Journal of Medical Internet Research

Age-Sensitive Design of Online Health Information: Comparative Usability Study

2009-11-16T11:32:25-05:00

Background: Older adults’ health maintenance may be enhanced by having access to online health information. However, usability issues may prevent older adults from easily accessing such information. Prior research has shown that aging is associated with a unique pattern of cognitive changes, and knowledge of these changes may be used in the design of health websites for older adults. Objective: The goal of the current study was to examine whether older adults use of a health information website was affected by an alternative information architecture and access interface (hierarchical versus tag-based). Methods: Fifty younger adults (aged 18-23) and 50 older adults (aged 60-80) navigated a health information website, which was organized hierarchically or used tags/keywords, to find answers to health-related questions while their performance was tracked. We hypothesized that older adults would perform better in the tag-based health information website because it placed greater demands on abilities that remain intact with aging (verbal ability and vocabulary). Results: The pattern of age-related differences in computer use was consistent with prior research with older adults. We found that older adults had been using computers for less time (F1,98= 10.6, P= .002) and used them less often (F1,98= 11.3, P= .001) than younger adults. Also consistent with the cognitive aging literature, younger adults had greater spatial visualization and orientation abilities (F1,98= 34.6, P< .001 and F1,98= 6.8, P= .01) and a larger memory span (F1,98= 5.7, P= .02) than older adults, but older adults had greater vocabulary (F1,98= 11.4, P= .001). Older adults also took significantly more medications than younger adults (F1,98= 57.7, P< .001). In the information search task, older adults performed worse than younger adults (F1,96= 18.0, P< .001). However, there was a significant age × condition interaction indicating that while younger adults outperformed older adults in the hierarchical condition (F1,96= 25.2, P< .001), there were no significant age-related differences in the tag-based condition, indicating that older adults performed as well as younger adults in this condition. Conclusions: Access to online health information is increasing in popularity and can lead to a more informed health consumer. However, usability barriers may differentially affect older adults. The results of the current study suggest that the design of health information websites that take into account age-related changes in cognition can enhance older adults’ access to such information.

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Use of Live Interactive Webcasting for an International Postgraduate Module in eHealth: Case Study Evaluation

2009-11-13T12:55:05-05:00

Background: Producing “traditional” e-learning can be time consuming, and in a topic such as eHealth, it may have a short shelf-life. Students sometimes report feeling isolated and lacking in motivation. Synchronous methods can play an important part in any blended approach to learning. Objective: The aim was to develop, deliver, and evaluate an international postgraduate module in eHealth using live interactive webcasting. Methods: We developed a hybrid solution for live interactive webcasting using a scan converter, mixer, and digitizer, and video server to embed a presenter-controlled talking head or copy of the presenter’s computer screen (normally a PowerPoint slide) in a student chat room. We recruited 16 students from six countries and ran weekly 2.5-hour live sessions for 10 weeks. The content included the use of computers by patients, patient access to records, different forms of e-learning for patients and professionals, research methods in eHealth, geographic information systems, and telehealth. All sessions were recorded—presentations as video files and the student interaction as text files. Students were sent an email questionnaire of mostly open questions seeking their views of this form of learning. Responses were collated and anonymized by a colleague who was not part of the teaching team. Results: Sessions were generally very interactive, with most students participating actively in breakout or full-class discussions. In a typical 2.5-hour session, students posted about 50 messages each. Two students did not complete all sessions; one withdrew from the pressure of work after session 6, and one from illness after session 7. Fourteen of the 16 responded to the feedback questionnaire. Most students (12/14) found the module useful or very useful, and all would recommend the module to others. All liked the method of delivery, in particular the interactivity, the variety of students, and the “closeness” of the group. Most (11/14) felt “connected” with the other students on the course. Many students (11/14) had previous experience with asynchronous e-learning, two as teachers; 12/14 students suggested advantages of synchronous methods, mostly associated with the interaction and feedback from teachers and peers. Conclusions: This model of synchronous e-learning based on interactive live webcasting was a successful method of delivering an international postgraduate module. Students found it engaging over a 10-week course. Although this is a small study, given that synchronous methods such as interactive webcasting are a much easier transition for lecturers used to face-to-face teaching than are asynchronous methods, they should be considered as part of the blend of e-learning methods. Further research and development is needed on interfaces and methods that are robust and accessible, on the most appropriate blend of synchronous and asynchronous work for different student groups, and on learning outcomes and effectiveness.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

