteristics in the clinical validation. Methods The mechanism of fecal specimen collection by the toilet-paper device was verified with repeatability and reproducibility tests. We also evaluated the analytical characteristics of the test reagents. For clinical validation, we conducted comparisons between JustWipe and other fecal occult blood tests. The first comparison was between JustWipe and typical fecal occult blood testing in a central laboratory setting with 70 fecal specimens from the hospital. For the second comparison, a total of 58 volunteers were recruited, and JustWipe was compared with the commercially available Hemoccult SENSA in a point-of-care setting. Results Adequate amounts of fecal specimens were collected using the toilet-paper device with small day-to-day and person-to-person variations. The limit of detection of the test reagent was evaluated to be 3.75 µg of hemoglobin per milliliter of reagent. Moreover, the test reagent also showed high repeatability (100%) on different days and high reproducibility (>96%) among different users. The overall agreement between JustWipe and a typical fecal occult blood test in a central laboratory setting was 82.9%. In the setting of point-of-care tests, the overall agreement between JustWipe and Hemoccult SENSA was 89.7%. Moreover, the usability questionnaire showed that the novel test tool had high scores in operation friendliness (87.3/100), ease of reading results (97.4/100), and information usefulness (96.1/100). Conclusions We developed and validated a toilet paper–based fecal occult blood test for use as a point-of-care test for the rapid (in 60 seconds) and easy testing of fecal occult blood. These favorable characteristics render it a promising tool for colorectal cancer screening as a public health instrument.

Background Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions. However, in this young field, there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions. Objective The INOVATE-Pain (Interdisciplinary Network on Virtual and Augmented Technologies for Pain management) consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population. Methods An interdisciplinary meeting of 16 academics, clinicians, industry partners, and philanthropy partners was held in January 2020. Results Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR and AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR and AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions. Conclusions To realize the promise of this realm of innovation, key ingredients for success include productive partnerships among industry, academic, and clinical stakeholders; a uniform set of outcome domains and measures for standardized evaluation; and widespread access to the latest opportunities, tools, and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

Background Accurate quantification of pain in a clinical setting is vital. The use of an electronic pain scale enables data to be collected, analyzed, and utilized much faster compared with traditional paper-based scales. The advancement of smart technology in pediatric and adult pain evaluation may offer opportunities to introduce easy-to-use and reliable pain assessment methods within different clinical settings. If promptly introduced within different pediatric and adult pain clinic services, validated and easily accessible mobile health pain apps may lead to early pain detection, promoting improvement in patient’s quality of life and leading to potentially less time off from school or work. Objective This cross-sectional observational study aimed to investigate the interchangeability of an electronic visual analog scale (eVAS) app with a traditional paper visual analog scale (pVAS) among Australian children, adolescents, and adults for pain evaluation. Methods Healthy participants (age range 10-75 years) were recruited from a sporting club and a secondary school in Melbourne (Australia). The data collection process involved application of pressure (8.5 kg/cm2) from a Wagner Force Dial FDK 20 to the midpoint of the thumb. The pressure was applied twice with a 5-minute interval. At each pressure application, participants were asked to randomly record their pain perception using the “eVAS” accessible via the “Interactive Clinics” app and the traditional pVAS. Statistical analysis was conducted to determine intermethod and intramethod reliabilities. Results Overall, 109 healthy participants were recruited. Adults (mean age 42.43 years, SD 14.50 years) had excellent reliability, with an intraclass correlation coefficient (ICC) of 0.94 (95% CI 0.91-0.96). Children and adolescents (mean age 13.91 years, SD 2.89 years) had moderate-to-good intermethod and intramethod reliabilities, with an ICC of 0.80 (95% CI 0.70-0.87) and average ICC of 0.80 (95% CI 0.69-0.87), respectively. Conclusions The eVAS app appears to be interchangeable compared with the traditional pVAS among children, adolescents, and adults. This pain evaluation method may offer new opportunities to introduce user-friendly and validated pain assessment apps for patients, clinicians, and allied health professionals.

Background: Paper questionnaires have traditionally been the first choice for data collection in research. However, declining response rates over the past decade have increased the risk of selection bias in cross-sectional studies. The growing use of the Internet offers new ways of collecting data, but trials using Web-based questionnaires have so far seen mixed results. A secure, online digital mailbox (e-Boks) linked to a civil registration number became mandatory for all Danish citizens in 2014 (exemption granted only in extraordinary cases). Approximately 89% of the Danish population have a digital mailbox, which is used for correspondence with public authorities. Objective: We aimed to compare response rates, completeness of data, and financial costs for different invitation methods: traditional surface mail and digital mail. Methods: We designed a cross-sectional comparative study. An invitation to participate in a survey on help-seeking behavior in out-of-hours care was sent to two groups of randomly selected citizens from age groups 30-39 and 50-59 years and parents to those aged 0-4 years using either traditional surface mail (paper group) or digital mail sent to a secure online mailbox (digital group). Costs per respondent were measured by adding up all costs for handling, dispatch, printing, and work salary and then dividing the total figure by the number of respondents. Data completeness was assessed by comparing the number of missing values between the two methods. Socioeconomic variables (age, gender, family income, education duration, immigrant status, and job status) were compared both between respondents and nonrespondents and within these groups to evaluate the degree of selection bias. Results: A total 3600 citizens were invited in each group; 1303 (36.29%) responded to the digital invitation and 1653 (45.99%) to the paper invitation (difference 9.66%, 95% CI 7.40-11.92). The costs were €1.51 per respondent for the digital group and €15.67 for paper group respondents. Paper questionnaires generally had more missing values; this was significant in five of 17 variables (P

Background: Major international guidelines recommend mental health screening during the perinatal period. However, substantial barriers to screening have been reported by pregnant and postpartum women and perinatal care providers. E-screening offers benefits that may address implementation challenges. Objective: The primary objective of this randomized controlled trial was to evaluate the feasibility and acceptability of Web-based mental health e-screening compared with paper-based screening among pregnant women. A secondary objective was to identify factors associated with women’s preferences for e-screening and disclosure of mental health concerns. Methods: Pregnant women recruited from community and hospital-based antenatal clinics and hospital-based prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control group. Women were eligible if they spoke or read English, were willing to be randomized to e-screening, and were willing to participate in a follow-up diagnostic interview. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a tablet computer, while controls completed them on paper. All women completed self-report baseline questions and were telephoned 1 week after randomization by a blinded research assistant for a MINI International Neuropsychiatric Interview. Renker and Tonkin’s tool of feasibility and acceptability of computerized screening was used to assess the feasibility and acceptability of e-screening compared with paper-based screening. Intention-to-treat analysis was used. To identify factors associated with preference for e-screening and disclosure, variables associated with each outcome at P

Background: As eye tracking-based assessment of cognition becomes more widely used in older adults, particularly those at risk for dementia, reliable and scalable methods to collect high-quality data are required. Eye tracking-based cognitive tests that utilize device-embedded cameras have the potential to reach large numbers of people as a screening tool for preclinical cognitive decline. However, to fully validate this approach, more empirical evidence about the comparability of eyetracking-based paradigms to existing cognitive batteries is needed. Objective: Using a population of clinically normal older adults, we examined the relationship between a 30-minute Visual Paired Comparison (VPC) recognition memory task and cognitive composite indices sensitive to a subtle decline in domains associated with Alzheimer disease. Additionally, the scoring accuracy between software used with a commercial grade eye tracking camera at 60 frames per second (FPS) and a manually scored procedure used with a laptop-embedded web camera (3 FPS) on the VPC task was compared, as well as the relationship between VPC task performance and domain-specific cognitive function. Methods: A group of 49 clinically normal older adults completed a 30-min VPC recognition memory task with simultaneous recording of eye movements by a commercial-grade eye-tracking camera and a laptop-embedded camera. Relationships between webcam VPC performance and the Preclinical Alzheimer Cognitive Composite (PACC) and National Institutes of Health Toolbox Cognitive Battery (NIHTB-CB) were examined. Inter-rater reliability for manually scored tests was analyzed using Krippendorff’s kappa formula, and we used Spearman’s Rho correlations to investigate the relationship between VPC performance scores with both cameras. We also examined the relationship between VPC performance with the device-embedded camera and domain-specific cognitive performance. Results: Modest relationships were seen between mean VPC novelty preference and the PACC (r=.39, P=.007) and NIHTB-CB (r=.35, P=.03) composite scores, and additional individual neurocognitive task scores including letter fluency (r=.33, P=.02), category fluency (r=.36, P=.01), and Trail Making Test A (–.40, P=.006). Robust relationships were observed between the 60 FPS eye tracker and 3 FPS webcam on both trial-level VPC novelty preference (r=.82, P

BackgroundElectronic applications are increasingly being used in hospitals for numerous purposes. ObjectiveOur aim was to assess differences in the characteristics of patients who choose paper versus electronic questionnaires and to evaluate the data quality of both approaches. MethodsBetween October 2012 and June 2013, 136 patients participated in a study on diagnosis-induced stress and anxiety. Patients were asked to fill out questionnaires at six different moments during the diagnostic phase. They were given the opportunity to fill out the questionnaires on paper or electronically (a combination of tablet and Web-based questionnaires). Demographic characteristics and completeness of returned data were compared between groups. ResultsNearly two-thirds of patients (88/136, 64.7%) chose to fill out the questionnaires on paper, and just over a third (48/136, 35.3%) preferred the electronic option. Patients choosing electronic questionnaires were significantly younger (mean 47.3 years vs mean 53.5 in the paper group, P=.01) and higher educated (P=.004). There was significantly more missing information (ie, at least one question not answered) in the paper group during the diagnostic day compared to the electronic group (using a tablet) (28/88 vs 1/48, P

