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Background Population based reference intervals are fundamental for interpreting results for quantitative laboratory tests. In patients with a specific chronic disorder, however, results of various tests may regularly be different than in healthy individuals. Health-associated reference intervals may therefore have limited value in such patients. Instead, disease-associated reference intervals may be useful, as they describe the results distribution in populations resembling the specific patients. Few disease-associated reference intervals are available in the literature. The aim of this study was to estimate reference intervals for common laboratory tests for patient populations with rheumatoid arthritis, Crohn’s disease or ulcerative colitis without significant comorbidity, using a novel algorithm. Material and methods Laboratory test results and hospital discharge diagnoses were collected for relevant patients. An algorithm was developed to identify discharge diagnoses significantly associated with high or low results for specific tests. After excluding patients with such diagnoses, reference intervals were estimated, representing results distributions in patients with each of the specific chronic disorders, but without significant comorbidity. Results Disease-associated reference intervals were estimated for 20 common laboratory tests. Most of the estimated reference limits were significantly different from corresponding health-associated reference limits. Thirty percent of the estimated reference intervals were different from estimates based on crude patient populations, indicating that the algorithm applied managed to exclude patients with relevant comorbidity. Conclusion Disease-associated reference intervals could be estimated for a number of tests in patients with rheumatoid arthritis, ulcerative colitis or Crohn’s disease using a highly automated algorithm based on routinely recorded patient data., Highlights • Patients with chronic disorders have different lab results than healthy individuals. • Reference intervals for patients with chronic disorders are often lacking. • We estimated reference intervals for patients with chronic inflammatory disorders.

Background Health care systems are currently undergoing a digital transformation that has been primarily triggered by emerging technologies, such as artificial intelligence, the Internet of Things, 5G, blockchain, and the digital representation of patients using (mobile) sensor devices. One of the results of this transformation is the gradual virtualization of care. Irrespective of the care environment, trust between caregivers and patients is essential for achieving favorable health outcomes. Given the many breaches of information security and patient safety, today’s health information system portfolios do not suffice as infrastructure for establishing and maintaining trust in virtual care environments. Objective This study aims to establish a theoretical foundation for a complex health care system intervention that aims to exploit a cryptographically secured infrastructure for establishing and maintaining trust in virtualized care environments and, based on this theoretical foundation, present a proof of concept that fulfills the necessary requirements. Methods This work applies the following framework for the design and evaluation of complex intervention research within health care: a review of the literature and expert consultation for technology forecasting. A proof of concept was developed by following the principles of design science and requirements engineering. Results This study determined and defined the crucial functional and nonfunctional requirements and principles for enhancing trust between caregivers and patients within a virtualized health care environment. The cornerstone of our architecture is an approach that uses blockchain technology. The proposed decentralized system offers an innovative governance structure for a novel trust model. The presented theoretical design principles are supported by a concrete implementation of an Ethereum-based platform called VerifyMed. Conclusions A service for enhancing trust in a virtualized health care environment that is built on a public blockchain has a high fit for purpose in Healthcare 4.0.

Background Recently, there has been an increasing focus among healthcare organisations on implementing patient portals. Previous studies have mainly focussed on the experiences of patient portal use. Few have investigated the processes of deciding what content and features to make available, in particular for shared portals across healthcare domains. The aim of the study was to investigate views on content and experiences from the configuration process among participants involved in setting up a shared patient portal for primary and specialist health services. Methods A qualitative study including 15 semi-structured interviews with persons participating in patient portal configuration was conducted from October 2019 to June 2020. Results Whether a shared patient portal for all the health services in the region should be established was not questioned by any of the informants. It was experienced as a good thing to have numerous participants present in the discussions on configuration, but it also was said to increase the complexity of the work. The informants considered a patient portal to be of great value for patient care, among other things because it would lead to improvements in patient follow-up and increased patient empowerment. Nevertheless, some informants advocated caution as they thought the patient portal possibly could lead to an increase in healthcare providers’ workloads and to anxiety and worries, as well as to inequality in access to health care among patients. The findings were categorized into the themes ‘A tool for increased patient involvement’, ‘Which information should be available for the patient’, ‘Concerns about increased workload’, ‘Too complex to use versus not interesting enough’, ‘Involving all services’ and ‘Patient involvement’. Conclusions Establishing a shared patient portal for primary and specialist health services was considered unproblematic. There was, however, variation in opinions on which content and features to include. This variation was related to concerns about increasing the workload for health care providers, causing anxiety and inequality among patients, and ensuring that the solution would be interesting enough to adopt. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

