Combining online and offline peer support groups in community mental health care settings: a qualitative study of service users' experiences.

BACKGROUND: Peer support for people with long-term mental health problems is central to recovery-oriented approaches in mental health care. Peer support has traditionally been conducted offline in face-to-face groups, while online groups on the Internet have increased rapidly. Offline and online peer support groups are shown to have differing strengths and weaknesses. However, little is known about how combining the two formats might be experienced by service users, which this paper aims to illuminate. METHODS: In this exploratory and descriptive study, a recovery-oriented Internet-based portal called ReConnect was used by service users in two mental health communities in Norway for 6-12 months. The portal included an online peer support group which also facilitated participation in local offline peer support groups. Both group formats were moderated by an employed service user consultant. Qualitative data about service users' experiences were collected through focus groups and individual interviews and inductively analyzed thematically. RESULTS: A total of 14 female service users 22-67 years of age with various diagnoses participated in three focus groups and 10 individual interviews. Two main themes were identified: (1) balancing anonymity and openness, and (2) enabling connectedness. These themes are further illustrated with the subthemes: (i) dilemmas of anonymity and confidentiality, (ii) towards self-disclosure and openness, (iii) new friendships, and (iv) networks in the local community. Three of the subthemes mainly describe benefits, while challenges were more implicit and cut across the subthemes. Identified challenges were related to transitions from anonymity online to revealing one's identity offline, confidentiality, and barriers related to participation in offline peer support groups. CONCLUSIONS: This study suggests that online and offline peer support groups complement each other, and that combining them is mainly described as beneficial by service users. Identified benefits appeared to arise from service users' options of one format or the other, or that they could combine formats in ways that suited their individual values and comfort zones. Moderation by a trained service user consultant appeared essential for both formats and can be used systematically to address identified challenges. Combining online and offline peer support groups is a promising concept for facilitating recovery-oriented care and warrants continued research.

Digitally Enhanced Mentoring for Immigrant Youth Social Capital: Protocol for a Mixed Methods Pilot Study and a Randomized Controlled Trial.

BACKGROUND: There are large disparities between immigrants and native Norwegians in domains such as health, education, and employment. Reducing such disparities is essential for individual and societal well-being. Social capital is associated with positive effects on these domains, and mentoring programs have the potential to boost social capital. However, few studies have assessed mentoring as a social capital intervention among youth or the potential barriers and facilitators of implementing digitally augmented mentoring. OBJECTIVE: The goal of this paper is to describe a protocol for assessing the implementation and effectiveness of a digitally augmented mentoring program for immigrant youth as a health intervention to promote social capital. The two-stage analytical framework for a pilot study followed by a randomized controlled trial (RCT) is presented. The pilot aims to assess program fidelity and make necessary intervention adjustments before the RCT. The RCT aims to assess the effects of the implemented intervention program on social capital and the relationship between program fidelity and effects. METHODS: Both the pilot and RCT will use mixed methods with a process evaluation approach used to structure the intervention and a pre-post test survey component to measure social capital and fidelity of program implementation. Interviews will also be used to enrich the quantitative data from the survey. RESULTS: The pilot study is scheduled to begin in fall 2019. Based on data analyses in spring 2020, potential adjustments will be made to the intervention, with findings used in preparation for the full-scale RCT study. CONCLUSIONS: Digitally enhanced mentoring programs may be a helpful intervention for providing immigrant youth with tools for increasing their social capital and indirectly improving health outcomes. This protocol provides new knowledge about the implementation and evaluation of such programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/16472.

Experiences and Needs of Multicultural Youth and Their Mentors, and Implications for Digital Mentoring Platforms: Qualitative Exploratory Study.

