title: Tips and Traps: Lessons From Codesigning a Clinician E-Monitoring Tool for Computerized Cognitive Behavioral Therapy.
abstract: BACKGROUND
  Computerized cognitive behavioral therapy (cCBT) is an acceptable and promising treatment modality for adolescents with mild-to-moderate depression. Many cCBT programs are standalone packages with no way for clinicians to monitor progress or outcomes. We sought to develop an electronic monitoring (e-monitoring) tool in consultation with clinicians and adolescents to allow clinicians to monitor mood, risk, and treatment adherence of adolescents completing a cCBT program called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts).
  
  
  OBJECTIVE
  The objectives of our study were as follows: (1) assess clinicians' and adolescents' views on using an e-monitoring tool and to use this information to help shape the development of the tool and (2) assess clinician experiences with a fully developed version of the tool that was implemented in their clinical service.
  
  
  METHODS
  A descriptive qualitative study using semistructured focus groups was conducted in New Zealand. In total, 7 focus groups included clinicians (n=50) who worked in primary care, and 3 separate groups included adolescents (n=29). Clinicians were general practitioners (GPs), school guidance counselors, clinical psychologists, youth workers, and nurses. Adolescents were recruited from health services and a high school. Focus groups were run to enable feedback at 3 phases that corresponded to the consultation, development, and postimplementation stages. Thematic analysis was applied to transcribed responses.
  
  
  RESULTS
  Focus groups during the consultation and development phases revealed the need for a simple e-monitoring registration process with guides for end users. Common concerns were raised in relation to clinical burden, monitoring risk (and effects on the therapeutic relationship), alongside confidentiality or privacy and technical considerations. Adolescents did not want to use their social media login credentials for e-monitoring, as they valued their privacy. However, adolescents did want information on seeking help and personalized monitoring and communication arrangements. Postimplementation, clinicians who had used the tool in practice revealed no adverse impact on the therapeutic relationship, and adolescents were not concerned about being e-monitored. Clinicians did need additional time to monitor adolescents, and the e-monitoring tool was used in a different way than was originally anticipated. Also, it was suggested that the registration process could be further streamlined and integrated with existing clinical data management systems, and the use of clinician alerts could be expanded beyond the scope of simply flagging adolescents of concern.
  
  
  CONCLUSIONS
  An e-monitoring tool was developed in consultation with clinicians and adolescents. However, the study revealed the complexity of implementing the tool in clinical practice. Of salience were privacy, parallel monitoring systems, integration with existing electronic medical record systems, customization of the e-monitor, and preagreed monitoring arrangements between clinicians and adolescents.
authors.affiliation: Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
authors.forename: Frederick
authors.identifier: http://orcid.org/0000-0002-6311-9856
authors.initials: F
authors.lastname: Sundram
authors.affiliation: Department of General Practice and Primary Health Care, The University of Auckland, Auckland, New Zealand.
authors.forename: Susan J
authors.identifier: http://orcid.org/0000-0002-6560-2892
authors.initials: SJ
authors.lastname: Hawken
authors.affiliation: Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
authors.forename: Karolina
authors.identifier: http://orcid.org/0000-0002-1153-3123
authors.initials: K
authors.lastname: Stasiak
authors.affiliation: Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.|School of Health, Wellbeing and Social Care, The Open University, Milton Keynes, United Kingdom.
authors.forename: Mathijs Fg
authors.identifier: http://orcid.org/0000-0001-6958-3468
authors.initials: MF
authors.lastname: Lucassen
authors.affiliation: Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.|Department of Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand.
authors.forename: Theresa
authors.identifier: http://orcid.org/0000-0002-5174-9359
authors.initials: T
authors.lastname: Fleming
authors.affiliation: School of Counselling, Human Services and Social Work, The University of Auckland, Auckland, New Zealand.
authors.forename: Matthew
authors.identifier: http://orcid.org/0000-0003-4238-7541
authors.initials: M
authors.lastname: Shepherd
authors.affiliation: Department of Clinical Psychology, The University of Auckland, Auckland, New Zealand.
authors.forename: Andrea
authors.identifier: http://orcid.org/0000-0002-5781-9397
authors.initials: A
authors.lastname: Greenwood
authors.affiliation: Kapiti Youth Support, Paraparaumu, New Zealand.
authors.forename: Raechel
authors.identifier: http://orcid.org/0000-0002-5320-8281
authors.initials: R
authors.lastname: Osborne
authors.affiliation: Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
authors.forename: Sally N
authors.identifier: http://orcid.org/0000-0002-8281-1573
authors.initials: SN
authors.lastname: Merry
keywords: cognitive therapy; depression; e-therapy; primary health care; psychology, adolescent; psychotherapy