This paper addresses how conditions external to participatory activities in large-scale information technology (IT) projects may affect participation and potentially reduce user impact. We propose boundary conditions to denote such conditions. We explore this issue through interviews with eight participants in a large ongoing health IT project. The aim of the project is to implement a shared electronic health record system for health care services in a region of Norway. Four phenomena are discussed—group discontinuity, informal follow-up meetings, contractual discussions in the participatory activity, and the “parking” of design decisions. For each phenomenon, we reflect on the associated boundary conditions and their effects on participation and user impact. Based on the findings, the following recommendations are made to help participatory design scale with the complexities of large-scale projects: (1) make the boundary conditions explicit; (2) plan for reflections on the process; and (3) plan for peer interaction between users.

The transparent and decentralized characteristics associated with blockchain can be both appealing and problematic when applied to a healthcare use-case. As health data is highly sensitive, it is therefore, highly regulated to ensure the privacy of patients. At the same time, access to health data and interoperability are in high demand. Regulatory frameworks such as GDPR and HIPAA are, amongst other objectives, meant to contribute to mitigating the risk of privacy violations of health data. Blockchain features can likely improve interoperability and access control to health data, and at the same time, preserve or even increase, the privacy of patients. Blockchain applications should address compliance with the current regulatory framework to increase real-world feasibility. This exploratory work indicates that published proof-of-concepts in the healthcare domain comply with GDPR, to an extent. Blockchain developers need to make design choices to be compliant with GDPR since currently, none available blockchain platform can show compliance out of the box. (c) 2020 by Academy & Industry Research Collaboration Center (AIRCC) Dubai, UAE

The Nordic eHealth Research Network (NeRN) was established by the Nordic Council of Ministers (NCM) eHealth group in 2012. The objective was to develop, test, and evaluate a common set of indicators for monitoring eHealth in the Nordic countries, Greenland, Faroe Islands and Aaland, for use to support the development of Nordic welfare.The results of the network’s first three mandate periods were published in the Nordic Council of Ministers reports. Links can be found on the NeRN web page: https://thl.fi/en/web/thlfi-en/research-and-expertwork/projects-and-programmes/nordic-ehealth-research-network-nern This publication reports the outcomes of the fourth mandate period focusing on five tasks: 1 New analysis of eHealth policies in the Nordic countries. 2 Updating common indicators in accordance with emerging new policy goals. 3 Developing a Nordic model survey to monitor citizen views on eHealth. 4 Cyber security in the Nordic Countries. 5 Personas for users of indicators of eHealth availability, use and outcome in the Nordic countries.

Background Oral anticancer therapies can be self-administered by patients outside the hospital setting, which poses challenges of adherence to a drug plan and monitoring of side effects. Modern information technology may be developed and implemented to address these pertinent issues. Objective The aim of this study was to explore how a smartphone app developed through a stepwise, iterative process can help patients using oral chemotherapy to take their drug, and to report adherence and side effects in a reliable and verifiable manner. Methods Fourteen patients starting capecitabine treatment were included in this study and used the smartphone app in addition to regular follow up of capecitabine treatment. Nine of these patients fulfilled the treatment plan and were interviewed based on a semistructured interview guide and the System Usability Scale (SUS). In addition, two focus groups were completed with 7 oncologists and 7 oncology nurses, respectively. Interview data were analyzed in accordance with the principles of systematic text condensation. Features of the app were also assessed. Results The smartphone app provided the patients with a feeling of reassurance regarding correct adherence of their oral chemotherapy treatment. They used the app as a memory tool about their treatment and possible serious side effects, as well as for treatment education. Patients expressed concerns about using the app to report side effects that were not considered to be obviously serious, fearing overreporting. The health personnel expressed an overall positive attitude to integrate this new tool in their everyday work. Conclusions Patients on oral chemotherapy treatment at home felt safe and found the app to be helpful. The app promoted learning about their treatment and made the patients more independent of the cancer clinic, reducing the need for the clinic’s limited resources for follow up of patients on oral anticancer medications.