BACKGROUND: Mentoring programs (ie, programs that connect youths with adult volunteers) have been shown to improve outcomes across the behavioral, social, and academic domains of youth development. As in other European countries, mentoring programs have few traditions in Norway, where interventions for multicultural youths are usually profession driven and publicly funded. Faced with the risk of disparities in education and health, there is a need to better understand this group's experiences and requirements relative to mentoring. This would also serve as a basis for designing and implementing digital support. OBJECTIVE: The objective of this study was to gain insight into multicultural youth mentees' and adult mentors' experiences and needs in the context of an ongoing mentoring program, how digital support (electronic mentoring) might address these needs, and how such support could be designed and implemented. METHODS: The study used a qualitative approach, with data from 28 respondents (21 mentees and 7 mentors). In total, 4 workshops with mentees as well as semistructured interviews with mentees and mentors were conducted. The sessions were audio recorded, transcribed, and analyzed thematically. RESULTS: In total, 3 main themes were identified from the experiences and needs reported by the mentees and mentors. These included a need for connection, help in achieving goals, and the need for security and control. Subthemes encompassed a desire to socialize with others, balancing the nature of the relationship, paying it forward, building trust, sharing insights and information with peers, goal-oriented mentees and mentors wanting to assist with goal achievement, and the fundamental need for privacy and anonymity in the digital platform. CONCLUSIONS: The findings of this study are supported by the literature on traditional mentoring, while also offering suggestions for the design of digital solutions to supplement the in-person mentoring of multicultural youth. Suggestions include digital support for managing the mentee-mentor relationships, fostering social capital, and ways of ensuring security and control. Features of existing electronic health apps can be readily adapted to a mentoring program context, potentially boosting the reach and benefits of mentoring.

Policies Make Coherent Care Pathways a Personal Responsibility for Clinicians: A Discourse Analysis of Policy Documents about Coordinators in Hospitals.

INTRODUCTION: In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement. METHODS: This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi's 'What's the problem represented to be?'. We analysed six legal documents (2011-2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals. RESULTS: The 'problem' represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient's pathway (e.g. resources, infrastructure) are scarcely addressed. CONCLUSIONS AND DISCUSSION: We suggest that the policies' construction of the 'problem' as a responsibility issue, result in that neither diversity of patients' coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs.

A person-centered integrated care quality framework, based on a qualitative study of patients' evaluation of care in light of chronic care ideals.

BACKGROUND: Person-Centered Integrated Care (PC-IC) is believed to improve outcomes and experience for persons with multiple long-term and complex conditions. No broad consensus exists regarding how to capture the patient-experienced quality of PC-IC. Most PC-IC evaluation tools focus on care events or care in general. Building on others' and our previous work, we outlined a 4-stage goal-oriented PC-IC process ideal: 1) Personalized goal setting 2) Care planning aligned with goals 3) Care delivery according to plan, and 4) Evaluation of goal attainment. We aimed to explore, apply, refine and operationalize this quality of care framework. METHODS: This paper is a qualitative evaluative review of the individual Patient Pathways (iPP) experiences of 19 strategically chosen persons with multimorbidity in light of ideals for chronic care. The iPP includes all care events, addressing the persons collected health issues, organized by time. We constructed iPPs based on the electronic health record (from general practice, nursing services, and hospital) with patient follow-up interviews. The application of the framework and its refinement were parallel processes. Both were based on analysis of salient themes in the empirical material in light of the PC-IC process ideal and progressively more informed applications of themes and questions. RESULTS: The informants consistently reviewed care quality by how care supported/ threatened their long-term goals. Personal goals were either implicit or identified by "What matters to you?" Informants expected care to address their long-term goals and placed responsibility for care quality and delivery at the system level. The PC-IC process framework exposed system failure in identifying long-term goals, provision of shared long-term multimorbidity care plans, monitoring of care delivery and goal evaluation. The PC-IC framework includes descriptions of ideal care, key questions and literature references for each stage of the PC-IC process. This first version of a PC-IC process framework needs further validation in other settings. CONCLUSION: Gaps in care that are invisible with event-based quality of care frameworks become apparent when evaluated by a long-term goal-driven PC-IC process framework. The framework appears meaningful to persons with multimorbidity.