Background: Improving questionnaire response rates is an everlasting issue for research. Today, the Internet can easily be used to collect data quickly. However, collecting data on the Internet can lead to biased samples because not everyone is able to access or use the Internet. The older population, for example, is much less likely to use the Internet. The Patient-Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship (PROFILES) registry offers a platform to collect Web-based and paper questionnaires and to try different measures to improve response rates.Objective: In this study, our aim was to study the influence of two methods of invitation on the response rate. Our second aim was to examine the preference of questionnaire mode of administration (paper or Web-based) for the older patient in particular.Methods: To test these two invitational methods, 3406 colorectal cancer patients between ages 18 and 85 years received an invitation containing an access code for the Web-based questionnaire. They could also request a paper questionnaire with an included reply card (paper-optional group). In contrast, 179 randomly selected colorectal cancer patients received a paper questionnaire with the invitation (paper-included group). They could also choose to fill out the Web-based questionnaire with the included access code.Results: Response rates did not differ between the paper-optional and the paper-included groups (73.14%, 2491/3406 and 74.9%, 134/179, P=.57). In the paper-optional group, online response was significantly higher when compared to the paper-included group (41.23%, 1027/2491 vs 12.7%, 17/134, PConclusions: The lack of difference in response rates between invitation modes implies that researchers can leave out a paper questionnaire at invitation without lowering response rates. It may be preferable not to include a paper questionnaire because more respondents then will fill out a Web-based questionnaire, which will lead to faster available data. However, due to respondent preference, it is not likely that paper questionnaires can be left out completely in the near future.Keywords: Internet; questionnaires; aged; aged, 80 and over; cancer, colon; cancer, rectum; characteristics, population; survey methods; respondents; patient-reported outcomes

Background: Electronic patient-reported outcomes (PRO) provide quick and usually reliable assessments of patients’ health-related quality of life (HRQL). Objective: An electronic version of the Patient-Reported Outcomes Quality of Life-human immunodeficiency virus (PROQOL-HIV) questionnaire was developed, and its face validity and reliability were assessed using standard psychometric methods. Methods: A sample of 80 French outpatients (66% male, 52/79; mean age 46.7 years, SD 10.9) were recruited. Paper-based and electronic questionnaires were completed in a randomized crossover design (2-7 day interval). Biomedical data were collected. Questionnaire version and order effects were tested on full-scale scores in a 2-way ANOVA with patients as random effects. Test-retest reliability was evaluated using Pearson and intraclass correlation coefficients (ICC, with 95% confidence interval) for each dimension. Usability testing was carried out from patients’ survey reports, specifically, general satisfaction, ease of completion, quality and clarity of user interface, and motivation to participate in follow-up PROQOL-HIV electronic assessments. Results: Questionnaire version and administration order effects (N=59 complete cases) were not significant at the 5% level, and no interaction was found between these 2 factors ( P =.94). Reliability indexes were acceptable, with Pearson correlations greater than .7 and ICCs ranging from .708 to .939; scores were not statistically different between the two versions. A total of 63 (79%) complete patients’ survey reports were available, and 55% of patients (30/55) reported being satisfied and interested in electronic assessment of their HRQL in clinical follow-up. Individual ratings of PROQOL-HIV user interface (85%-100% of positive responses) confirmed user interface clarity and usability. Conclusions: The electronic PROQOL-HIV introduces minor modifications to the original paper-based version, following International Society for Pharmacoeconomics and Outcomes Research (ISPOR) ePRO Task Force guidelines, and shows good reliability and face validity. Patients can complete the computerized PROQOL-HIV questionnaire and the scores from the paper or electronic versions share comparable accuracy and interpretation. [J Med Internet Res 2014;16(4):e115]

Background: Problem-based learning (PBL) is well established in medical education and beyond, and continues to be developed and explored. Challenges include how to connect the somewhat abstract nature of classroom-based PBL with clinical practice and how to maintain learner engagement in the process of PBL over time. Objective: A study was conducted to investigate the efficacy of decision-PBL (D-PBL), a variant form of PBL that replaces linear PBL cases with virtual patients. These Web-based interactive cases provided learners with a series of patient management pathways. Learners were encouraged to consider and discuss courses of action, take their chosen management pathway, and experience the consequences of their decisions. A Web-based application was essential to allow scenarios to respond dynamically to learners’ decisions, to deliver the scenarios to multiple PBL classrooms in the same timeframe, and to record centrally the paths taken by the PBL groups. Methods: A randomized controlled trial in crossover design was run involving all learners (N=81) in the second year of the graduate entry stream for the undergraduate medicine program at St George’s University of London. Learners were randomized to study groups; half engaged in a D-PBL activity whereas the other half had a traditional linear PBL activity on the same subject material. Groups alternated D-PBL and linear PBL over the semester. The measure was mean cohort performance on specific face-to-face exam questions at the end of the semester. Results: D-PBL groups performed better than linear PBL groups on questions related to D-PBL with the difference being statistically significant for all questions. Differences between the exam performances of the 2 groups were not statistically significant for the questions not related to D-PBL. The effect sizes for D-PBL–related questions were large and positive (>0.6) except for 1 question that showed a medium positive effect size. The effect sizes for questions not related to D-PBL were all small (≤0.3) with a mix of positive and negative values. Conclusions: The efficacy of D-PBL was indicated by improved exam performance for learners who had D-PBL compared to those who had linear PBL. This suggests that the use of D-PBL leads to better midterm learning outcomes than linear PBL, at least for learners with prior experience with linear PBL. On the basis of tutor and student feedback, St George’s University of London and the University of Nicosia, Cyprus have replaced paper PBL cases for midstage undergraduate teaching with D-PBL virtual patients, and 6 more institutions in the ePBLnet partnership will be implementing D-PBL in Autumn 2015. [J Med Internet Res 2014;16(11):e240]

Background: Survey response rates have been declining over the past decade. The more widespread use of the Internet and Web-based technologies among potential health survey participants suggests that Web-based questionnaires may be an alternative to paper questionnaires in future epidemiological studies. Objective: To compare response rates in a population of parents by using 4 different modes of data collection for a questionnaire survey of which 1 involved a nonmonetary incentive. Methods: A random sample of 3148 parents of Danish children aged 2-17 years were invited to participate in the Danish part of the NordChild 2011 survey on their children’s health and welfare. NordChild was conducted in 1984 and 1996 in collaboration with Finland, Iceland, Norway, and Sweden using mailed paper questionnaires only. In 2011, all countries used conventional paper versions only except Denmark where the parents were randomized into 4 groups: (1) 789 received a paper questionnaire only (paper), (2) 786 received the paper questionnaire and a log-in code to the Web-based questionnaire (paper/Web), (3) 787 received a log-in code to the Web-based questionnaire (Web), and (4) 786 received log-in details to the Web-based questionnaire and were given an incentive consisting of a chance to win a tablet computer (Web/tablet). In connection with the first reminder, the nonresponders in the paper, paper/Web, and Web groups were also present with the opportunity to win a tablet computer as a means of motivation. Descriptive analysis was performed using chi-square tests. Odds ratios were used to estimate differences in response rates between the 4 modes. Results: In 2011, 1704 of 3148 (54.13%) respondents answered the Danish questionnaire. The highest response rate was with the paper mode (n=443, 56.2%). The other groups had similar response rates: paper/Web (n=422, 53.7%), Web (n=420, 53.4%), and Web/tablet (n=419, 53.3%) modes. Compared to the paper mode, the odds for response rate in the paper/Web decreased by 9% (OR 0.91, 95% CI 0.74-1.10) and by 11% (OR 0.89, 95% CI 0.73-1.09) in the Web and Web/tablet modes. The total number of responders for NordChild declined from 10,291 of 15,339 (67.09%) in 1984 and 10,667 of 15,254 (69.93%) in 1996 to 7805 of 15,945 (48.95%) in 2011 with similar declines in all 5 Nordic countries. Conclusions: Web-based questionnaires could replace traditional paper questionnaires with minor effects on response rates and lower costs. The increasing effect on the response rate on participants replying for a nonmonetary incentive could only be estimated within the 2 Web-based questionnaire modes before the first reminder. Alternative platforms to reach higher participation rates in population surveys should reflect the development of electronic devices and the ways in which the population primarily accesses the Internet. [J Med Internet Res 2013;15(8):e173]