Patients living in a digitized world can now interact with medical professionals through online services such as chat applications, video conferencing or indirectly through consulting services. These applications need to tackle several fundamental trust issues: 1. Checking and confirming that the person they are interacting with is a real person; 2. Validating that the healthcare professional has competence within the field in question; and 3. Confirming that the healthcare professional has a valid license to practice. In this paper, we present VerifyMed -- the first proof-of-concept platform, built on Ethereum, for transparently validating the authorization and competence of medical professionals using blockchain technology. Our platform models trust relationships within the healthcare industry to validate professional clinical authorization. Furthermore, it enables a healthcare professional to build a portfolio of real-life work experience and further validates the competence by storing outcome metrics reported by the patients. The extensive realistic simulations show that with our platform, an average cost for creating a smart contract for a treatment and getting it approved is around 1 USD, and the cost for evaluating a treatment is around 50 cents., Comment: Accepted for publication at Blockchain and Internet of Things Conference (BIOTC 2020)

Background Increased digitization of health care might challenge some of the trust functions that are established in a traditional health care system. We have, with the concept of VerifyMed, developed a decentralized service for work history and competence verification, as a means to increase trust in the virtual interaction between a patient and a caregiver, mitigate administrative burden, and provide patient-reported outcomes seamlessly for health professionals. Objective This research aimed to validate the use case of a decentralized credentials service for health care professionals in Norway. We also aimed to evaluate the proof-of-concept of VerifyMed, a blockchain-based credential service for health care professionals. Methods A qualitative approach was applied with data collection through 9 semistructured interviews and 2 focus groups (one with 4 participants and the other with 5 participants). The System Usability Scale (SUS) was used as a part of the interviews. Data were analyzed through the principles of systematic text condensation. The recruitment of participants ended when it was concluded that the data had reached saturation. Results The following 5 themes were identified from the interviews and focus groups: (1) the need for aggregated storage of work- and study-related verification, (2) trust in a virtual health care environment, (3) the potential use of patient feedback, (4) trust in blockchain technology, and (5) improvements of the VerifyMed concept. The SUS questionnaire gave a score of 69.7. Conclusions This study has validated the need for a decentralized system where health care professionals can control their credentials and, potentially, their reputation. Future work should update the VerifyMed system according to this input. We concluded that a decentralized system for the storage of work-related verifiable credentials could increase trust in a virtualized health care system.

With rising smartphone ownership, mobile health applications (mHealth apps) have the potential to support high-need, high-cost populations in managing their health. While the number of available mH...

Background Blockchain can be described as an immutable ledger, logging data entries in a decentralized manner. This new technology has been suggested to disrupt a wide range of data-driven domains, including the health domain. Objective The purpose of this study was to systematically review, assess and synthesize peer-reviewed publications utilizing/proposing to utilize blockchain to improve processes and services in healthcare, health sciences and health education. Method A structured literature search on the topic was conducted in October 2018 relevant bibliographic databases. Result 39 publications fulfilled the inclusion criteria. The result indicates that Electronic Health Records and Personal Health Records are the most targeted areas using blockchain technology. Access control, interoperability, provenance and data integrity are all issues that are meant to be improved by blockchain technology in this field. Ethereum and Hyperledger fabric seem to be the most used platforms/frameworks in this domain. Conclusion This study shows that the endeavors of using blockchain technology in the health domain are increasing exponentially. There are areas within the health domain that potentially could be highly impacted by blockchain technology. © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

This report proposes a long-term management of earlier NeRN work to be utilized also in the European and OECD context, and indicators on patients and citizens' use and experiences of eHealth servic ...

Coordination of perioperative work is challenging. Advancements in diagnostic and therapeutic possibilities have not been followed by similar advancements in the ability to coordinate care. In this paper, we report on a study that explored the nature of continuous coordination as practiced by perioperative staff in order to coordinate their own activities with respect to those of their colleagues. We conducted in-depth interviews (n = 14), and combined observations and focused interviews (n = 31) with perioperative staff (physicians, nurses, technicians, and cleaners) at a major university hospital in Norway. Data were analysed qualitatively with systematic text condensation. The results indicated that a surgical schedule was important for informing staff members about the cases and tasks they had been assigned. Staff also depended on ad hoc, explicit communication to ensure timeliness of particular perioperative activities. This, however, left little room for adjustments of other activities. Hence, to be able to proactively coordinate their own work some staff tried to predict future perioperative activities by observing the workplace, monitoring the surgical scheduling software for changes, and sharing their colleagues' progress updates and predictions. These findings could be important for those developing support for perioperative coordination.