Exploring Working Relationships in Mental Health Care via an E-Recovery Portal: Qualitative Study on the Experiences of Service Users and Health Providers.

BACKGROUND: The quality of working relationships between service users and health providers is fundamental in the processes of recovery in mental health. How Internet-based interventions will influence these relationships for persons with long-term care needs, and the measures that can be taken to maintain and enhance working relationships through Internet, is still not well understood. OBJECTIVE: The aim of this study was to gain insights into how service users and health providers experience their working relationships when they are offered the option of supplementing ongoing collaboration with an e-recovery portal. METHODS: In this exploratory and descriptive study, an e-recovery portal was used by service users and their health providers in 2 mental health communities in Norway for at least 6 months and at most 12 months (2015-2016). The portal consists of secure messaging, a peer support forum, and a toolbox of resources for working with life domains including status, goals and activities, network map, crisis plan, and exercises. The portal was owned and managed by the service user while health providers could remotely access parts of the service user-generated content. The participants could use the portal in whatever way they wished, to suit their collaboration. Data from 6 focus groups, 17 individual interviews, and an interview with 1 dyad about their experiences of use of the portal over the study period were inductively coded and thematically analyzed. RESULTS: The thematic analysis resulted in 2 main themes: (1) new relational avenues and (2) out of alignment, illustrated by 8 subthemes. The first main theme is about dyads who reported new and enriching ways of working together through the portal, particularly related to written communication and use of the goal module. Illustrative subthemes are ownership, common ground, goals and direction, and sense of presence and availability. The second main theme illuminates the difficulties that arose when service users' and health providers' expectations for portal use were not aligned, and the consequences of not addressing these difficulties. Illustrative subthemes are initiative and responsibility, waiting for the other, feeling overwhelmed, and clarifications and agreements. CONCLUSIONS: The degree to which dyads benefited from using the e-recovery portal appeared to be mainly associated with the degree to which the dyads' relations were open and flexible before the portal was introduced. For those who experienced frustrations, the portal may have both exposed and added to suboptimal working relationships. Use of the goal module appeared to strengthen the person-centered nature of collaboration. A key question is how health providers balance between enabling service users' greater control over their care, without relinquishing responsibility for the quality of the working relationship, also when using an e-recovery portal. Implications for implementation are discussed.

Identifying Personal Goals of Patients With Long Term Condition: A Service Design Thinking Approach.

Care for patients with long term conditions is often characterized as fragmented and ineffective, and fails to engage the resources of patients and their families in the care process. Information and communication technology can potentially help bridge the gap between patients' lives and resources and services provided by professionals. However, there is little attention on how to identify and incorporate the patients' individual needs, values, preferences and care goals into the digitally driven care settings. We conducted a case study with healthcare professionals and patients participated applying a service design thinking approach. The participants could elaborate some personal goals of patients with long term condition which can potentially be incorporated in digitally driven care plans using examples from their own experiences.

Shifting Practices Toward Recovery-Oriented Care Through an E-Recovery Portal in Community Mental Health Care: A Mixed-Methods Exploratory Study.