BackgroundWeb-based questionnaires have become increasingly popular in health research. However, reported response rates vary and response bias may be introduced. ObjectiveThe aim of this study was to evaluate whether sending a mixed invitation (paper-based together with Web-based questionnaire) rather than a Web-only invitation (Web-based questionnaire only) results in higher response and participation rates for female childhood cancer survivors filling out a questionnaire on fertility issues. In addition, differences in type of response and characteristics of the responders and nonresponders were investigated. Moreover, factors influencing preferences for either the Web- or paper-based version of the questionnaire were examined. MethodsThis study is part of a nationwide study on reproductive function, ovarian reserve, and risk of premature menopause in female childhood cancer survivors. The Web-based version of the questionnaire was available for participants through the Internet by means of a personalized user name and password. Participants were randomly selected to receive either a mixed invitation (paper-based questionnaire together with log-in details for Web-based questionnaire, n = 137) or a Web-only invitation (log-in details only, n = 140). Furthermore, the latter group could request a paper-based version of the questionnaire by filling out a form. ResultsOverall response rates were comparable in both randomization groups (83% mixed invitation group vs 89% in Web-only invitation group, P = .20). In addition, participation rates appeared not to differ (66% or 90/137, mixed invitation group vs 59% or 83/140, Web-only invitation group, P =.27). However, in the mixed invitation group, significantly more respondents filled out the paper-based questionnaire compared with the Web-only invitation group (83% or 75/90 and 65% or 54/83, respectively, P = .01). The 44 women who filled out the Web-based version of the questionnaire had a higher educational level than the 129 women who filled out the paper-based version (P = .01). Furthermore, the probability of filling out the Web-based questionnaire appeared to be greater for women who were allocated to the Web-only invitation group (OR = 2.85, 95% CI 1.31 - 6.21), were older (OR = 1.08, 95% CI 1.02 - 1.15), had a higher educational level (OR high vs low = 0.06, 95% CI 0.01 - 0.52), or were students (OR employed vs student = 3.25, 95% CI 1.00 - 10.56). ConclusionsAlthough overall response as well as participation rates to both types of invitations were similar, adding a paper version of a questionnaire to a Web-only invitation resulted in more respondents filling out the paper-based version. In addition, women who were older, had a higher level of education, or were students, were more likely to have filled out the Web-based version of the questionnaire. Given the many advantages of Web-based over paper-based questionnaires, researchers should strongly consider using Web-based questionnaires, although possible response bias when using these types of questionnaires should be taken into account. Trial RegistrationNederlands Trial Register NTR2922; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2922 (Archived by WebCite at http://www.webcitation.org/5zRRdMrDv)

Background: Maternal, Newborn, and Child Health (MNCH) household survey data are collected mainly with pen-and-paper. Smartphone data collection may have advantages over pen-and-paper, but little evidence exists on how they compare. Objective: To compare smartphone data collection versus the use of pen-and-paper for infant feeding practices of the MNCH household survey. We compared the two data collection methods for differences in data quality (data recording, data entry, open-ended answers, and interrater reliability), time consumption, costs, interviewers’ perceptions, and problems encountered. Methods: We recruited mothers of infants aged 0 to 23 months in four village clinics in Zhaozhou Township, Zhao County, Hebei Province, China. We randomly assigned mothers to a smartphone or a pen-and-paper questionnaire group. A pair of interviewers simultaneously questioned mothers on infant feeding practices, each using the same method (either smartphone or pen-and-paper). Results: We enrolled 120 mothers, and all completed the study. Data recording errors were prevented in the smartphone questionnaire. In the 120 pen-and-paper questionnaires (60 mothers), we found 192 data recording errors in 55 questionnaires. There was no significant difference in recording variation between the groups for the questionnaire pairs (P = .32) or variables (P = .45). The smartphone questionnaires were automatically uploaded and no data entry errors occurred. We found that even after double data entry of the pen-and-paper questionnaires, 65.0% (78/120) of the questionnaires did not match and needed to be checked. The mean duration of an interview was 10.22 (SD 2.17) minutes for the smartphone method and 10.83 (SD 2.94) minutes for the pen-and-paper method, which was not significantly different between the methods (P = .19). The mean costs per questionnaire were higher for the smartphone questionnaire (¥143, equal to US $23 at the exchange rate on April 24, 2012) than for the pen-and-paper questionnaire (¥83, equal to US $13). The smartphone method was acceptable to interviewers, and after a pilot test we encountered only minor problems (eg, the system halted for a few seconds or it shut off), which did not result in data loss. Conclusions: This is the first study showing that smartphones can be successfully used for household data collection on infant feeding in rural China. Using smartphones for data collection, compared with pen-and-paper, eliminated data recording and entry errors, had similar interrater reliability, and took an equal amount of time per interview. While the costs for the smartphone method were higher than the pen-and-paper method in our small-scale survey, the costs for both methods would be similar for a large-scale survey. Smartphone data collection should be further evaluated for other surveys and on a larger scale to deliver maximum benefits in China and elsewhere. [J Med Internet Res 2012;14(5):e119]

BackgroundThere is growing interest in the use of information communication technologies to treat obesity. An intervention delivered by smartphone could be a convenient, potentially cost-effective, and wide-reaching weight management strategy. Although there have been studies of texting-based interventions and smartphone applications (apps) used as adjuncts to other treatments, there are currently no randomized controlled trials (RCT) of a stand-alone smartphone application for weight loss that focuses primarily on self-monitoring of diet and physical activity. ObjectiveThe aim of this pilot study was to collect acceptability and feasibility outcomes of a self-monitoring weight management intervention delivered by a smartphone app, compared to a website and paper diary. MethodsA sample of 128 overweight volunteers were randomized to receive a weight management intervention delivered by smartphone app, website, or paper diary. The smartphone app intervention, My Meal Mate (MMM), was developed by the research team using an evidence-based behavioral approach. The app incorporates goal setting, self-monitoring of diet and activity, and feedback via weekly text message. The website group used an existing commercially available slimming website from a company called Weight Loss Resources who also provided the paper diaries. The comparator groups delivered a similar self-monitoring intervention to the app, but by different modes of delivery. Participants were recruited by email, intranet, newsletters, and posters from large local employers. Trial duration was 6 months. The intervention and comparator groups were self-directed with no ongoing human input from the research team. The only face-to-face components were at baseline enrollment and brief follow-up sessions at 6 weeks and 6 months to take anthropometric measures and administer questionnaires. ResultsTrial retention was 40/43 (93%) in the smartphone group, 19/42 (55%) in the website group, and 20/43 (53%) in the diary group at 6 months. Adherence was statistically significantly higher in the smartphone group with a mean of 92 days (SD 67) of dietary recording compared with 35 days (SD 44) in the website group and 29 days (SD 39) in the diary group (P

The coronavirus disease (COVID-19) pandemic has created an urgent need for coordinated mechanisms to respond to the outbreak across health sectors, and digital health solutions have been identified as promising approaches to address this challenge. This editorial discusses the current situation regarding digital health solutions to fight COVID-19 as well as the challenges and ethical hurdles to broad and long-term implementation of these solutions. To decrease the risk of infection, telemedicine has been used as a successful health care model in both emergency and primary care. Official communication plans should promote facile and diverse channels to inform people about the pandemic and to avoid rumors and reduce threats to public health. Social media platforms such as Twitter and Google Trends analyses are highly beneficial to model pandemic trends as well as to monitor the evolution of patients’ symptoms or public reaction to the pandemic over time. However, acceptability of digital solutions may face challenges due to potential conflicts with users’ cultural, moral, and religious backgrounds. Digital tools can provide collective public health benefits; however, they may be intrusive and can erode individual freedoms or leave vulnerable populations behind. The COVID-19 pandemic has demonstrated the strong potential of various digital health solutions that have been tested during the crisis. More concerted measures should be implemented to ensure that future digital health initiatives will have a greater impact on the epidemic and meet the most strategic needs to ease the life of people who are at the forefront of the crisis.

Background The use of the Internet to administer questionnaires has many potential advantages over the use of pen-and-paper administration. Yet it is important to validate Internet administration, as most questionnaires were initially developed and validated for pen-and-paper delivery. While some have been validated for use over the Internet, these questionnaires have predominately been used amongst the healthy general population. To date, information is lacking on the validity of questionnaires administered over the Internet in patients with chronic diseases such as heart failure. Objectives To determine the validity of three heart failure questionnaires administered over the Internet compared to pen-and-paper administration in patients with heart failure. Methods We conducted a prospective randomized study using test-retest design comparing administration via the Internet to pen-and-paper administration for three heart failure questionnaires provided to patients recruited from a heart failure clinic in Toronto, Ontario, Canada: the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and the Self-Care Heart Failure Index (SCHFI). Results Of the 58 subjects enrolled, 34 completed all three questionnaires. The mean difference and confidence intervals for the summary scores of the KCCQ, MLHFQ, and SCHFI were 1.2 (CI -1.5 to 4.0, scale from 0 to 100), 4.0 (CI -1.98 to 10.04, scale from 0 to 105), and 10.1 (CI 1.18 to 19.07, scale from 66.7 to 300), respectively. Conclusions Internet administration of the KCCQ appears to be equivalent to pen-and-paper administration. For the MLHFQ and SCHFI, we were unable to demonstrate equivalence. Further research is necessary to determine if the administration methods are equivalent for these instruments.

