eHealth in the Forensic Context – What are our Next Steps?

Hanneke Kip, Centre for eHealth and Wellbeing Research, University of Twente; Department of Research, Transfore
Kira Oberschmidt, eHealth Group, Roessingh Research and Development; Biomedical Signals and Systems Group, University of Twente
Joyce, J.P.A. Bierbooms, Tilburg University; Research Group Evidence Based Management of Innovation, GGzE

While eHealth technologies such as web-based interventions, mobile apps, and virtual reality have the potential to be of added value for forensic mental healthcare, there is a gap between this potential and the current situation in practice. The goal of this study was to identify recommendations to bridge this gap. In total, 21 semi-structured interviews and 89 questionnaires were conducted in a Dutch forensic mental healthcare sample consisting of professionals, patients, and eHealth experts. Based on the broad range of identified recommendations, it can be concluded that attention should be paid to the characteristics of professionals, patients, technology, and the organization throughout the development, implementation and evaluation of eHealth.

eHealth, forensic mental healthcare, forensic psychiatry, web-based interventions, virtual reality

“Research on eHealth in mental healthcare in general has shown multiple actual and potential advantages, such as an effectiveness comparable to face-to-face treatment, increased efficiency, an increase in patients’ autonomy, and the delivery of healthcare independent of time and place. However, these positive findings cannot simply be generalized and applied to forensic mental healthcare due to its unique nature of transpiring at the intersect between psychiatry and law.”

The current study… aimed to…identify recommendations to achieve the benefits and overcome the barriers of eHealth in forensic mental healthcare, as determined by professionals, patients, and experts. The study described in this paper applies a qualitative multi-method approach in which data from two different sources are triangulated. The interview study aimed to gain insight into the participants’ recommendations to optimize the use of technology in forensic mental healthcare and to overcome potential barriers by discussing the current state of affairs of technology in forensic mental healthcare. The questionnaire aimed to also gain insight into recommendations by means of asking participants to evaluate the potential of 12 different types of technologies.”

Development process

Participants indicated that the main goal of such a development process was to achieve a fit between the technology, users and context. The importance of developing personalized technology was emphasized to ensure its adaptation to the diverse, broad forensic patient population… Furthermore, participants stated that development never stops; technologies should be updated to ensure the optimization of the aforementioned fit with the patients, therapists and context. Finally, collaboration at a national level between organizations and IT developers was recommended.”

Implementation in forensic organizations

“Implementation refers to activities that are conducted to ensure the technology’s dissemination, adoption, and long-term use in practice. Participants highlighted the importance of integrating technology into the existing situation in order to prevent the technology from being overlooked and seen as a separate, stand-alone tool, which is currently often the case. This might require re-arranging the way care is delivered and organized. Furthermore, since many therapists and managers do not have enough knowledge of the possibilities of technology, there should be more activities – such as courses, team meetings, websites or ambassadors – to disseminate technological knowledge. Participants also emphasized the importance of meeting basic prerequisites, such as a good internet connection and/or suitable hardware…interdisciplinary collaboration on a national level between different types of stakeholders was deemed essential for successful implementation.”

Evaluation

“…participants indicated that it was not only important to conduct more research to determine if eHealth works, but also to better understand why and for whom the technology works. Suitable and innovative research methods are fractional factorial designs or log data analyses. To illustrate, web-based modules might work better for patients with higher literacy and reflective skills, while VR might be most effective for patients with low educational levels and aggression regulation problems. Furthermore, besides effectiveness, participants also stated that the evaluation should focus on whether a technology is a reliable and a valid method to measure certain behaviors, biases or other phenomena. Finally, participants indicated that research needs to show if the use of eHealth results in decreased costs and more efficient healthcare, especially since this type of information was deemed important for management and healthcare insurance companies.”

Guidelines and standards

“To ensure that therapists are aware of the numerous possibilities, participants indicated that there should be an overview of available eHealth technologies, for example, by means of an online database. Furthermore, there was a need for more guidelines on ethical dilemmas, such as what can be shown to sexual offenders in VR. Participants also indicated that there should be more protocols to support therapists in integrating eHealth technology into their treatment. The importance of clear and suitable legislation was raised as well. Participants indicated the need for more clarity and guidelines on topics such as privacy, data security and ownership of data.”

Readiness of user and technology

“Participants pointed out the importance of improving the skills of therapists via, for example, training or intervision. Training should not only focus on technical knowledge, but also on attitudes toward technology and skills that are required for embedding eHealth technology into treatment, such as discussing the technology with patients, motivating patients, and integrating data into follow-up conversations. The way technology is designed was also deemed important. For example, participants indicated that many web-based interventions contain too much text and are hard to navigate. Aligned with this, participants also stated that technology should not have too many hard- or software errors since these types of problems can hinder usage.”

Improving technology

“Participants pointed out that technology should be constantly improved and recommended that, in order to achieve this, it is important to have up-to-date knowledge about innovations elsewhere, such as artificial intelligence or robotics. Trying out combinations of technologies was also recommended, such as virtual reality and neurofeedback. This underlines the importance of a broader, more holistic view of technology. Participants suggested that another way to further improve eHealth technology was to ground these technologies in existing, evidence-based theories from different domains. Furthermore, adapting existing technologies to fit specific types of forensic psychiatric patients was recommended, since this is more efficient than creating an entirely new technology.”