Objectives To study incidence, handling and outcome of patients hospitalised with symptomatic and ruptured abdominal aortic aneurysm in Norway. Design, material and methods Retrospective study of 1291 patients, between January 2008 and August 2010 using the National Patient Registry and a regional vascular surgery registry. We applied a stepwise logistic regression model to detect differences in regional in-hospital mortality. Results 385/711 (54%) patients hospitalised for aneurysm rupture, rAAA (ICD-10: I71.3), died. The odds of dying varied with a factor 2.3 between the extreme regions. 475/711 (67%) underwent repair, 323 survived, giving an in-hospital mortality rate of 32% after surgery. Older patients were significantly less likely to be transported for surgery. The overall incidence for patients aged >50 was 16.6 rAAA per 100 000 person-years. There was remarkable variation across counties with rates between 7.7 and 26.8. A total of 580 patients were hospitalised with suspected symptomatic aneurysms (ICD-10:I71.4, acute admission); 224 (39%) were treated with aneurysm repair, 356 (61%) were discharged without repair without a significant difference across health regions. Conclusions For rAAA, we found substantial geographical variations in incidence, surgery and patient outcome. These results highlight the need for increased awareness about the condition and suggest ways to improve care trajectories to reduce delay to surgery, thereby minimising rupture mortality.

Objective To inform the design of IT support, the authors explored the characteristics and sources of process variability in a surgical care process that transcends multiple institutions and professional boundaries. Setting A case study of the care process in the Abdominal Aortic Aneurysm surveillance programme of three hospitals in Norway. Design Observational study of encounters between patients and surgeons accompanied by semistructured interviews of patients and key health personnel. Results Four process variety dimensions were identified. The captured process variations were further classified into intended and unintended variations according to the cause of the variations. Our main findings, however, suggest that the care process is best understood as systematised analysis and mitigation of risk. Even if major variations accommodated for the flexibility needed to achieve particular clinical aims and/or to satisfy patient preferences, other variations reflected healthcare actors9 responses to risks arising from a lack of resilience in the existing system. On this basis, the authors outlined suggestions for a resilience-based approach by including awareness in workflow as well as feedback loops for adaptive learning. The authors suggest that IT process support should be designed to prevent process breakdowns with patient dropouts as well as to sustain risk-mitigating performance. Conclusion Process variation was in part induced by systemised risk mitigation. IT-based process support for monitoring processes such as that studied here should aim to ensure resilience and further mitigate risk to enhance patient safety.

Summary Background: Healthcare professionals in hospital care increasingly use small-screen handheld computers. Studies that have investigated doctors’ concerns about handheld usage have mainly focused on technical, organizational and performance issues. Very few have looked at the effects of Personal Digital Assistants (PDAs) on the interaction between physician and patient. Objective: The aim of this study was to explore the effects of PDA usage on the physicians’ prescription work, their concerns about using it in point-of-care situations, and the effects on the patient-physician dialog. Methods: We used a qualitative and comparative approach where 14 physicians each carried out four simulated ward rounds in which they modified the medication of patient actors using a paper-based medical chart and three versions of a PDA-based system. We analyzed ward round video recordings, semi-structured interviews with the doctors, and focus group using approaches based on ethnomethodology and grounded theory. Results: Physicians used PDA and paper differently. Physicians’ actions, as well as their non-verbal communication, were less transparent and clear for the patient when using a PDA. Doctors were worried about distractions from the handheld device and about a negative impact on the physician-patient conversation. In general, physicians were more comfortable with paper, but preferred PDA because it offered an undo function and reduced the need to memorize drug names and dosages by providing concrete alternatives in the user interface. Conclusions: Despite the many benefits, PDA usage at the point-of-care comes with the increased risk of distractions for physicians and can cause a negative patient experience. Designers of point-of-care systems need to be aware of, and address, the problems with handhelds and learn from the attributes and access capabilities of paper charts.