BACKGROUND: Internet psychology services are rapidly increasing and that implies online assessment. To guarantee the results of these new online evaluation procedures, it is necessary to have reliable and valid assessment tools. OBJECTIVE: In this work we analyzed the online versions of two popular psychopathology screening questionnaires: the General Health Questionnaire-28 (GHQ-28) and the Symptoms Check-List-90-Revised (SCL-90-R). METHODS: A total of 185 psychology students were recruited from two universities in Madrid, Spain. All of them had Internet access at home. A test-retest situation and factorial analysis were used to generate reliability and validity data. Both paper-and-pencil questionnaires (test) and their online versions (retest) were completed by 100 participants (median gap = 17 days). RESULTS: Results suggest that both online questionnaires were fairly equivalent to their paper-and-pencil versions, with higher reliability values for the SCL-90-R. Factorial analysis tended to reproduce the structure shown in former investigations of both questionnaires, replicating the four-factor structure of the GHQ-28 but failing to do so with the nine-factor structure of the SCL-90-R. Instead, a large unrotated factor appeared. CONCLUSIONS: Further research should be carried out to confirm these data, but our work supports the online use of both assessment tools. The psychometric properties of the online version of GHQ-28 is similar to the paper-and-pencil and we can recommend its utilization in a Web environment. In contrast, SCL-90-R can only be recommended as a global index for psychological distress, using the Global Severity Index (GSI), not necessarily its subscales; and it should be considered that the online scores were lower than the ones with the paper-and-pencil version. [J Med Internet Res 2007;9(1):e2]

This article will provide a framework for producing immersive 360-degree videos for pediatric and adult patients in hospitals. This information may be useful to hospitals across the globe who may wish to produce similar videos for their patients. Advancements in immersive 360-degree technologies have allowed us to produce our own “virtual experience” where our children can prepare for anesthesia by “experiencing” all the sights and sounds of receiving and recovering from an anesthetic. We have shown that health care professionals, children, and their parents find this form of preparation valid, acceptable and fun. Perhaps more importantly, children and parents have self-reported that undertaking our virtual experience has led to a reduction in their anxiety when they go to the operating room. We provide definitions, and technical aspects to assist other health care professionals in the development of low-cost 360-degree videos.

BackgroundSatisfactory psychometric properties in offline questionnaires do not guarantee the same outcome in Web-based versions. Any construct that is measured online should be compared to a paper-based assessment so that the appropriateness of online questionnaire data can be tested. Little research has been done in this area regarding Attention-Deficit/Hyperactivity Disorder (ADHD) in adults. ObjectiveThe objective was to simultaneously collect paper-based and Web-based ADHD questionnaire data in adults not diagnosed with ADHD in order to compare the two data sources regarding their equivalence in raw scores, in measures of reliability, and in factorial structures. MethodsData from the German versions of the Connors Adult ADHD Rating Scales (CAARS-S), the Wender Utah Rating Scale (WURS-k), and the ADHD Self Rating Scale (ADHS-SB) were collected via online and paper questionnaires in a cross-sectional study with convenience sampling. We performed confirmatory factor analyses to examine the postulated factor structures in both groups separately and multiple group confirmatory factor analyses to test whether the postulated factor structures of the questionnaires were equivalent across groups. With Cronbach alpha, we investigated the internal consistency of the postulated factors in the different questionnaires. Mann-Whitney U tests with the effect size “Probability of Superiority (PS)” were used to compare absolute values in the questionnaires between the two groups. ResultsIn the paper-based sample, there were 311 subjects (73.3% female); in the online sample, we reached 255 subjects (69% female). The paper-based sample had a mean age of 39.2 years (SD 18.6); the Web-based sample had a mean age of 30.4 years (SD 10.5) and had a higher educational background. The original four factor structure of the CAARS-S could be replicated in both samples, but factor loadings were different. The Web-based sample had significantly higher total scores on three scales. The five-factor structure of the German short form of the WURS-k could be replicated only in the Web-based sample. The Web-based sample had substantially higher total scores, and nearly 40% of the Web-based sample scored above the clinically relevant cut-off value. The three-factor structure of the ADHS-SB could be replicated in both samples, but factor loadings were different. Women in the Web-based sample had substantially higher total scores, and 30% of the Web-based sample scored above the clinically relevant cut-off value. Internal consistencies in all questionnaires were acceptable to high in both groups. ConclusionsData from the Web-based administration of ADHD questionnaires for adults should not be used for the extraction of population norms. Separate norms should be established for ADHD online questionnaires. General psychometric properties of ADHD questionnaires (factor structure, internal consistency) were largely unaffected by sampling bias. Extended validity studies of existing ADHD questionnaires should be performed by including subjects with a diagnosis of ADHD and by randomizing them to Web- or paper-based administration.

BackgroundResearch in quality of life traditionally relies on paper-and-pencil questionnaires. Easy access to the Internet has inspired a number of studies that use the Internet to collect questionnaire data. However, Internet-based data collection may differ from traditional methods with respect to response rate and data quality as well as the validity and reliability of the involved scales. Objective We used a randomized design to compare a paper-and-pencil questionnaire with an Internet version of the same questionnaire with respect to differences in response rate and completeness of data. Methods Women referred for mammography at a Danish public hospital from September 2004 to April 2005, aged less than 67 years and without a history of breast cancer, were eligible for the study. The women received the invitation to participate along with the usual letter from the Department of Radiology. A total of 533 women were invited to participate. They were randomized to receive either a paper questionnaire, with a prepaid return envelope, or a guideline on how to fill in the Internet-based version online. The questionnaire consisted of 17 pages with a total of 119 items, including the Short Form-36, Multidimensional Fatigue Inventory-20, Hospital Anxiety and Depression Scale, and questions regarding social status, education level, occupation, and access to the Internet. Nonrespondents received a postal reminder giving them the option of filling out the other version of the questionnaire. Results The response rate before the reminder was 17.9% for the Internet group compared to 73.2% for the paper-and-pencil group (risk difference 55.3%, P < .001). After the reminder, when the participant could chose between versions of the questionnaire, the total response rate for the Internet and paper-and-pencil group was 64.2% and 76.5%, respectively (risk difference 12.2%, P = .002). For the Internet version, 97.8% filled in a complete questionnaire without missing data, while 63.4% filled in a complete questionnaire for the paper-and-pencil version (risk difference 34.5%, P < .001). Conclusions The Internet version of the questionnaire was superior with respect to completeness of data, but the response rate in this population of unselected patients was low. The general population has yet to become more familiar with the Internet before an online survey can be the first choice of researchers, although it is worthwhile considering within selected populations of patients as it saves resources and provides more complete answers. An Internet version may be combined with the traditional version of a questionnaire, and in follow-up studies of patients it may be more feasible to offer Internet versions.

BACKGROUND: Searches for health information are among the most common reasons that consumers use the Internet. Both consumers and quality experts have raised concerns about the quality of information on the Web and the ability of consumers to find accurate information that meets their needs. OBJECTIVE: To produce a national stakeholder-driven agenda for research, technical improvements, and education that will improve the results of consumer searches for health information on the Internet. METHODS: URAC, a national accreditation organization, and Consumer WebWatch (CWW), a project of Consumers Union (a consumer advocacy organization), conducted a review of factors influencing the results of online health searches. The organizations convened two stakeholder groups of consumers, quality experts, search engine experts, researchers, health-care providers, informatics specialists, and others. Meeting participants reviewed existing information and developed recommendations for improving the results of online consumer searches for health information. Participants were not asked to vote on or endorse the recommendations. Our working definition of a quality Web site was one that contained accurate, reliable, and complete information. RESULTS: The Internet has greatly improved access to health information for consumers. There is great variation in how consumers seek information via the Internet, and in how successful they are in searching for health information. Further, there is variation among Web sites, both in quality and accessibility. Many Web site features affect the capability of search engines to find and index them. CONCLUSIONS: Research is needed to define quality elements of Web sites that could be retrieved by search engines and understand how to meet the needs of different types of searchers. Technological research should seek to develop more sophisticated approaches for tagging information, and to develop searches that "learn" from consumer behavior. Finally, education initiatives are needed to help consumers search more effectively and to help them critically evaluate the information they find. [J Med Internet Res 2004;6(2):e18]

The Internet is becoming increasingly important as a way for patients to acquire medical information and as a means for patient-physician communication. Questions about appropriate use of this new technology have been brought to the fore by the many patients using the Internet to seek sildenafil prescriptions.To present the first description of a physician designed and directed Internet-based prescribing system of sildenafil, together with data covering more than 2,100 patient encounters.Retrospective analysis of a large case series from a medical practice that prescribes sildenafil based on medical and sexual histories obtained through a physician designed and directed World Wide Web (WWW) site, compared against patients from clinics at a Midwestern inner city medical center. We compared all 2,104 Internet patients seeking sildenafil prescriptions online between June 14, 1998, and March 1, 1999, with all 36 medical center patients obtaining sildenafil prescriptions during the same period. The outcome measures compared were: completeness of medical record; patient safety as noted by the follow up responses of all patients requesting refills, any comments received by the internet site (webmaster), and patient or physician comments noted in the clinic medical record; satisfaction as noted by the follow up responses of all patients requesting refills, any comments received by the internet site (webmaster), and patient or physician comments noted in the clinic medical record; examinations and laboratory tests.Fifty-six percent of Internet requests came from 46 states, and 44% from eight foreign countries. Of 2,104 requests, 2,100 were granted. Three hundred ten patients have requested medication refills: all reported erections sufficient for intercourse and 69% said their satisfaction exceeded all expectations; none were at all dissatisfied. Side effect rates were comparable to those in the literature. Comparison of the medical history obtained from Internet patients with that recorded in clinic patients' charts revealed that the former was far more complete. No clinic patient received any examination or laboratory test specific for erectile dysfunction or its causes. There were no reported deaths or serious complications in either group.Internet-based prescription of sildenafil provides the physician with a complete and very detailed medical and sexual history for 100% of patients without denying any information routinely obtained in a direct patient contact setting. Internet-based practice, which may be expected to require far fewer healthcare resources than traditional settings, rates very high in patient satisfaction among patients requesting a refill; no negative comments were received from all other patients. Overall, these data support the safety and effectiveness of Internet prescribing of selected medications.