BACKGROUND: Mental health care is shifting from a primary focus on symptom reduction toward personal recovery-oriented care, especially for persons with long-term mental health care needs. Web-based portals may facilitate this shift, but little is known about how such tools are used or the role they may play in personal recovery. OBJECTIVE: The aim was to illustrate uses and experiences with the secure e-recovery portal "ReConnect" as an adjunct to ongoing community mental health care and explore its potential role in shifting practices toward recovery. METHODS: ReConnect was introduced into two Norwegian mental health care communities and used for 6 months. The aim was to support personal recovery and collaboration between service users and health care providers. Among inclusion criteria for participation were long-term care needs and at least one provider willing to interact with service users through ReConnect. The portal was designed to support ongoing collaboration as each service user-provider dyad/team found appropriate and consisted of (1) a toolbox of resources for articulating and working with recovery processes, such as status/goals/activities relative to life domains (eg, employment, social network, health), medications, network map, and exercises (eg, sleep hygiene, mindfulness); (2) messaging with providers who had partial access to toolbox content; and (3) a peer support forum. Quantitative data (ie, system log, questionnaires) were analyzed using descriptive statistics. Qualitative data (eg, focus groups, forum postings) are presented relative to four recovery-oriented practice domains: personally defined recovery, promoting citizenship, working relationships, and organizational commitment. RESULTS: Fifty-six participants (29 service users and 27 providers) made up 29 service user-provider dyads. Service users reported having 11 different mental health diagnoses, with a median 2 (range 1-7) diagnoses each. The 27 providers represented nine different professional backgrounds. The forum was the most frequently used module with 1870 visits and 542 postings. Service users' control over toolbox resources (eg, defining and working toward personal goals), coupled with peer support, activated service users in their personal recovery processes and in community engagement. Some providers (30%, 8/27) did not interact with service users through ReConnect. Dyads that used the portal resources did so in highly diverse ways, and participants reported needing more than 6 months to discover and adapt optimal uses relative to their individual and collaborative needs. CONCLUSIONS: Regardless of providers' portal use, service users' control over toolbox resources, coupled with peer support, offered an empowering common frame of reference that represented a shift toward recovery-oriented practices within communities. Although service users' autonomous use of the portal can eventually influence providers in the direction of recovery practices, a fundamental shift is unlikely without broader organizational commitments aligned with recovery principles (eg, quantified goals for service user involvement in care plans).

Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions.

BACKGROUND: The Internet is transforming mental health care services by increasing access to, and potentially improving the quality of, care. Internet-based interventions in mental health can potentially play a role in transitions from biomedical to recovery-oriented research and practices, but an overview of what this may entail, current work, and issues that need addressing, is lacking. The objective of this study is to describe Internet-based recovery-oriented interventions (referred to as e-recovery) and current research, and to identify gaps and issues relevant to advancing recovery research and practices through opportunities provided by the Internet. METHODS: Five iterative stages of a scoping review framework were followed in searching and analyzing the literature. A recovery framework with four domains and 16 themes was used to deductively code intervention characteristics according to their support for recovery-oriented practices. Only Internet-based interventions used in conjunction with ongoing care were included. RESULTS: Twenty studies describing six e-recovery interventions were identified and originated in Australia, Finland, the Netherlands, Norway and USA. The domain supporting personal recovery was most clearly reflected in interventions, whereas the last three domains, i.e., promoting citizenship, organizational commitment and working relationship were less evident. Support for the formulation and follow-up of personal goals and preferences, and in accessing peer-support, were the characteristics shared by most interventions. Three of the six studies that employed a comparison group used randomization, and none presented definitive findings. None used recovery-oriented frameworks or specific recovery outcome measures. Four of the interventions were specific to a diagnosis. CONCLUSION: Research about how technologies might aid in illuminating and shaping recovery processes is in its formative stages. We recommend that future e-recovery research and innovation attend to four dimensions: evidence-supported interventions, new knowledge about personal recovery, values-based approaches and Internet as a facilitator for organizational transformation. The incremental changes facilitated by e-recovery may help propel a shift in mental health care toward recovery-oriented practices.

Using the Consolidated Framework for Implementation Research to Identify Barriers and Facilitators for the Implementation of an Internet-Based Patient-Provider Communication Service in Five Settings: A Qualitative Study.

BACKGROUND: Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge. OBJECTIVE: The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success. METHODS: This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients. RESULTS: Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers' beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies. CONCLUSIONS: The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR's strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions. CLINICALTRIAL: Clinicaltrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6cWeqN1uY).

Middle Managers' Experiences and Role in Implementing an Interactive Tailored Patient Assessment eHealth Intervention in Clinical Practice.