The professional

“A large share of the identified recommendations revolved around the key role of the professional in enabling successful use of technology in forensic mental healthcare. In order to improve the current situation, participants indicated that more training of professionals is necessary and that training should not just focus on technical skills…To successfully use eHealth technologies, education would also have to focus on, for example, developing a positive attitude toward eHealth, creating a sense of ownership for maintaining up-to-date knowledge, improving skills to discuss collected data with patients, and gaining knowledge on how to support patients in their use of eHealth technologies. Subsequently, the use of technology by practitioners might require more than upgrading skills; in fact, the introduction of technology can implicate in practice a change in people’s professional roles.”

“A therapist’s role might shift from taking the lead in treatment to a more supportive role that includes: giving feedback on assignments in a web-based module, creating environments to allow a patient to individually practice with social skills in VR, or supporting a patient in drawing conclusions on data collected by a wearable to gain insight into what triggers them.”

The patient

“Participants indicated that patients often do not possess the required skills for using technologies. For example, in case of webbased modules, many patients were said to have difficulty reading and writing and lack the motivation to individually work on assignments at home, which appears to be a major barrier hindering the use of these types of interventions.
Consequently, developers of eHealth interventions should take the skill level and preferences of patients into account to prevent a mismatch between the technology and patient. Such a mismatch might result in high levels of non-adherence.”

“On the one hand, it can be beneficial to further investigate how patients can be better supported in using these mostly text-based apps or websites, which are used a great deal in current practice. This might be done by adding more options for personalization – for example, offering information as videos instead of text or with different literacy levels, or by training therapists to better support patients in using a technology. On the other hand, organizations might have to invest more in technologies of which the characteristics might better fit the forensic psychiatric patient population. An example of such a technology is virtual reality, which was seen as most promising by participants of this study. An important advantage of interactive VR for forensic mental healthcare is that it offers the possibility to practice specific behavior in a realistic way instead of merely discussing it.”

“Wearables are another example of a technology that focuses less on cognitive reflection. These wearables, such as smartwatches, can collect physiological data such as heart rate variability or skin conductance, which can be used to gain more insights into a patient’s physiological arousal and its potential causes.”

The technology

“With regard to technology itself, personalization appeared to be important, mostly because of the different needs and characteristics of the diverse forensic psychiatric patient population…In order to ensure that a technology seamlessly fits the needs of patients and therapists, participants indicated that a multi-method, participatory development process is pivotal…. Within such a process, stakeholders should be involved as co-creators right from the start when the first ideas arise, instead of asking them for feedback on ideas that have already been developed by researchers or developers. To support this fit between the development of a technology and the users’ context, characteristics and needs, continuous formative evaluations of ideas and products are of great importance. This iterative nature of development with multiple formative evaluation cycles was also mentioned by participants in the current study.”

“Potential suitable methods are semi-structured interviews, questionnaires or usability tests. However, more knowledge needs to be gathered about suitable participatory development methods for personalized eHealth technologies in the unique and complex forensic psychiatric
context. This can for example be achieved by encouraging publications on development studies in which authors critically reflect on the methods used, or by means of an interview or questionnaire study with researchers and developers with experience on this topic.”

The context

“… participants emphasized the important role of the forensic organization in the technology’s implementation. Implementation of eHealth technologies should be improved to ensure successful and sustainable use, but this was seen as a complicated activity. In line with this complexity, participants provided a broad range of recommendations for improving implementation in organizations by, for example: investing more in technologies, better integrating eHealth into organizational structures, ensuring that all employees are aware of and educated in eHealth, and joining forces with other organizations to share knowledge and costs.”

“The diversity of the recommendations given by the participants can be explained by the broad, holistic nature of implementation…Consequently, organizations might need to invest more in multilevel implementation plans and activities that focus on these different domains. Also, to systematically plan and guide implementation processes, organizations can use existing implementation frameworks that are suitable for eHealth implementation, such as the non-adoption, abandonment, scaleup, spread and sustainability (NASSS) framework or the consolidated framework for implementation research.”

Research

“…research can be used to gain more insight into development and implementation methods that are suitable in forensic mental healthcare…it is probable that strategies that were successful in other settings, such as in hospitals or regular mental healthcare facilities, cannot simply be copied-and-pasted into forensic mental healthcare.”

“Several participants indicated that, while a randomized controlled trial (RCT) can be very useful, other types of evaluation methods might be more suitable for eHealth evaluation in context, from a practical and methodological point of view. RCTs often require major investments of time and money, which is not always feasible. Also, RCTs do not provide much insight into what elements of an intervention works best for which type of patient and why. Examples of evaluation approaches that might better address these issues are: (fractional) factorial designs to gain insight into effective components of an intervention; single case experimental designs in which in-depth analyses are conducted on single subjects; RCTs in combination with log data analyses to provide insight into usage patterns and potential relationships of usage with effectiveness; realist evaluations to determine what works, how, in which conditions and for whom; or mixed-methods approaches in which quantitative data is integrated with qualitative findings to provide more insight into reasons for effectiveness.”

“…with regard to the use of eHealth technologies in forensic mental healthcare, attention should be paid to professionals’ and patients’ perspectives, the technological characteristics and the organization throughout the eHealth technology’s development, implementation and evaluation processes. Such a holistic approach in which multiple perspectives are integrated is necessary to ensure that eHealth is of actual added value for forensic mental healthcare and not merely used for the sake of using technology. Consequently, an interdisciplinary, collaborative approach is necessary in order to optimally benefit from the potential of different types of technology. Developers, therapists, patients, researchers, financers, managers and other stakeholders should closely collaborate and learn from each other. In order to ensure that eHealth is of actual added value for forensic mental healthcare, people need to cross the borders of their own discipline in order to integrate knowledge and experiences.”

As always, please join the discussion below if you have thoughts or comments to add!