Usability of a Patient Education and Motivation Tool Using Heuristic Evaluation

2009-11-06T11:30:45-05:00

Background: Computer-mediated educational applications can provide a self-paced, interactive environment to deliver educational content to individuals about their health condition. These programs have been used to deliver health-related information about a variety of topics, including breast cancer screening, asthma management, and injury prevention. We have designed the Patient Education and Motivation Tool (PEMT), an interactive computer-based educational program based on behavioral, cognitive, and humanistic learning theories. The tool is designed to educate users and has three key components: screening, learning, and evaluation. Objective: The objective of this tutorial is to illustrate a heuristic evaluation using a computer-based patient education program (PEMT) as a case study. The aims were to improve the usability of PEMT through heuristic evaluation of the interface; to report the results of these usability evaluations; to make changes based on the findings of the usability experts; and to describe the benefits and limitations of applying usability evaluations to PEMT. Methods: PEMT was evaluated by three usability experts using Nielsen’s usability heuristics while reviewing the interface to produce a list of heuristic violations with severity ratings. The violations were sorted by heuristic and ordered from most to least severe within each heuristic. Results: A total of 127 violations were identified with a median severity of 3 (range 0 to 4 with 0 = no problem to 4 = catastrophic problem). Results showed 13 violations for visibility (median severity = 2), 38 violations for match between system and real world (median severity = 2), 6 violations for user control and freedom (median severity = 3), 34 violations for consistency and standards (median severity = 2), 11 violations for error severity (median severity = 3), 1 violation for recognition and control (median severity = 3), 7 violations for flexibility and efficiency (median severity = 2), 9 violations for aesthetic and minimalist design (median severity = 2), 4 violations for help users recognize, diagnose, and recover from errors (median severity = 3), and 4 violations for help and documentation (median severity = 4). Conclusion: We describe the heuristic evaluation method employed to assess the usability of PEMT, a method which uncovers heuristic violations in the interface design in a quick and efficient manner. Bringing together usability experts and health professionals to evaluate a computer-mediated patient education program can help to identify problems in a timely manner. This makes this method particularly well suited to the iterative design process when developing other computer-mediated health education programs. Heuristic evaluations provided a means to assess the user interface of PEMT.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

Challenges to Using an Electronic Personal Health Record by a Low-income Elderly Population

2009-11-06T11:30:45-05:00

Background: Electronic personal health records (PHRs) are increasingly recognized and used as a tool to address various challenges stemming from scattered and incompatible personal health information (PHI) in the contemporary U.S. healthcare system. Although activities on PHR development and deployment have increased in recent years, little has been reported regarding the use and utility of PHRs among low-income and/or elderly populations. Objective: To assess the use and utility of PHRs in a low-income, elderly population. Methods: We have deployed a web-based, institution-neutral PHR system, the Personal Health Information Management System (PHIMS), in a federally-funded housing facility which houses low-income and elderly residents. We assessed system use and user satisfaction through system logs, questionnaire surveys and user group meetings. Results: During the study period of 33 months, 70 residents participated in the study. At the end of the study, 44 lived in the housing complex. Although PHIMS was available for free and computers with Internet connection and personal assistance were provided without any cost to residents, only about 13% (44/330) of the eligible residents used the system, and system usage was limited. Almost one half of the users (47%, 37/70) used the PHIMS only on a single day. Its use was also highly correlated with the availability of in-person assistance; 77% of user activities occurred while the assistance was available. Residents’ ability to use the PHR system was limited by poor computer and Internet skills, technophobia, low health literacy, and limited physical/cognitive abilities. On the contrary, the significant majority (82%, 9/11) of the survey participants used PHIMS 3 times or more and reported that PHIMS had improved the quality of overall healthcare they received. Conclusions: Our findings suggest that those who can benefit the most from a PHR system may be least able to use it. Disparities in access to and use of computers, the Internet and PHRs may exacerbate healthcare inequality in the future.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