The role of nurse and physician managers is considered crucial for implementing eHealth interventions in clinical practice, but few studies have explored this. The aim of the current study was to examine the perceptions of nurse and physician managers regarding facilitators, barriers, management role, responsibility, and action taken in the implementation of an eHealth intervention called Choice into clinical practice. Individual qualitative interviews were conducted with six nurses and three physicians in management positions at five hospital units. The findings revealed that nurse managers reported conscientiously supporting the implementation, but workloads prevented them from participating in the process as closely as they wanted. Physician managers reported less contribution. The implementation process was influenced by facilitating factors such as perceptions of benefits from Choice and use of implementation strategies, along with barriers such as physician resistance, contextual factors and difficulties for front-line providers in learning a new way of communicating with the patients. The findings suggest that role descriptions for both nurse and physician managers should include implementation knowledge and implementation skills. Managers could benefit from an implementation toolkit. Implementation management should be included in management education for healthcare managers to prepare them for the constant need for implementation and improvement in clinical practice.

The chronic care model and technological research and innovation: a scoping review at the crossroads.

BACKGROUND: Information and communication technologies (ICT) are key to optimizing the outcomes of the Chronic Care Model (CCM), currently acknowledged as the best synthesis of available evidence for chronic illness prevention and management. At the same time, CCM can offer a needed framework for increasing the relevance and feasibility of ICT innovation and research in health care. Little is known about how and to what extent CCM and ICT research inform each other to leverage mutual strengths. The current study examines: What characterizes work being done at the crossroads of CCM and ICT research and innovation? OBJECTIVE: Our aim is identify the gaps and potential that lie between the research domains CCM and ICT, thus enabling more substantive questions and opportunities for accelerating improvements in ICT-supported chronic care. METHODS: Using a scoping study approach, we developed a search strategy applied to medical and technical databases resulting in 1054 titles and abstracts that address CCM and ICT. After iteratively adapting our inclusion/exclusion criteria to balance between breadth and feasibility, 26 publications from 20 studies were found to fulfill our criteria. Following initial coding of each article according to predefined categories (eg, type of article, CCM component, ICT, health issue), a 1st level analysis was conducted resulting in a broad range of categories. These were gradually reduced by constantly comparing them for underlying commonalities and discrepancies. RESULTS: None of the studies included were from technical databases and interventions relied mostly on "old-fashioned" technologies. Technologies supporting "productive interactions" were often one-way (provider to patient), and it was sometimes difficult to decipher how CCM was guiding intervention design. In particular, the major focus on ICT to support providers did not appear unique to the challenges of chronic care. Challenges in facilitating CCM components through ICT included poorly designed user interfaces, digital divide issues, and lack of integration with existing infrastructure. CONCLUSIONS: The CCM is a highly influential guide for health care development, which recognizes the need for alignment of system tools such as ICT. Yet, there seem to be alarmingly few touch points between the subject fields of "health service development" and "ICT-innovation". Bridging these gaps needs explicit and urgent attention as the synergies between these domains have enormous potential. Policy makers and funding agencies need to facilitate the joining of forces between high-tech innovative expertise and experts in the chronic care system redesign that is required for tackling the current epidemic of long-term multiple conditions.

Service users' perspectives in the design of an online tool for assisted self-help in mental health: a case study of implications.