The evolving nature of surgical treatments creates gaps between evidence-based guidelines and actual clinical practice.This article addresses the emerging clinical practice of the EndoVascular Aneurysm Repair (EVAR), a surgical treatment of patients with Abdominal Aortic Aneurysm (AAA). Drawing on a qualitative study across three hospitals, we identified three interplaying expertise traits: the collective, the interpersonal and the technical, each being present to promote surgical work. The evolvement of EVAR is contextualized within technical artefacts and patient characteristics, along with a joint decision approach. The intertwinement between various expertise traits and contextual factors forms a ‘community of guidance’, nourishing further EVAR innovation without formalized institutions, evidence, training or guidelines. However, the lack of a shared context limits the transfer of evolving knowledge across hospital boundaries.

Objective To evaluate GPs use of three major electronic patient record systems with emphasis on the ability of the systems to support important clinical tasks and to compare the findings with results from a study of the three major hospital-wide systems. Methods A national, cross-sectional questionnaire survey was conducted in Norwegian primary care. 247 (73%) of 338 GPs responded. Proportions of the respondents who reported to use the EPR system to conduct 23 central clinical tasks, differences in the proportions of users of different EPR systems and user satisfaction and perceived usefulness of the EPR system were measured. Results The GPs reported extensive use of their EPR systems to support clinical tasks. There were no significant differences in functionality between the systems, but there were differences in reported software and hardware dysfunction and user satisfaction. The respondents reported high scores in computer literacy and there was no correlation between computer usage and respondent age or gender. A comparison with hospital physicians' use of three hospital-wide EPR systems revealed that GPs had higher usage than the hospital-based MDs. Primary care EPR systems support clinical tasks far better than hospital systems with better overall user satisfaction and reported impact on the overall quality of the work. Conclusion EPR systems in Norwegian primary care that have been developed in accordance with the principles of user-centered design have achieved widespread adoption and highly integrated use. The quality and efficiency of the clinical work has increased in contrast to the situation of their hospital colleagues, who report more modest use and benefits of EPR systems.

The report presents results of the Nordic eHealth Research Network, a subgroup of the eNordic Council of Ministers Health group. The network defined and collected data for altogether 49 common eHealth indicators from the Nordic Countries. Health information was quite comprehensively electronically available from other organisations in all the Nordic countries by end of 2014. Intensity of use of nationally stored data remained low except in Denmark. Sweden had best availability of the Patient portal functionalities. Patients used patient portal functionalities rarely except in Denmark. Doctors in Iceland had most positive experiences of their health information systems. Even with limitations, the current work presents a solid basis for working towards the goal of the eHealth network: generating comparable information to support development of Nordic welfare.

Objective: It is not automatically given that the paper-based medical record can be eliminated after the introduction of an electronic medical record (EMR) in a hospital. Many keep and update the paper-based counterpart, and this limits the use of the EMR system. The authors have evaluated the physicians' clinical work practices and attitudes toward a system in a hospital that has eliminated the paper-based counterpart using scanning technology. Design: Combined open-ended interviews (8 physicians) and cross-sectional survey (70 physicians) were conducted and compared with reference data from a previous national survey (69 physicians from six hospitals). The hospitals in the reference group were using the same EMR system without the scanning module. Measurements: The questionnaire (English translation available as an online data supplement at ) covered frequency of use of the EMR system for 19 defined tasks, ease of performing them, and user satisfaction. The interviews were open-ended. Results: The physicians routinely used the system for nine of 11 tasks regarding retrieval of patient data, which the majority of the physicians found more easily performed than before. However, 22% to 25% of the physicians found retrieval of patient data more difficult, particularly among internists (33%). Overall, the physicians were equally satisfied with the part of the system handling the regular electronic data as that of the physicians in the reference group. They were, however, much less satisfied with the use of scanned document images than that of regular electronic data, using the former less frequently than the latter. Conclusion: Scanning and elimination of the paper-based medical record is feasible, but the scanned document images should be considered an intermediate stage toward fully electronic medical records. To our knowledge, this is the first assessment from a hospital in the process of completing such a scanning project. [1]: http://www.jaminfo.oxfordjournals.org/lookup/suppl/doi:10.1197/jamia.M1337/-/DC5/