A Web-Based Nutrition Program Reduces Health Care Costs in Employees With Cardiac Risk Factors: Before and After Cost Analysis

2009-11-06T11:30:45-05:00

Background: Rising health insurance premiums represent a rapidly increasing burden on employer-sponsors of health insurance and their employees. Some employers have become proactive in managing health care costs by providing tools to encourage employees to directly manage their health and prevent disease. One example of such a tool is DASH for Health, an Internet-based nutrition and exercise behavior modification program. This program was offered as a free, opt-in benefit to US-based employees of the EMC Corporation. Objective: The aim was to determine whether an employer-sponsored, Internet-based diet and exercise program has an effect on health care costs. Methods: There were 15,237 total employees and spouses who were included in our analyses, of whom 1967 enrolled in the DASH for Health program (DASH participants). Using a retrospective, quasi-experimental design, study year health care costs among DASH participants and non-participants were compared, controlling for baseline year costs, risk, and demographic variables. The relationship between how often a subject visited the DASH website and health care costs also was examined. These relationships were examined among all study subjects and among a subgroup of 735 subjects with cardiovascular conditions (diabetes, hypertension, hyperlipidemia). Multiple linear regression analysis examined the relationship of program use to health care costs, comparing study year costs among DASH participants and non-participants and then examining the effects of increased website use on health care costs. Analyses were repeated among the cardiovascular condition subgroups. Results: Overall, program use was not associated with changes in health care costs. However, among the cardiovascular risk study subjects, health care costs were US$827 lower, on average, during the study year (P= .05; t729 = 1.95). Among 1028 program users, increased website use was significantly associated with lower health care costs among those who visited the website at least nine times during the study year (US$14 decrease per visit; P = .04; t1022 = 2.05), with annual savings highest among 80 program users with targeted conditions (US$55 decrease per visit; P < .001; t74 = 2.71). Conclusions: An employer-sponsored, Internet-based diet and exercise program shows promise as a low-cost benefit that contributes to lower health care costs among persons at higher risk for above-average health care costs and utilization.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

Health e-Cards as a Means of Encouraging Help Seeking for Depression Among Young Adults: Randomized Controlled Trial

2009-11-06T11:30:45-05:00

Background: There is a need to identify interventions that increase help seeking for depression among young adults. Objective: The aim was to evaluate a brief depression information intervention employing health e-cards (personalized emails containing links to health information presented on a Web page). Methods: A randomized controlled trial was carried out with 348 19- to 24-year-olds drawn from the community. Participants were randomized to receive one of three conditions, all of which delivered a short series of health e-cards. Two active conditions involved the delivery of depression information designed to increase help-seeking behavior and intentions and to improve beliefs and knowledge associated with help seeking. A control arm delivered information about general health issues unrelated to depression. The primary outcome was help-seeking behavior. Secondary outcomes were help-seeking intentions; beliefs about the efficacy of depression treatments and help sources; ability to recognize depression; knowledge of the help-seeking process; and depressive symptoms. The study’s primary focus was outcomes relating to formal help seeking (consultation with a general practitioner or mental health professional) but also targeted behaviors, intentions, and beliefs relating to informal help seeking. Results: Relative to the control condition, depression health e-cards were not associated with an increase in formal help-seeking behavior, nor were they associated with improved beliefs about depression treatments; ability to recognize depression; knowledge of the help-seeking process; or depressive symptoms. Depression e-cards were associated with improved beliefs about the overall efficacy of formal help sources (z = 2.4, P = .02). At post-intervention, participants in all conditions, relative to pre-intervention, were more likely to have higher intentions of seeking help for depression from a formal help source (t641 = 5.8, P < .001) and were more likely to rate interpersonal psychotherapy as being helpful (z = 2.0, P = .047). Depression e-cards were not associated with any significant changes in informal help-seeking behavior, intentions, or beliefs. Conclusions: The study found no evidence that providing depression information in the form of brief e-cards encourages help seeking for depression among young adults. Involvement in the study may have been associated with increased help-seeking intentions among participants in all conditions, suggesting that mechanisms other than depression information may increase help seeking. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN98406912; http://www.controlled-trials.com/ISRCTN98406912/ISRCTN98406912 (Archived by WebCite at http://www.webcitation.org/5k221KiMi)

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

Systematic Review on Internet Support Groups (ISGs) and Depression (1): Do ISGs Reduce Depressive Symptoms?