Background Social media has been extensively used for the communication of health-related information and consecutively for the potential spread of medical misinformation. Conventional systematic reviews have been published on this topic to identify original articles and to summarize their methodological approaches and themes. A bibliometric study could complement their findings, for instance, by evaluating the geographical distribution of the publications and determining if they were well cited and disseminated in high-impact journals. Objective The aim of this study was to perform a bibliometric analysis of the current literature to discover the prevalent trends and topics related to medical misinformation on social media. Methods The Web of Science Core Collection electronic database was accessed to identify relevant papers with the following search string: ALL=(misinformati* OR “wrong informati*” OR disinformati* OR “misleading informati*” OR “fake news*”) AND ALL=(medic* OR illness* OR disease* OR health* OR pharma* OR drug* OR therap*) AND ALL=(“social media*” OR Facebook* OR Twitter* OR Instagram* OR YouTube* OR Weibo* OR Whatsapp* OR Reddit* OR TikTok* OR WeChat*). Full records were exported to a bibliometric software, VOSviewer, to link bibliographic information with citation data. Term and keyword maps were created to illustrate recurring terms and keywords. Results Based on an analysis of 529 papers on medical and health-related misinformation on social media, we found that the most popularly investigated social media platforms were Twitter (n=90), YouTube (n=67), and Facebook (n=57). Articles targeting these 3 platforms had higher citations per paper (>13.7) than articles covering other social media platforms (Instagram, Weibo, WhatsApp, Reddit, and WeChat; citations per paper Conclusions There is a significant platform-specific topic preference for social media investigations on medical misinformation. With a large population of internet users from China, it may be reasonably expected that Weibo, WeChat, and TikTok (and its Chinese version Douyin) would be more investigated in future studies. Currently, these platforms present research gaps that leave their usage and information dissemination warranting further evaluation. Future studies should also include social platforms targeting non-English users to provide a wider global perspective.

Background Knowledge translation and dissemination are some of the main challenges that affect evidence-based medicine. Web 2.0 platforms promote the sharing and collaborative development of content. Executable knowledge tools, such as order sets, are a knowledge translation tool whose localization is critical to its effectiveness but a challenge for organizations to develop independently. Objective This paper describes a Web 2.0 resource, referred to as the collaborative network (TCN), for order set development designed to share executable knowledge (order sets). This paper also analyzes the scope of its use, describes its use through network analysis, and examines the provision and use of order sets in the platform by organizational size. Methods Data were collected from Think Research’s TxConnect platform. We measured interorganization sharing across Canadian hospitals using descriptive statistics. A weighted chi-square analysis was used to evaluate institutional size to share volumes based on institution size, with post hoc Cramer V score to measure the strength of association. Results TCN consisted of 12,495 order sets across 683 diagnoses or processes. Between January 2010 and March 2015, a total of 131 health care organizations representing 360 hospitals in Canada downloaded order sets 105,496 times. Order sets related to acute coronary syndrome, analgesia, and venous thromboembolism were most commonly shared. COVID-19 order sets were among the most actively shared, adjusting for order set lifetime. A weighted chi-square analysis showed nonrandom downloading behavior (P Conclusions In this paper, we have described and analyzed a Web 2.0 platform for the sharing of order set content with significant network activity. The robust use of TCN to access customized order sets reflects its value as a resource for health care organizations when they develop or update their own order sets.

Background Urinary tract infections (UTIs) are one of the most common conditions in women. Current information on the presentation, management, and natural course of the infection is based on paper diaries filled out and subsequently posted by patients. Objective The aim of this study is to explore the feasibility of a smartphone app to assess the natural course and management of UTIs. Methods A smartphone app was developed to collect data from study participants presenting with symptoms of UTI in general practice. After initial demographic and treatment information, symptom severity was recorded by the patient after a reminder on their smartphone, which occurred twice daily for a period of 7 days or until symptom resolution. Results A total of 181 women aged 18-76 years downloaded the smartphone app. The duration of symptoms was determined from the results of 178 participants. All patients submitted a urine sample, most patients were prescribed an antibiotic (163/181, 90.1%), and 38.7% (70/181) of the patients had a positive culture. Moderately bad or worse symptoms lasted a mean of 3.8 (SD 3.2; median 4) days, and 70.2% (125/178) of the patients indicated that they were cured on day 4 after consultation. This compares with other research assessing symptom duration and management of UTIs using paper diaries. Patients were very positive about the usability of the smartphone app and often found the reminders supportive. On the basis of the feedback and the analysis of the data, some suggestions for improvement were made. Conclusions Smartphone diaries for symptom scores over the course of infections are an efficient and acceptable means of collecting data in research.

Background All aging societies face the challenge of allocating limited resources for the highest value of use. The sharing economy provides one method to address the imbalance between the demand and supply of health services to the older adult population. With a substantial aging population, China’s practices in the sharing aging industry may set examples for other “getting old before getting rich” countries. Objective There is a gap in both the data and research on China’s aging industry sharing economy. This paper addresses these data and research lacunae by constructing a framework for the application of a sharing model in China’s aging industry, by assessing the current state of the aging industry sharing economy, by setting out the challenges to the sharing aging health care and service economy, and by making recommendations for the development of the aging industry sharing economy. Methods This paper constructs a sharing economy framework in the aging industry covering four aspects (people, facilities, capital, and information) to test the current state and future prospects of China’s aging industry sharing economy. Results In people sharing, we analyzed the sharing of emotional companionship, doctors, nurses, nursing attendants, and domestic helpers. We discussed facility sharing models from the point of land and housing, medical devices, and other items such as pensioner meals and shared medicine bins. We acknowledge that crowdfunding platforms have developed fast in China, but many older adult users faced problems in their operation. Information sharing is a developing field, which can optimize users’ experiences and should help older adults filter out misinformation, but China currently does not have adequate sharing information platforms for older adults. Conclusions We identified four major challenges in China’s aging industry sharing economy: poor adaptability to technology for older adults, mediocre quality of shared services, one-size-fits-all and the concept of the useless elderly, and shortage of qualified practitioners. We make recommendations for specific measures by governments, communities, and enterprises to improve the sharing economy in the aging industry.

Background As the use of smartphones and mobile apps is increasing, mobile health (mHealth) can be used as a cost-effective option to provide behavioral interventions aimed at educating and promoting self-management for chronic diseases such as diabetes. Although many mobile software apps have been developed for this purpose, they usually lack a theoretical foundation and do not follow the guidelines suggested for evidence-based practice. Therefore, this study aimed to develop a theory-based self-management app for people with type 2 diabetes and provide an app based on a needs assessment analysis. Objective This paper describes the development and usability evaluation of a cloud-based and mobile-based diabetes self-management app designed to help people with diabetes change their health behavior and also enable remote monitoring by health care providers. Methods The development of this mHealth solution comprises 3 phases. Phase I: feature extraction of the Android apps that had a user rating of 4 stars or more and review of papers related to mHealth for diabetes self-management were performed followed by seeking expert opinions about the extracted features to determine the essential features of the app. Phase II: design and implementation included selecting which behavioral change and structural theories were to be applied the app and design of the website. Phase III: evaluation of the usability and user experience of the mobile app by people with diabetes and the portal by health care providers using the User Experience Questionnaire. Results The developed mobile app includes modules that support several features. A person’s data were entered or collected and viewed in the form of graphs and tables. The theoretical foundation of behavioral intervention is the transtheoretical model. Users were able to receive customized messages based on the behavioral change preparation stage using the Kreuter algorithm. The clinician’s portal was used by health care providers to monitor the patients. The results of the usability evaluation revealed overall user satisfaction with the app. Conclusions Mobile- and cloud-based systems may be an effective tool for facilitating the modification of self-management of chronic care. The results of this study showed that the usability of mobile- and cloud-based systems can be satisfactory and promising. Given that the study used a behavioral model, assessment of the effectiveness of behavior change over time requires further research with long-term follow-up.

Background Many weight loss programs show short-term effectiveness, but subsequent weight loss maintenance is difficult to achieve. Digital technologies offer a promising means of delivering behavior change approaches at low costs and on a wide scale. The Navigating to a Healthy Weight (NoHoW) project, which was funded by the European Union’s Horizon 2020 research and innovation program, aimed to develop, test, and evaluate a digital toolkit designed to promote successful long-term weight management. The toolkit was tested in an 18-month, large-scale, international, 2×2 factorial (motivation and self-regulation vs emotion regulation) randomized controlled trial that was conducted on adults with overweight or obesity who lost ≥5% of their body weight in the preceding 12 months before enrollment into the intervention. Objective This paper aims to describe the development of the NoHoW Toolkit, focusing on the logic models, content, and specifications, as well as the results from user testing. Methods The toolkit was developed by using a systematic approach, which included the development of the theory-based logic models, the selection of behavior change techniques, the translation of these techniques into a web-based app (NoHoW Toolkit components), technical development, and the user evaluation and refinement of the toolkit. Results The toolkit included a set of web-based tools and inputs from digital tracking devices (smart scales and activity trackers) and modules that targeted weight, physical activity, and dietary behaviors. The final toolkit comprised 34 sessions that were distributed through 15 modules and provided active content over a 4-month period. The motivation and self-regulation arm consisted of 8 modules (17 sessions), the emotion regulation arm was presented with 7 modules (17 sessions), and the combined arm received the full toolkit (15 modules; 34 sessions). The sessions included a range of implementations, such as videos, testimonies, and questionnaires. Furthermore, the toolkit contained 5 specific data tiles for monitoring weight, steps, healthy eating, mood, and sleep. Conclusions A systematic approach to the development of digital solutions based on theory, evidence, and user testing may significantly contribute to the advancement of the science of behavior change and improve current solutions for sustained weight management. Testing the toolkit by using a 2×2 design provided a unique opportunity to examine the effect of motivation and self-regulation and emotion regulation separately, as well as the effect of their interaction in weight loss maintenance.