Background: Many patients who undergo weight loss (bariatric) surgery seek information and social support in online discussion forums, but the vast amount of available information raises concerns about the impact of such information. A secure online discussion forum was developed and offered to bariatric surgery patients. The forum was moderated and allowed contact with peers and health care professionals. Objective: The purposes of this study were to explore how individuals undergoing bariatric surgery used the moderated discussion forum and to better understand what influenced their participation in the forum. Methods: The study was designed as an explorative case study. We conducted participant observation of the discussion forum over a time period of approximately six months. For further insight, we carried out in-depth semistructured interviews with seven patients who had access to the forum. We analyzed the material inductively, using content and thematic analysis. Results: The patients used the forum as an arena in which to interact with peers and providers, as well as to provide and achieve informational and social support. The analysis suggests that there are three major themes that influenced participation in the online discussion forum: (1) the participant’s motivation to seek information, advice, and guidance, (2) the need for social support and networking among peers, and (3) concerns regarding self-disclosure. Conclusions: The findings of this study imply that a moderated discussion forum for bariatric surgery patients has potential for use in a therapeutic context. The discussion forum fulfilled the informational and support needs of the bariatric surgery patients and was particularly useful for those who excluded themselves from the traditional program and experienced barriers to expressing their own needs. Even though our findings imply that the patients benefitted from using the forum regardless of their active or passive participation, restraining factors, such as considerations regarding self-disclosure, must be further investigated to prevent certain users from being precluded from participation. ©Anita Das, Arild Faxvaag. Originally published in the Interactive Journal of Medical Research (http://www.i-jmr.org/), 06.02.2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Interactive Journal of Medical Research, is properly cited.

In this paper we explore how having cancer and receiving therapy influences upon patients' ability to use an online healthcare system. The motivation is that no empirically based design guidelines are available concerning this user group. Ignoring possible effects of illness and therapy can result in systems with poor usability and user acceptance. A case-control usability test with 14 cancer patients and 14 matched controls revealed that the cancer patients experienced significantly more difficulties compared with the healthy controls using a web-based online healthcare system. We conclude that designers of online healthcare systems need to take into consideration the unique challenges of being ill and/or using medication.

SummaryObjective: To assess the diffusion of Electronic Health Record (EHR) systems over time in Norwegian health care.Methods: This study was based on a retrospective cross-sectional questionnaire survey. Questionnaires for three groups of responders were based on two validated questionnaires from prior studies, which were further customized through workshops. The questionnaires were sent to a random sample of 180 municipalities and 150 general practices in all 26 hospitals in Norway.Results: The diffusion curves for EHR systems from 1980 to 2008 were established and analyzed. The most striking finding was the length of time from the availability of the first adequate EHR systems until full coverage was achieved in general practice and in hospitals. Diffusion of EHRs into nursing homes and maternal and child health centers started ten years later, and the diffusion for these centers has also been slow. In general practice the diffusion seems to follow the classical s-curve of diffusion. Costs and the increasing complexity of EHR systems were regarded by respondents as the most important challenges and concerns for the future. Resistance among health personnel was seen only as a small problem.Conclusion: National strategic processes account for the slow diffusion and complexity of EHR systems in the health sector.

An increasing number of patients with overweight undergo weight-reduction treatment. However, many people experience challenges with longterm maintenance and are in risk of weight-regain. Currently there is no unique solution that ensures long-term maintenance of lost weight. Several studies have explored the effectiveness of web-based and e-health interventions, on improving the outcomes of weight-management. The results are unclear. This paper describes requirements for e-health solutions for weight-loss patients. Our findings suggest that such solutions need to be developed in collaboration with both patients and healthcare professionals to ensure that they are in line with medical treatment in addition to taking consideration to the behavioral aspects of using such systems.

Background It has been shown that implementation of electronic medical records (EMR) and withdrawal of the paper-based medical record is feasible, but represents a drastic change in the information environment of hospital physicians. Previous investigations have revealed considerable inter-hospital variations in EMR system use and user satisfaction. The aim of this study was to further explore changes of clinicians' work after the EMR system implementation process and how they experienced working in a paper-deprived information environment. Methods Qualitative study based on 18 semi-structured interviews with physicians in two Norwegian hospitals. Results Ten different but related characteristics of work within the EMR-based practice were identified; (1) there was closer clinical and administrative cooperation during the implementation processes; (2) there were greater benefits when everybody used the system; (3) systems supported freshmen better than experienced physicians; (4) the EMR was useful in regard to professional learning; (5) new users were given an introduction to the system by experienced; (6) younger clinicians reported different attitudes than senior clinicians, but this might be related to more than age and previous experience with computers; (7) the EMR made it easier to generate free-text notes, but this also created a potential for information overflow; (8) there is little or no support for mobile work; (9) instances of downtime are still experienced, and this influenced the attitude towards the system and (10) clinicians preferred EMR-only compared to combined paper and electronic systems. Conclusion Despite the removal of paper-based records from clinical workflow (a change that hospital clinicians perceived as highly useful), many of the old routines remained unchanged, limiting the potential of the EMR system. Thus, there is a need to not only remove paper in the physical sense, but also to established routines to fully achieve the benefits of an EMR system.