2009-09-30T21:58:28-04:00

Background: Internet support groups (ISGs) enable individuals with specific health problems to readily communicate online. Peer support has been postulated to improve mental health, including depression, through the provision of social support. Given the growing role of ISGs for both users with depression and those with a physical disorder, there is a need to evaluate the evidence concerning the efficacy of ISGs in reducing depressive symptoms. Objective: The objective was to systematically review the available evidence concerning the effect of ISGs on depressive symptoms. Method: Three databases (PubMed, PsycINFO, Cochrane) were searched using over 150 search terms extracted from relevant papers, abstracts, and a thesaurus. Papers were included if they (1) employed an online peer-to-peer support group, (2) incorporated a depression outcome, and (3) reported quantitative data. Studies included both stand-alone ISGs and those used in the context of a complex multi-component intervention. All trials were coded for quality. Results: Thirty-one papers (involving 28 trials) satisfied the inclusion criteria from an initial pool of 12,692 abstracts. Sixteen trials used either a single-component intervention, a design in which non-ISG components were controlled, or a cross-sectional analysis, of which 10 (62.5%) reported a positive effect of the ISG on depressive symptoms. However, only two (20%) of these studies employed a control group. Only two studies investigated the efficacy of a depression ISG and neither employed a control group. Studies with lower design quality tended to be associated with more positive outcomes (P = .07). Overall, studies of breast cancer ISGs were more likely to report a reduction in depressive symptoms than studies of other ISG types (Fisher P = .02), but it is possible that this finding was due to confounding design factors rather than the nature of the ISG. Conclusions: There is a paucity of high-quality evidence concerning the efficacy or effectiveness of ISGs for depression. There is an urgent need to conduct high-quality randomized controlled trials of the efficacy of depression ISGs to inform the practice of consumers, practitioners, policy makers, and other relevant users and providers of online support groups.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

Systematic Review on Internet Support Groups (ISGs) and Depression (2): What Is Known About Depression ISGs?

2009-09-30T21:58:28-04:00

Background: Internet support groups (ISGs) are a popular means by which consumers with depression communicate online. A number of studies have evaluated the nature and impact of depression-specific ISGs. However, to date there have been no published systematic reviews of this evidence. Objective: The aim was to systematically identify and summarize the available evidence concerning the scope and findings of studies of depression ISGs. Methods: Three databases (PubMed, PsycINFO, Cochrane) were searched using over 150 search terms extracted from relevant papers, abstracts, and a thesaurus. Papers were included if they employed an online peer-to-peer depression-specific support group and reported either quantitative or qualitative empirical data. The objective of each study was coded according to a 20-category classification system, which included the effect on depression and other outcomes, including help seeking; user characteristics, activity, satisfaction, perceived benefits, perceived disadvantages; the reason for using the ISG; the nature of ISG posts; characteristics of depression ISGs compared to other ISG types, face-to-face groups, and face-to-face counseling; ISG structure and longitudinal changes; and predictors of ISG adherence. Results: Thirteen papers satisfied the inclusion criteria from an initial pool of 12,692 abstracts. Of these, three collected data using survey questionnaires, nine analyzed samples of posts, and one both collected survey data and analyzed a sample of posts. The quality of most studies was not high, and little data were collected on most key aspects of depression ISGs. The most common objective of the studies was to analyze the nature of the posts (eight studies) and to describe site usage (six studies) and user characteristics (five studies). The most prevalent types of social support were emotional, informational, and social companionship. Conclusions: Given the popularity of depression ISGs and the paucity of available evidence about them, there is a need for high-quality, systematic studies of these groups, their impact, and the characteristics of their members and users. Such information is required to inform decision making by consumers, provider and educational organizations, guideline developers, policy makers, and funding bodies considering using, recommending, providing, or funding such groups.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