BACKGROUND: The involvement of persons with lived experiences of mental illness and service use is increasingly viewed as key to improving the relevance and utility of mental health research and service innovation. Guided by the principles of Community-Based Participatory Research we developed an online tool for assisted self-help in mental health. The resulting tool, PsyConnect, is ready for testing in two communities starting 2014. This case study reports from the design phase which entailed clarifying very basic questions: Who is the primary target group? What are the aims? What functions are priorities? Roles and responsibilities? What types of evidence can legitimize tool design decisions? Here we highlight the views of service users as a basis for discussing implications of user involvement for service design and research. CASE DESCRIPTION: PsyConnect has become a tool for those who expect to need assistance over long periods of time regardless of their specific condition(s). The aim is to support service users in gaining greater overview and control, legitimacy, and sense of continuity in relationships. It has a personalized "my control panel" which depicts status → process → goals. Functionality includes support for: mapping life domains; medication overview; crisis management; coping exercises; secure messaging; and social support. While the types of evidence that can legitimize design decisions are scattered and indirectly relevant, recent trends in recovery research will be used to guide further refinements. DISCUSSION: PsyConnect has undoubtedly become something other than it would have been without careful attention to the views of service users. The tool invites a proactive approach that is likely to challenge treatment cultures that are reactive, disorder-focused and consultation-based. Service user representatives will need to play central roles in training peers and clinicians in order to increase the likelihood of tool usage in line with intentions. Similarly, their influence on tool design has implications for choice of methods for evaluation. CONCLUSIONS: Starting down the path of service user involvement in intervention design fosters commitment to follow through in the remaining implementation and research phases. While this can be time-consuming and less meriting for researchers, it is probably vital to increasing the likelihood of success of person-centered service innovations.

Patients' reported reasons for non-use of an internet-based patient-provider communication service: qualitative interview study.

BACKGROUND: The adoption of Internet-based patient-provider communication services (IPPC) in health care has been slow. Patients want electronic communication, and the quality of health care can be improved by offering such IPPCs. However, the rate of enrollment in such services remains low, and the reasons for this are unclear. Knowledge about the barriers to use is valuable during implementation of IPPCs in the health care services, and it can help timing, targeting, and tailoring IPPCs to different groups of patients. OBJECTIVE: The goal of our study was to investigate patients' views of an IPPC that they could use from home to pose questions to nurses and physicians at their treatment facility, and their reported reasons for non-use of the service. METHODS: This qualitative study was based on individual interviews with 22 patients who signed up for, but did not use, the IPPC. RESULTS: Patients appreciated the availability and the possibility of using the IPPC as needed, even if they did not use it. Their reported reasons for not using the IPPC fell into three main categories: (1) they felt that they did not need the IPPC and had sufficient access to information elsewhere, (2) they preferred other types of communication such as telephone or face-to-face contact, or (3) they were hindered by IPPC attributes such as login problems. CONCLUSIONS: Patients were satisfied with having the opportunity to send messages to health care providers through an IPPC, even if they did not use the service. IPPCs should be offered to the patients at an appropriate time in the illness trajectory, both when they need the service and when they are receptive to information about the service. A live demonstration of the IPPC at the point of enrollment might have increased its use. TRIAL REGISTRATION: ClinicalTrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6KlOiYJrW).

Pilot users in agile development processes: motivational factors.

Despite a wealth of research on user participation, few studies offer insights into how to involve multi-organizational users in agile development methods. This paper is a case study of user involvement in developing a system for electronic laboratory requisitions using agile methodologies in a multi-organizational context. Building on an interpretive approach, we illuminate questions such as: How does collaboration between users and developers evolve and how might it be improved? What key motivational aspects are at play when users volunteer and continue contributing in the face of considerable added burdens? The study highlights how agile methods in themselves appear to facilitate mutually motivating collaboration between user groups and developers. Lessons learned for leveraging the advantages of agile development processes include acknowledging the substantial and ongoing contributions of users and their roles as co-designers of the system.

Challenges in telemedicine and eHealth: lessons learned from 20 years with telemedicine in Tromsø.