Background Elective colorectal cancer (CRC) surgeries offer enhanced surgical outcomes but demand high self-efficacy in prehabilitation and competency in self-care and disease management postsurgery. Conventional strategies to meet perioperative needs have not been pragmatic, and there remains a pressing need for novel technologies that could improve health outcomes. Objective The aim of this paper was to describe the development of a smartphone-based interactive CRC self-management enhancement psychosocial program (iCanManage) in order to improve health outcomes among patients who undergo elective CRC surgeries and their family caregivers. Methods A multidisciplinary international team comprising physicians, specialist nurses, a psychologist, software engineers, academic researchers, cancer survivors, patient ambassadors, and ostomy care medical equipment suppliers was formed to facilitate the development of this patient-centric digital solution. The process occurred in several stages: (1) review of current practice through clinic visits and on-site observations; (2) review of literature and findings from preliminary studies; (3) content development grounded in an underpinning theory; (4) integration of support services; and (5) optimizing user experience through improving interface aesthetics and customization. In our study, 5 participants with CRC performed preliminary assessments on the quality of the developed solution using the 20-item user version of the Mobile App Rating Scale (uMARS), which had good psychometric properties. Results Based on the collected uMARS data, the smartphone app was rated highly for functionality, aesthetics, information quality, and perceived impact, and moderately for engagement and subjective quality. Several limiting factors such as poor agility in the adoption of digital technology and low eHealth literacy were identified despite efforts to promote engagement and ensure ease of use of the mobile app. To overcome such barriers, additional app-training sessions, an instruction manual, and regular telephone calls will be incorporated into the iCanManage program during the trial period. Conclusions This form of multidisciplinary collaboration is advantageous as it can potentially streamline existing care paths and allow the delivery of more holistic care to the CRC population during the perioperative period. Should the program be found to be effective and sustainable, hospitals adopting this digital solution may achieve better resource allocation and reduce overall health care costs in the long run. Trial Registration ClinicalTrials.gov NCT04159363; https://clinicaltrials.gov/ct2/show/NCT04159363

Background The delivery of standardized self-report assessments is essential for measurement-based care in mental health. Paper-based methods of measurement-based care data collection may result in transcription errors, missing data, and other data quality issues when entered into patient electronic health records (EHRs). Objective This study aims to help address these issues by using a dedicated instance of REDCap (Research Electronic Data Capture; Vanderbilt University)—a free, widely used electronic data capture platform—that was established to enable the deployment of digitized self-assessments in clinical care pathways to inform clinical decision making. Methods REDCap was integrated with the primary clinical information system to facilitate the real-time transfer of discrete data and PDF reports from REDCap into the EHR. Both technical and administrative components were required for complete implementation. A technology acceptance survey was also administered to capture physicians’ and clinicians’ attitudes toward the new system. Results The integration of REDCap with the EHR transitioned clinical workflows from paper-based methods of data collection to electronic data collection. This resulted in significant time savings, improved data quality, and valuable real-time information delivery. The digitization of self-report assessments at each appointment contributed to the clinic-wide implementation of the major depressive disorder integrated care pathway. This digital transformation facilitated a 4-fold increase in the physician adoption of this integrated care pathway workflow and a 3-fold increase in patient enrollment, resulting in an overall significant increase in major depressive disorder integrated care pathway capacity. Physicians’ and clinicians’ attitudes were overall positive, with almost all respondents agreeing that the system was useful to their work. Conclusions REDCap provided an intuitive patient interface for collecting self-report measures and accessing results in real time to inform clinical decisions and an extensible backend for system integration. The approach scaled effectively and expanded to high-impact clinics throughout the hospital, allowing for the broad deployment of complex workflows and standardized assessments, which led to the accumulation of harmonized data across clinics and care pathways. REDCap is a flexible tool that can be effectively leveraged to facilitate the automatic transfer of self-report data to the EHR; however, thoughtful governance is required to complement the technical implementation to ensure that data standardization, data quality, patient safety, and privacy are maintained.

Background Gender imbalances in academia have been evident historically and persist today. For the past 60 years, we have witnessed the increase of participation of women in biomedical disciplines, showing that the gender gap is shrinking. However, preliminary evidence suggests that women, including female researchers, are disproportionately affected by the COVID-19 pandemic in terms of unequal distribution of childcare, elderly care, and other kinds of domestic and emotional labor. Sudden lockdowns and abrupt shifts in daily routines have had disproportionate consequences on their productivity, which is reflected by a sudden drop in research output in biomedical research, consequently affecting the number of female authors of scientific publications. Objective The objective of this study is to test the hypothesis that the COVID-19 pandemic has had a disproportionate adverse effect on the productivity of female researchers in the biomedical field in terms of authorship of scientific publications. Methods This is a retrospective observational bibliometric study. We investigated the proportion of male and female researchers who published scientific papers during the COVID-19 pandemic, using bibliometric data from biomedical preprint servers and selected Springer-Nature journals. We used the ordinary least squares regression model to estimate the expected proportions over time by correcting for temporal trends. We also used a set of statistical methods, such as the Kolmogorov-Smirnov test and regression discontinuity design, to test the validity of the results. Results A total of 78,950 papers from the bioRxiv and medRxiv repositories and from 62 selected Springer-Nature journals by 346,354 unique authors were analyzed. The acquired data set consisted of papers that were published between January 1, 2019, and August 2, 2020. The proportion of female first authors publishing in the biomedical field during the pandemic dropped by 9.1%, on average, across disciplines (expected arithmetic mean yest=0.39; observed arithmetic mean y=0.35; standard error of the estimate, Sest=0.007; standard error of the observation, σx=0.004). The impact was particularly pronounced for papers related to COVID-19 research, where the proportion of female scientists in the first author position dropped by 28% (yest=0.39; y=0.28; Sest=0.007; σx=0.007). When looking at the last authors, the proportion of women dropped by 7.9%, on average (yest=0.25; y=0.23; Sest=0.005; σx=0.003), while the proportion of women writing about COVID-19 as the last author decreased by 18.8% (yest=0.25; y=0.21; Sest=0.005; σx=0.007). Further, by geocoding authors’ affiliations, we showed that the gender disparities became even more apparent when disaggregated by country, up to 35% in some cases. Conclusions Our findings document a decrease in the number of publications by female authors in the biomedical field during the global pandemic. This effect was particularly pronounced for papers related to COVID-19, indicating that women are producing fewer publications related to COVID-19 research. This sudden increase in the gender gap was persistent across the 10 countries with the highest number of researchers. These results should be used to inform the scientific community of this worrying trend in COVID-19 research and the disproportionate effect that the pandemic has had on female academics.

Background A large proportion of surgical patient harm is preventable; yet, our ability to systematically learn from these incidents and improve clinical practice remains limited. The Operating Room Black Box was developed to address the need for comprehensive assessments of clinical performance in the operating room. It captures synchronized audio, video, patient, and environmental clinical data in real time, which are subsequently analyzed by a combination of expert raters and software-based algorithms. Despite its significant potential to facilitate research and practice improvement, there are many potential implementation challenges at the institutional, clinician, and patient level. This paper summarizes our approach to implementation of the Operating Room Black Box at a large academic Canadian center. Objective We aimed to contribute to the development of evidence-based best practices for implementing innovative technology in the operating room for direct observation of the clinical performance by using the case of the Operating Room Black Box. Specifically, we outline the systematic approach to the Operating Room Black Box implementation undertaken at our center. Methods Our implementation approach included seeking support from hospital leadership; building frontline support and a team of champions among patients, nurses, anesthesiologists, and surgeons; accounting for stakeholder perceptions using theory-informed qualitative interviews; engaging patients; and documenting the implementation process, including barriers and facilitators, using the consolidated framework for implementation research. Results During the 12-month implementation period, we conducted 23 stakeholder engagement activities with over 200 participants. We recruited 10 clinician champions representing nursing, anesthesia, and surgery. We formally interviewed 15 patients and 17 perioperative clinicians and identified key themes to include in an information campaign run as part of the implementation process. Two patient partners were engaged and advised on communications as well as grant and protocol development. Many anticipated and unanticipated challenges were encountered at all levels. Implementation was ultimately successful, with the Operating Room Black Box installed in August 2018, and data collection beginning shortly thereafter. Conclusions This paper represents the first step toward evidence-guided implementation of technologies for direct observation of performance for research and quality improvement in surgery. With technology increasingly being used in health care settings, the health care community should aim to optimize implementation processes in the best interest of health care professionals and patients.

Background Virtual reality (VR) and augmented reality (AR) have recently become popular research themes. However, there are no published bibliometric reports that have analyzed the corresponding scientific literature in relation to the application of these technologies in medicine. Objective We used a bibliometric approach to identify and analyze the scientific literature on VR and AR research in medicine, revealing the popular research topics, key authors, scientific institutions, countries, and journals. We further aimed to capture and describe the themes and medical conditions most commonly investigated by VR and AR research. Methods The Web of Science electronic database was searched to identify relevant papers on VR research in medicine. Basic publication and citation data were acquired using the “Analyze” and “Create Citation Report” functions of the database. Complete bibliographic data were exported to VOSviewer and Bibliometrix, dedicated bibliometric software packages, for further analyses. Visualization maps were generated to illustrate the recurring keywords and words mentioned in the titles and abstracts. Results The analysis was based on data from 8399 papers. Major research themes were diagnostic and surgical procedures, as well as rehabilitation. Commonly studied medical conditions were pain, stroke, anxiety, depression, fear, cancer, and neurodegenerative disorders. Overall, contributions to the literature were globally distributed with heaviest contributions from the United States and United Kingdom. Studies from more clinically related research areas such as surgery, psychology, neurosciences, and rehabilitation had higher average numbers of citations than studies from computer sciences and engineering. Conclusions The conducted bibliometric analysis unequivocally reveals the versatile emerging applications of VR and AR in medicine. With the further maturation of the technology and improved accessibility in countries where VR and AR research is strong, we expect it to have a marked impact on clinical practice and in the life of patients.

Background Access to neurological care for Parkinson disease (PD) is a rare privilege for millions of people worldwide, especially in resource-limited countries. In 2013, there were just 1200 neurologists in India for a population of 1.3 billion people; in Africa, the average population per neurologist exceeds 3.3 million people. In contrast, 60,000 people receive a diagnosis of PD every year in the United States alone, and similar patterns of rising PD cases—fueled mostly by environmental pollution and an aging population—can be seen worldwide. The current projection of more than 12 million patients with PD worldwide by 2040 is only part of the picture given that more than 20% of patients with PD remain undiagnosed. Timely diagnosis and frequent assessment are key to ensure timely and appropriate medical intervention, thus improving the quality of life of patients with PD. Objective In this paper, we propose a web-based framework that can help anyone anywhere around the world record a short speech task and analyze the recorded data to screen for PD. Methods We collected data from 726 unique participants (PD: 262/726, 36.1% were women; non-PD: 464/726, 63.9% were women; average age 61 years) from all over the United States and beyond. A small portion of the data (approximately 54/726, 7.4%) was collected in a laboratory setting to compare the performance of the models trained with noisy home environment data against high-quality laboratory-environment data. The participants were instructed to utter a popular pangram containing all the letters in the English alphabet, “the quick brown fox jumps over the lazy dog.” We extracted both standard acoustic features (mel-frequency cepstral coefficients and jitter and shimmer variants) and deep learning–based embedding features from the speech data. Using these features, we trained several machine learning algorithms. We also applied model interpretation techniques such as Shapley additive explanations to ascertain the importance of each feature in determining the model’s output. Results We achieved an area under the curve of 0.753 for determining the presence of self-reported PD by modeling the standard acoustic features through the XGBoost—a gradient-boosted decision tree model. Further analysis revealed that the widely used mel-frequency cepstral coefficient features and a subset of previously validated dysphonia features designed for detecting PD from a verbal phonation task (pronouncing “ahh”) influence the model’s decision the most. Conclusions Our model performed equally well on data collected in a controlled laboratory environment and in the wild across different gender and age groups. Using this tool, we can collect data from almost anyone anywhere with an audio-enabled device and help the participants screen for PD remotely, contributing to equity and access in neurological care.

Background The use of government health data for secondary purposes, such as monitoring the quality of hospital services, researching the health needs of populations, and testing how well new treatments work, is increasing. This increase in the secondary uses of health data has led to increased interest in what the public thinks about data sharing, in particular, the possibilities of sharing with the private sector for research and development. Although international evidence demonstrates broad public support for the secondary use of health data, this support does not extend to sharing health data with the private sector. If governments intend to share health data with the private sector, knowing what the public thinks will be important. This paper reports a national survey to explore public attitudes in Australia toward sharing health data with private companies for research on and development of therapeutic drugs and medical devices. Objective This study aims to explore public attitudes in Australia toward sharing government health data with the private sector. Methods A web-based survey tool was developed to assess attitudes about sharing government health data with the private sector. A market research company was employed to administer the web-based survey in June 2019. Results The survey was completed by 2537 individuals residing in Australia. Between 51.8% and 57.98% of all participants were willing to share their data, with slightly fewer in favor of sharing to improve health services (51.99%) and a slightly higher proportion in favor of sharing for research and development (57.98%). There was a preference for opt-in consent (53.44%) and broad support for placing conditions on sharing health information with private companies (62% to 91.99%). Wide variability was also observed in participants’ views about the extent to which the private sector could be trusted and how well they would behave if entrusted with people’s health information. In their qualitative responses, the participants noted concerns about private sector corporate interests, corruption, and profit making and expressed doubt about the Australian government’s capacity to manage data sharing safely. The percentages presented are adjusted against the Australian population. Conclusions This nationally representative survey provides preliminary evidence that Australians are uncertain about sharing their health data with the private sector. Although just over half of all the respondents supported sharing health data with the private sector, there was also strong support for strict conditions on sharing data and for opt-in consent and significant concerns about how well the private sector would manage government health data. Addressing public concern about sharing government health data with the private sector will require more and better engagement to build community understanding about how agencies can collect, share, protect, and use their personal data.

Background In many countries, depressed individuals often first visit primary care settings for consultation, but a considerable number of clinically depressed patients remain unidentified. Introducing additional screening tools may facilitate the diagnostic process. Objective This study aimed to examine whether experience sampling method (ESM)-based measures of depressive affect and behaviors can discriminate depressed from nondepressed individuals. In addition, the added value of actigraphy-based measures was examined. Methods We used data from 2 samples to develop and validate prediction models. The development data set included 14 days of ESM and continuous actigraphy of currently depressed (n=43) and nondepressed individuals (n=82). The validation data set included 30 days of ESM and continuous actigraphy of currently depressed (n=27) and nondepressed individuals (n=27). Backward stepwise logistic regression analysis was applied to build the prediction models. Performance of the models was assessed with goodness-of-fit indices, calibration curves, and discriminative ability (area under the receiver operating characteristic curve [AUC]). Results In the development data set, the discriminative ability was good for the actigraphy model (AUC=0.790) and excellent for both the ESM (AUC=0.991) and the combined-domains model (AUC=0.993). In the validation data set, the discriminative ability was reasonable for the actigraphy model (AUC=0.648) and excellent for both the ESM (AUC=0.891) and the combined-domains model (AUC=0.892). Conclusions ESM is a good diagnostic predictor and is easy to calculate, and it therefore holds promise for implementation in clinical practice. Actigraphy shows no added value to ESM as a diagnostic predictor but might still be useful when ESM use is restricted.

BACKGROUND Modern neurosurgery is a relatively young discipline characterized by finesse and complexity. In recent years, neurosurgery in China has made continuous developments, with long-term progress and outstanding discoveries in many aspects of the field. OBJECTIVE This scientometric investigation aimed to comprehensively provide insight into the development trends of neurosurgery in China, to demonstrate how the field has evolved. METHODS PubMed database was searched to retrieve relevant papers published between 1988 and 2018 from neurosurgery institutions in China. The database of the National Natural Science Foundation of China was also retrieved for funding information. Information (eg, year of publication, journal, institute of origin) and keywords were collected from each paper after removing duplicates and filtering unintentional words. Co-word analysis was performed on the papers’ keywords, and a time distribution matrix of coexisting keywords in a given paper (ie, termed co-words) was established. Co-words were clustered according to their growth rate within years and visually presented with a mountain plot and a heatmap. Trends and potential subspecialties were identified, and each topic, represented either by a co-word from publications or funding from the National Natural Science Foundation of China during the period from 2011 to 2018, was collected and analyzed. RESULTS Within 15,972 publications on neurosurgery from institutions in China, diagnostic image was found to coexist the most with other keywords. Cluster 0, represented by diagnostic image with retrospective study, contained emerging topics with great developmental potential and demonstrated high growth rates in recent years. This finding suggests that the topics represented in Cluster 0 may represent future areas of important neurosurgical research. We also found that the developmental trend of China’s neurosurgical research is highly correlated with National Natural Science Foundation of China funding acquisition. CONCLUSIONS Co-word analysis and visualization results provided insight into the emerging research topics that are of vital importance, which can be used as a reference by neurosurgeons and researchers for future investigations. In this study, our analysis strategy based on co-word biclustering was able to clearly demonstrate current academic subject development; therefore, co-word biclustering is a reliable bibliometric analysis strategy.

Background Longitudinal follow-up of older persons living with HIV is essential for the ascertainment of aging-related clinical and behavioral outcomes, and self-administered questionnaires are necessary for collecting behavioral information in research involving persons living with HIV. Web-based self-reported data collection results in higher data quality than paper-and-pencil questionnaires in a wide range of populations. The option of remote web-based surveys may also increase retention in long-term research studies. However, the acceptability and feasibility of web-based data collection in clinical research involving older persons living with HIV have never been studied. Objective This study aims to assess the acceptability and feasibility of a web-based survey to collect information on sexual, substance use, and physical activity behaviors; compare the data quality of the web-based survey with that of a paper-and-pencil questionnaire; and summarize web-based survey metrics. Methods This pilot study took place within the AIDS Clinical Trials Group A5322 study, a longitudinal cohort of men and women living with HIV (aged ≥40 years), followed at 32 clinical sites in the United States and Puerto Rico. A total of 4 sites participated in this study. A web-based survey was created using self-administered questionnaires typically completed in A5322 via paper and pencil. Pilot study participants completed these questionnaires via web-based survey at one research visit in lieu of paper-and-pencil administration. Two questions were added to assess feasibility, defined as participants’ perception of the ease of web-based survey completion (very hard, hard, easy, very easy), and their preferred format (computer or tablet, paper and pencil, no preference) for completing the questions in the future (acceptability). Feasibility and acceptability were summarized overall and by demographic and clinical characteristics; the proportion of evaluable data by web-based survey versus previously administered paper-and-pencil questionnaires (data quality) was compared for each question. Results Acceptability and feasibility were high overall: 50.0% (79/158) preferred computer or tablet, 38.0% (60/158) reported no preference, and 12.0% (19/158) preferred paper and pencil; 93.0% (147/158) reported survey completion easy or very easy. Older age was associated with lower odds of preferring computer or tablet to paper and pencil (odds ratio per 1-year increase in age: 0.91, 95% CI 0.85-0.98). Individuals who found the survey hard or very hard had a lower median neurocognitive test score than those who found it easy or very easy. Data quality with web-based survey administration was similar to or higher than that with paper-and-pencil administration for most questions. Conclusions Web-based survey administration was acceptable and feasible in this cohort of older adults living with HIV, and data quality was high. Web-based surveys can be a useful tool for valid data collection and can potentially improve retention in long-term follow-up studies.

