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Table 1 Description and examples of themes

From: Implementation of eMental Health care: viewpoints from key informants from organizations and agencies with eHealth mandates

Theme Description of the Theme (D) and Example of Statements (E)
Capacity
 Broadband D: Heterogeneity in broadband access
E: “So broadband speed and availability of broadband around the country, it varies, so a lot of people say get it online, get it online. I think that works if you’re in cities, with good technology and there are some…where getting access is really difficult.”
 Change D: Speed at which technology is evolving
E: “With [technology] moving fast, the strategies might become outdated but also if it’s not part of a big change program, then I guess the strategy could be ignored and there could still be surprise pop-ups or emerging things that take it in a different direction.”
 Credibility D: Uncertain credibility about how technology works
E: “So in that sense, yes we might say that a certain treatment, based on CBT [cognitive behavioural therapy] for what I know of is effective, but we actually do not really know why and so that’s a bit of the scary part.”
 Cyber Security D: Privacy protection issues around personal health information
E: “There needs to be some really clear guidelines or mandates, legislation that states exactly, if there are going to be mental health conversations occurring, who is able to look at that outside of the practitioner and the client?”
 Engagement D: Patient engagement with eHealth is low
E: “Interestingly I think the barriers are not technological or even resource based. I think the barrier is actually a much more ancient problem and that’s getting people to care enough about their health to do something.”
 Insecurity D: Insecurities about work obsolescence and employment
E: “I think that there’s potentially a bit of professional insecurity there as well. You know, with the availability of these programs, it’s kind of saying, you invested all these years in your own professional training and now there’s a program that can do the job that you did without any need for you anymore.”
 Interference D: How technology changes and ‘interferes’ with patient relationship
E: “…not wanting the technology to kind of take the human element out of clinical treatment and so you get a lot of different kind of attitudinal and kind of negative reactions and a lack of openness in some cases.”
 Knowledge Gap D: Lack of knowledge about existence and effectiveness of available eHealth technologies
E: “I think the biggest barrier is just a lack of knowledge that these things actually exist and that in many cases they can be as effective as face-to-face treatment and you know. I think it’s just a matter of there being a bit of a gap of knowledge about these things existing.”
 Literacy D: Levels of computer literacy for patients and providers
E: “Some providers and some decision makers are early adopters and others are, you know, very much just kind of comfortable with their practices and don’t really see value or see that an introduction of technology is more troubling than helpful and for a number of different reasons, you know, it can be just not wanting or not having the capacity to learn a new system.”
 Marketing D: How eHealth technologies are marketed and promoted
E: “We need to be able to tell the story of those successes so that more and more people become aware of the potential of this resource.”
 Product D:Treating eHealth as products as opposed to services
E: “I think that organizations are really going to have to take this on and then I think that people who are interested in the development of eHealth are going to have to think about how they…how they partner with those organizations to be able to build eHealth interventions that are kind of tailored to the different problems that those organizations encounter.”
 Workflow D: How technologies change provider workflow
E: “If the technology adds more work (paperwork, bureaucracy, etc.) to the employee that’s it. I mean if it’s not part of the clinical workflow, it doesn’t matter what is it, it’s never going to work”
Motivation
 Big Data D: Ability to use data analytics to inform practice (at patient or public health level)
E: “I think improving the records keeping and sharing of data, I think has the potential to change things quite dramatically but in terms of allowing the health service…to look after people more effectively because they’re able to get the picture about what’s going on, but then there’s a big trend…at the moment for the idea of giving patients access to their own information, which is sort of happening, albeit quite slowly, and I think we really see this within our work as something that service users in mental health really want.”
 Blended Care D: Role of eMental Health in stepped and blended care
E: “Increasing access way beyond the capacity of parent services requires us to looks at blended care models and that’s really where online technology can increase capacity of our health systems.”
 Cost/Benefit D: Economic benefits of eMental Health and costs of delivery
E: “The potential for spending on health way outweighs the number of dollars available, so I think it’s thinking about how we can use it in a smart way. I think the dilemma is finding a balance between finding a place for it, but not shortcutting things so that we don’t just say, oh we don’t need therapists anymore because it’s cheaper”
 Empowerment D: Empowering patients to engage in managing their own care
E: “We need to break down the barriers to sharing information when the client wants it shared and have it not mandated by government.”
 Electronic Medical Record D: Role of electronic health records in eMental Health care
E: “Implementation of meaningful use around electronic health record…I think that’s definitely one facilitating eMental Health strategy and you know, we’re starting to see mental health and behavioural health indicators added into EHR [electronic health record] systems more and more, so that’s one piece of it.”
 Unreached D: Providing access to eMental Health care for people who might otherwise not have it
E: “There’s way more people who could benefit from assistance than we have the resources to help in person and a lot of people, and the research bears this out…it’s having that access to a professional online that makes the difference.”
 Wait Times D: Improving health system inefficiencies with shorter wait times
E: “Because the reality is people are waiting really long times to get care right now and so we have to think about a kind of system transformation that includes technology”
Opportunity
 Alignment D: Align programs and initiatives with policy objectives
E: “The only way bureaucrats like to fund programs, initiatives, if it meets their policy objectives and a lot of times when I am sitting in an environment where I'm simply leading innovation and driving innovation, I don’t think of policy right off the bat, because it’s not transparent”
 Endorsement D: Develop guidelines to support superior projects
E: “Some [eHealth technologies] are really superior and some aren’t very good, let’s be frank about it. And it’s really trying…what would be helpful is teasing out and supporting the ones that are very good.”
 Funding D: Need for sustainable funding
E: “I mean that’s the only way I can think of it being really robust is that, you know, there’s policy statements that support it as an integral part of the health care system and then there’s funding directed to it because if there’s not funding directed to it, it just becomes a bit on the fringe.”
 Incentives D: Lack of incentives for adoption and use
E: “Give professionals more time to get used to a program. So you could reward their attention to adopt a new way of working by giving them more time off or giving them more incentives to get used to the new method.”
 Infrastructure D: Technology tools (software, hardware) that allow eMental Health delivery
E: “The approach we’re taking is that if we’re building stuff, we’re building it on open source so you don’t have that lock in and you can reuse and repurpose it. So we’re trying to build a sustainable approach, which means you don’t have to get locked into a provider each time.”
 Licensing D: Absence of national licensing system (United States specific)
E: “For instance, I know that you can’t treat patients across states, so because of different legislations that may apply. So your license doesn’t apply to the other state, even though you could treat patients in other states over the Internet.”
 Mandate D: Guidelines, mandates and legislation
E: “There needs to be additional policy, additional clarification around the regulatory aspects of…and confidentiality aspects of using eHealth tools, either within or outside of the clinical setting.”
 Networks D: Build stronger networks between academics, professionals, health providers and end users
E: “I feel there just seems to be such a gap between what’s happening in the academic world and what’s happening at the community, kind of delivery level and also what people are saying they need. We need all components involved: academics, end users, health providers, etc.”
 Partnership D: Encourage public-private partnerships
E: “Working with the private sector because they’re way ahead of us in lots of ways and in other ways they’re not because [academics] have the content knowledge, we have the experts but they have the resources and the technology.”
 Patient Cost D: Coverage of eHealth services
E: “The government and the insurance companies need to recognize that the proven technologies should be paid for. They should be part of a coverage that a person has on their insurance program.”
 Reimbursement D: Unclear reimbursement model for patients and providers
E: “If you can’t get it reimbursed, if people have to pay for these kinds of treatments themselves, they won’t come at all because if you can get something for free, face-to-face, why should you pay for it online?”