An Evaluation of Patient-Physician Communication Style During Telemedicine Consultations

2009-09-30T21:58:28-04:00

Background: The quality of physician-patient communication is a critical factor influencing treatment outcomes and patient satisfaction with care. To date, there is little research to document the effect of telemedicine (TM) on physician-patient communication. Objective: The objectives of this study are to measure and describe verbal and nonverbal communication during clinical TM consultations and to compare TM with in-person (IP) consultations in terms of the quality of physician-patient communication. Methods: Veteran patients (n = 19) requiring pulmonary medicine consultations were enrolled into the study. The study group included 11 patients from the Iron Mountain Veterans Affairs Hospital (VAMC) remote site. Patients had individual TM consultations with a pulmonary physician at the Milwaukee VAMC hub site. A control group of 8 patients had IP consultations with a pulmonary physician at the Milwaukee VAMC. Video recordings of medical consultations were coded for patient-physician verbal and nonverbal communication patterns using the Roter Interaction Analysis System (RIAS). Results: There were no differences in the length of TM consultations (22.2 minutes) and IP consultations (21.9 minutes). Analysis of visit dialogue indicated that the ratio of physician to patient talk was 1.45 for TM and 1.13 for IP consultations, indicating physician verbal dominance. Physicians were more likely to use orientation statements during IP consultations (P = .047). There were greater requests for repetition from patients during TM consultations (P = .034), indicating perceptual difficulties. Conclusions: The study findings indicate differences between TM and IP consultations in terms of physician-patient communication style. Results suggest that, when comparing TM and IP consultations in terms of physician-patient communication, TM visits are more physician centered, with the physician controlling the dialogue and the patient taking a relatively passive role. Further research is needed to determine whether these differences are significant and whether they have relevance in terms of health outcomes and patient satisfaction with care.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.

An Internet Tool for Creation of Cancer Survivorship Care Plans for Survivors and Health Care Providers: Design, Implementation, Use and User Satisfaction

2009-09-30T21:58:28-04:00

Background: Survivorship care plans have been recommended by the Institute of Medicine for all cancer survivors. We implemented an Internet-based tool for creation of individualized survivorship care plans. To our knowledge, this is the first tool of this type to be designed and made publicly accessible. Objective: To investigate patterns of use and satisfaction with an Internet-based tool for creation of survivorship care plans. Methods: OncoLife, an Internet-based program for creation of survivorship care plans, was designed by a team of dedicated oncology nurses and physicians at the University of Pennsylvania. The program was designed to provide individualized, comprehensive health care recommendations to users responding to queries regarding demographics, diagnosis, and cancer treatments. After being piloted to test populations, OncoLife was made publicly accessible via Oncolink, a cancer information website based at the University of Pennsylvania which averages 3.9 million page views and over 385,000 unique visits per month. Data entered by anonymous public users was maintained and analyzed. Results: From May 2007 to November 2008, 3343 individuals utilized this tool. Most (63%) identified themselves as survivors, but also health care providers (25%) and friends/family of survivors (12%). Median age at diagnosis was 48 years (18 - 100+), and median current age 51 (19 - 100+). Most users were Caucasian (87%), female (71%), and college-educated (82%). Breast cancer was the most common diagnosis (46%), followed by hematologic (12%), gastrointestinal (11%), gynecologic (9%), and genitourinary (8%). Of all users, 84% had undergone surgery, 80% chemotherapy, and 60% radiotherapy. Half of users (53%) reported receiving follow-up care from only an oncologist, 13% only a primary care provider (PCP), and 32% both; 12% reported having received survivorship information previously. Over 90% of users, both survivors and health care providers, reported satisfaction levels of “good” to “excellent” using this tool. Conclusions: Based on our experience with implementation of what is, to our knowledge, the first Web-based program for creation of survivorship care plans, survivors and health care providers appear both willing to use this type of tool and satisfied with the information provided. Most users have never before received survivorship information. Future iterations will focus on expanding accessibility and improving understanding of the needs of cancer survivors in the era of the Internet.

This is the abstract only. Read the full article on the JMIR site. JMIR is the leading open access journal for eHealth and healthcare in the Internet age.