Objective Many Norwegian hospitals that are equipped with an electronic medical record (EMR) system now have proceeded to withdraw the paper-based medical record from clinical workflow. In two previous survey-based studies on the effect of removing the paper-based medical record on the work of physicians, nurses and medical secretaries, we concluded that to scan and eliminate the paper based record was feasible, but that the medical secretaries were the group that reported to benefit the most from the change. To further explore the effects of removing the paper based record, especially in regard to medical personnel, we now have conducted a follow up study of a hospital that has scanned and eliminated its paper-based record. Design A survey of 27 physicians, 60 nurses and 30 medical secretaries was conducted. The results were compared with those from a previous study conducted three years earlier at the same department. Measurements The questionnaire (see online Appendix) covered the frequency of use of the EMR system for specific tasks by physicians, nurses and medical secretaries, the ease of performing these tasks compared to previous routines, user satisfaction and computer literacy. Results Both physicians and nurses displayed increased use of the EMR compared to the previous study, while medical secretaries reported generally unchanged but high use. Conclusion The increase in use was not accompanied by a similar change in factors such as computer literacy or technical changes, suggesting that these typical success factors are necessary but not sufficient.

BACKGROUND: Direct electronic communication between patients and physicians has the potential to empower patients and improve health care services. Communication by regular email is, however, considered a security threat in many countries and is not recommended. Systems which offer secure communication have now emerged. Unlike regular email, secure systems require that users authenticate themselves. However, the authentication steps per se may become barriers that reduce use. OBJECTIVES: The objective was to study the experiences of patients who were using a secure electronic communication system. The focus of the study was the users' privacy versus the usability of the system. METHODS: Qualitative interviews were conducted with 15 patients who used a secure communication system (MedAxess) to exchange personal health information with their primary care physician. RESULTS: Six main themes were identified from the interviews: (1) supporting simple questions, (2) security issues, (3) aspects of written communication, (4) trust in the physician, (5) simplicity of MedAxess, and (6) trouble using the system. By using the system, about half of the patients (8/15) experienced easier access to their physician, with whom they tended to solve minor health problems and elaborate on more complex illness experiences. Two thirds of the respondents (10/15) found that their physician quickly responded to their MedAxess requests. As a result of the security barriers, the users felt that the system was secure. However, due to the same barriers, the patients considered the log-in procedure cumbersome, which had considerable negative impact on the actual use of the system. CONCLUSIONS: Despite a perceived need for secure electronic patient-physician communication systems, security barriers may diminish their overall usefulness. A dual approach is necessary to improve this situation: patients need to be better informed about security issues, and, at the same time, their experiences of using secure systems must be studied and used to improve user interfaces. [J Med Internet Res 2005;7(2):e15]

Rheumatic diseases are often associated with changes in bone metabolism. Excessive production and release of cytokines and other growth factors due to inflammation, e.g. tumor necrosis factor-alpha (TNF-alpha), receptor activator of NF-kappaB ligand (RANKL), interleukins such as IL-1 and IL-6, may cause alterations in bone homeostasis leading to bone degradation. Other components such as osteoprotegerin (OPG) and possibly the ligand-receptor pair hepatocyte growth factor (HGF) and c-met may counteract this destruction, we have measured the levels of OPG, and HGF c-met, in serum, synovial fluid (SF), and cartilage from patients with rheumatoid arthritis (RA) and other arthritides. We found a) elevated levels of both OPG and HGF in SF from RA patients relative to arthritides of other causes, b) increased levels of both OPG and HGF in SF from seropositive RA patients (RA+) compared to seronegative RA patients (RA-), c) elevated levels or both OPG and HGF in serum from RA patients compared to healthy controls, d) no correlation between severity of inflammation and levels of OPG or HGF, and e) presence of HGF c-met in both cartilage and synovial tissue. The most significant elevations of OPG and HGF were found in patients with RA, the rheumatic disease most frequently associated with the development of secondary osteoporosis.