Background Incorporating cognitive testing into routine clinical practice is a challenge in multiple sclerosis (MS), given the wide spectrum of both cognitive and physical impairments people can have and the time that testing requires. Shortened paper and verbal assessments predominate but still are not used routinely. Computer-based tests are becoming more widespread; however, changes in how a paper test is implemented can impact what exactly is being assessed in an individual. The Symbol Digit Modalities Test (SDMT) is one validated test that forms part of the cognitive batteries used in MS and has some computer-based versions. We developed a tablet-based SDMT variant that has the potential to be ultimately deployed to patients’ own devices. Objective This paper aims to develop, validate, and deploy a computer-based SDMT variant, the Cognition Reaction (CoRe) test, that can reliably replicate the characteristics of the paper-based SDMT. Methods We carried out analysis using Pearson and intraclass correlations, as well as a Bland-Altman comparison, to examine consistency between the SDMT and CoRe tests and for test-retest reliability. The SDMT and CoRe tests were evaluated for sensitivity to disability levels and age. A novel metric in CoRe was found: question answering velocity could be calculated. This was evaluated in relation to disability levels and age for people with MS and compared with a group of healthy control volunteers. Results SDMT and CoRe test scores were highly correlated and consistent with 1-month retest values. Lower scores were seen in patients with higher age and some effect was seen with increasing disability. There was no learning effect evident. Question answering velocity demonstrated a small increase in speed over the 90-second duration of the test in people with MS and healthy controls. Conclusions This study validates a computer-based alternative to the SDMT that can be used in clinics and beyond. It enables accurate recording of elements of cognition relevant in MS but offers additional metrics that may offer further value to clinicians and people with MS.

Background COVID-19 is the most widely discussed topic worldwide in 2020, and at the beginning of the Italian epidemic, scientists tried to understand the virus diffusion and the epidemic curve of positive cases with controversial findings and numbers. Objective In this paper, a data analytics study on the diffusion of COVID-19 in Italy and the Lombardy Region is developed to define a predictive model tailored to forecast the evolution of the diffusion over time. Methods Starting with all available official data collected worldwide about the diffusion of COVID-19, we defined a predictive model at the beginning of March 2020 for the Italian country. Results This paper aims at showing how this predictive model was able to forecast the behavior of the COVID-19 diffusion and how it predicted the total number of positive cases in Italy over time. The predictive model forecasted, for the Italian country, the end of the COVID-19 first wave by the beginning of June. Conclusions This paper shows that big data and data analytics can help medical experts and epidemiologists in promptly designing accurate and generalized models to predict the different COVID-19 evolutionary phases in other countries and regions, and for second and third possible epidemic waves.

Background Health services researchers spend a substantial amount of time performing integration, cleansing, interpretation, and aggregation of raw data from multiple public or private data sources. Often, each researcher (or someone in their team) duplicates this effort for their own project, facing the same challenges and experiencing the same pitfalls discovered by those before them. Objective This paper described a design process for creating a data warehouse that includes the most frequently used databases in health services research. Methods The design is based on a conceptual iterative process model framework that utilizes the sociotechnical systems theory approach and includes the capacity for subsequent updates of the existing data sources and the addition of new ones. We introduce the theory and the framework and then explain how they are used to inform the methodology of this study. Results The application of the iterative process model to the design research process of problem identification and solution design for the Healthcare Research and Analytics Data Infrastructure Solution (HRADIS) is described. Each phase of the iterative model produced end products to inform the implementation of HRADIS. The analysis phase produced the problem statement and requirements documents. The projection phase produced a list of tasks and goals for the ideal system. Finally, the synthesis phase provided the process for a plan to implement HRADIS. HRADIS structures and integrates data dictionaries provided by the data sources, allowing the creation of dimensions and measures for a multidimensional business intelligence system. We discuss how HRADIS is complemented with a set of data mining, analytics, and visualization tools to enable researchers to more efficiently apply multiple methods to a given research project. HRADIS also includes a built-in security and account management framework for data governance purposes to ensure customized authorization depending on user roles and parts of the data the roles are authorized to access. Conclusions To address existing inefficiencies during the obtaining, extracting, preprocessing, cleansing, and filtering stages of data processing in health services research, we envision HRADIS as a full-service data warehouse integrating frequently used data sources, processes, and methods along with a variety of data analytics and visualization tools. This paper presents the application of the iterative process model to build such a solution. It also includes a discussion on several prominent issues, lessons learned, reflections and recommendations, and future considerations, as this model was applied.

Background Technological interventions provide many opportunities for improving the health and quality of life of older adults. However, interaction with new technologies can also cause frustration. Although these themes have been explored in extant research, much remains to be learned with regard to how the challenges of aging and technology use and the experiences of participating in a social and learning environment are interrelated. Objective This study aimed to perform a qualitative analysis of data collected from MoodTech, a pilot study of an internet-based intervention with a peer support component for older adults with symptoms of depression, to better understand the participants’ experience of using technological interventions, including the challenges and benefits that they experienced over the course of these interventions. Methods We employed an inductive qualitative analysis method based on grounded theory methodology and interpretative phenomenological analysis to analyze participant textual data. These textual data were of 3 main types: (1) assignments in which participants challenged their negative thoughts, (2) status updates, and (3) comments in the peer support component of the intervention. Results We have presented the results through 3 main themes: (1) the challenges of aging as seen through the participants’ comments, (2) the difficulties experienced by the participants in using MoodTech, and (3) the benefits they derived from participating. Conclusions This paper offers several contributions concerning study participants’ experiences with internet-based cognitive behavioral therapy (iCBT) interventions with a peer support component and design considerations for developing complex technological interventions that support the challenges participants experience due to aging and cognitive difficulties. First, technical issues encountered by older adults within the context of the intervention can interact with and exacerbate the insecurities they experience in life, and it is important to consider how intervention components might be designed to mitigate these issues. Second, peer support can be employed as a mechanism to facilitate communication, support, and collaborative problem solving among participants in an intervention. The insights from this paper can inform the design of iCBT interventions for older adults.

Background Since the beginning of December 2019, the coronavirus disease (COVID-19) has spread rapidly around the world, which has led to increased discussions across online platforms. These conversations have also included various conspiracies shared by social media users. Amongst them, a popular theory has linked 5G to the spread of COVID-19, leading to misinformation and the burning of 5G towers in the United Kingdom. The understanding of the drivers of fake news and quick policies oriented to isolate and rebate misinformation are keys to combating it. Objective The aim of this study is to develop an understanding of the drivers of the 5G COVID-19 conspiracy theory and strategies to deal with such misinformation. Methods This paper performs a social network analysis and content analysis of Twitter data from a 7-day period (Friday, March 27, 2020, to Saturday, April 4, 2020) in which the #5GCoronavirus hashtag was trending on Twitter in the United Kingdom. Influential users were analyzed through social network graph clusters. The size of the nodes were ranked by their betweenness centrality score, and the graph’s vertices were grouped by cluster using the Clauset-Newman-Moore algorithm. The topics and web sources used were also examined. Results Social network analysis identified that the two largest network structures consisted of an isolates group and a broadcast group. The analysis also revealed that there was a lack of an authority figure who was actively combating such misinformation. Content analysis revealed that, of 233 sample tweets, 34.8% (n=81) contained views that 5G and COVID-19 were linked, 32.2% (n=75) denounced the conspiracy theory, and 33.0% (n=77) were general tweets not expressing any personal views or opinions. Thus, 65.2% (n=152) of tweets derived from nonconspiracy theory supporters, which suggests that, although the topic attracted high volume, only a handful of users genuinely believed the conspiracy. This paper also shows that fake news websites were the most popular web source shared by users; although, YouTube videos were also shared. The study also identified an account whose sole aim was to spread the conspiracy theory on Twitter. Conclusions The combination of quick and targeted interventions oriented to delegitimize the sources of fake information is key to reducing their impact. Those users voicing their views against the conspiracy theory, link baiting, or sharing humorous tweets inadvertently raised the profile of the topic, suggesting that policymakers should insist in the efforts of isolating opinions that are based on fake news. Many social media platforms provide users with the ability to report inappropriate content, which should be used. This study is the first to analyze the 5G conspiracy theory in the context of COVID-19 on Twitter offering practical guidance to health authorities in how, in the context of a pandemic, rumors may be combated in the future.