The Norwegian Centre for Telemedicine (NST) has, over the past two decades, contributed to the development and implementation of telemedicine and ehealth services in Norway. From 2002, NST has been a WHO Collaboration Center for telemedicine. In August 1996, Norway became the first country to implement an official telemedicine fee schedule making telemedicine services reimbursable by the national health insurer. Telemedicine is widely used in Northern Norway. Since the late 1980's, the University Hospital of North-Norway has experience in the following areas: teleradiology, telepathology, teledermatology, teleotorhinolaryngology (remote endoscopy), remote gastroscopy, tele-echocardiography, remote transmission of ECGs, telepsychiatry, teleophthalmology, teledialysis, teleemergency medicine, teleoncology, telecare, telegeriatric, teledentistry, maritime telemedicine, referrals and discharge letters, electronic delivery of laboratory results and distant teaching for healthcare personnel and patients. Based on the result achieved, the health authority in North-Norway plans to implement several large-scale telemedicine services: Teleradiology (incl. solutions for neurosurgery, orthopedic, different kinds of surgery, nuclear medicine, acute traumatic and oncology), digital communication and integration of patient data, and distant education. In addition, the following services will also be considered for large-scale implementation: teledialysis, prehospital thrombolysis, telepsychiatry, teledermatology. Last in line for implementation are: pediatric, district medical center (DMS), teleophthalmology and ear-nose-throat (ENT).

A systematic review of research methodology in telemedicine studies.

We conducted a systematic review of 15 relevant databases for articles about telemedicine. After eliminating articles that did not meet the inclusion criteria, 1615 remained for analysis. Three raters coded the articles to assess various theoretical and methodological variables. Only 5% (n = 85) of the telemedicine articles made mention of any theory or paradigmatic approach. Studies commonly reported the objectives (96%) but rarely stated a research question or hypothesis (11%). Randomized selection of the subjects was reported in 11% of patient studies and 4% of studies where providers were the subject. There was a wide range in the number of subjects employed, although the majority of studies were based on sample sizes of less than 100. Only 26% of the studies reported a time frame. Until the telemedicine field adheres to agreed standards of reporting methodological details it will be difficult to draw firm conclusions from review studies.

In the eyes of the beholder: exploring psychologists' attitudes towards and use of e-therapy in Norway.

Norwegian psychologists' use of and attitudes towards e-media such as email and mobile text messaging in interaction with clients (e-therapy) were explored. A two-dimensional scale for measuring attitudes towards e-therapy was developed. A total of 1040 (23%) members of the psychologist association responded to a questionnaire June 2003. Of these, 45% had used e-media in interaction with clients. The mean reported attitude towards e-therapy was neutral, with only 3% of the psychologists feeling that use of e-media between client and therapist is unacceptable. Having a psychodynamic theoretical stance was related to attitudes towards e-therapy. Positive attitude was related to clinical use of email and Short Messages Service (SMS). It appears likely that e-therapy will become more common, and that therapist's attitudes are related to such use.

Use of videoconferencing in Norwegian psychiatry.

We conducted a national survey about access to and use of videoconferencing in Norwegian mental health care. A questionnaire was mailed to 300 institutions, with 113 returned (38%). Attitudes towards videoconferencing were positive. 58 of the respondents had access to videoconferencing equipment. 51 institutions had used videoconferencing in the previous year. Geographical and climatic factors and travel-related strain were predictors of access. Videoconferencing was mostly used for meetings, supervision and lectures, and to a lesser degree was used clinically, with the patient present. 90% of the institutions had experienced videoconferencing as useful. Lack of videoconferencing equipment in collaborating institutions was an inhibiting factor for use. There is a gap between the potential of videoconferencing and its actual utilization in Norway's mental health sector.

Patients who use e-mediated communication with their doctor: new constructions of trust in the patient-doctor relationship.

The introduction of information and communication technology (ICT) into the patient-doctor relationship represents a significant change in modern health care. Communication via computers-e-mediated communication-is affecting the context of patient-doctor interaction, touching core elements of the relationship. Based on data from a qualitative study conducted among Norwegian patients who had used ICT to communicate with their doctors, the authors argue that patients' use of ICT and the element of trust in the patient-doctor relationship influence each other. Furthermore, they contend that patients' constructions of trust in this relationship can be understood in light of basic mechanisms in modern society. The study sheds light on some potential concerns and benefits as communication technology increasingly is integrated into the patient-doctor relationship.