Cytokines are signalling glycoproteins mediating acute inflammation, chronic inflammation, and connective tissue destruction. The present study was designed to characterize the profile of cytokine message in normal human articular cartilage and from patients with rheumatoid arthritis (RA) and osteoarthritis (OA), by means of the reverse transcriptase-polymerase chain reaction (RT-PCR). Message RNA (mRNA) was extracted from fresh or frozen cartilage. The results showed expression of mRNA for IL-6, IL-6R, IL-7, IL-8, IL-10, and IL-12 (p35 and p40) exclusively in the RA cartilage. Except for mRNA for IL-8 and IL-10, no other cytokine or cytokine receptor was expressed in OA and control cartilage. mRNA for IL-1beta, IL-4, TNF-alpha, and TNFR-p75, was not detected in any cartilage sample except for one RA specimen expressing IL-1beta mRNA. However, the expression of message for pro-inflammatory cytokines was far more prominent than anti-inflammatory cytokines. This may suggest a disturbed balance of pro- and anti-inflammatory activity in RA cartilage.

Background Many hospital departments have implemented small clinical departmental systems (CDSs) to collect and use patient data for documentation as well as for other department-specific purposes. As hospitals are implementing institution-wide electronic patient records (EPRs), the EPR is thought to be integrated with, and gradually substitute the smaller systems. Many EPR systems however fail to support important clinical workflows. Also, successful integration of systems has proven hard to achieve. As a result, CDSs are still in widespread use. This study was conducted to see which tasks are supported by CDSs and to compare this to the support offered by the EPR. Methods Semi-structured interviews with users of 16 clinicians using 15 different clinical departmental systems (CDS) at a Medium-sized University hospital in Norway. Inductive analysis of transcriptions from the audio taped interviews. Results The roles of CDSs were complementary to those of the hospital-wide EPR system. The use of structured patient data was a characteristic feature. This facilitated quality development and supervision, tasks that were poorly supported by the EPR system. The structuring of the data also improved filtering of information to better support clinical decision-making. Because of the high value of the structured patient data, the users put much effort in maintaining their integrity and representativeness. Employees from the departments were also engaged in the funding, development, implementation and maintenance of the systems. Conclusion Clinical departmental systems are vital to the activities of a clinical hospital department. The development, implementation and clinical use of such systems can be seen as bottom-up, user-driven innovations.

Background Evaluation is a challenging but necessary part of the development cycle of clinical information systems like the electronic medical records (EMR) system. It is believed that such evaluations should include multiple perspectives, be comparative and employ both qualitative and quantitative methods. Self-administered questionnaires are frequently used as a quantitative evaluation method in medical informatics, but very few validated questionnaires address clinical use of EMR systems. Methods We have developed a task-oriented questionnaire for evaluating EMR systems from the clinician's perspective. The key feature of the questionnaire is a list of 24 general clinical tasks. It is applicable to physicians of most specialties and covers essential parts of their information-oriented work. The task list appears in two separate sections, about EMR use and task performance using the EMR, respectively. By combining these sections, the evaluator may estimate the potential impact of the EMR system on health care delivery. The results may also be compared across time, site or vendor. This paper describes the development, performance and validation of the questionnaire. Its performance is shown in two demonstration studies (n = 219 and 80). Its content is validated in an interview study (n = 10), and its reliability is investigated in a test-retest study (n = 37) and a scaling study (n = 31). Results In the interviews, the physicians found the general clinical tasks in the questionnaire relevant and comprehensible. The tasks were interpreted concordant to their definitions. However, the physicians found questions about tasks not explicitly or only partially supported by the EMR systems difficult to answer. The two demonstration studies provided unambiguous results and low percentages of missing responses. In addition, criterion validity was demonstrated for a majority of task-oriented questions. Their test-retest reliability was generally high, and the non-standard scale was found symmetric and ordinal. Conclusion This questionnaire is relevant for clinical work and EMR systems, provides reliable and interpretable results, and may be used as part of any evaluation effort involving the clinician's perspective of an EMR system.

Background Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians. Methods We have used questionnaires and interviews to assess and compare frequency of use of the HIS for essential tasks, task performance and user satisfaction among medical secretaries, nurses and physicians. Results The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images. Conclusions Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS.