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BackgroundDepression is common and treatable with cognitive behavior therapy (CBT), for example. However, access to this therapy is limited. Internet-based interventions have been found to be effective in reducing symptoms of depression. The International Society for Research on Internet Interventions has highlighted the importance of translating effective Internet programs into multiple languages to enable worldwide dissemination. ObjectiveThe aim of the current study was to determine if it would be cost effective to translate an existing English-language Internet-based intervention for use in a non-English-speaking country. MethodsThis paper reports an evaluation of a trial in which a research group in Norway translated two English-language Internet-based interventions into Norwegian (MoodGYM and BluePages) that had previously been shown to reduce symptoms of depression. The translation process and estimates of the cost-effectiveness of such a translation process is described. Estimated health effect was found by using quality-adjusted life years (QALY). ResultsConservative estimates indicate that for every 1000 persons treated, 16 QALYs are gained. The investment is returned 9 times and the cost-effectiveness ratio (CER) is 3432. The costs of the translation project totaled to approximately 27% of the estimated original English-language version development costs. ConclusionsThe economic analysis shows that the cost-effectiveness of the translation project was substantial. Hopefully, these results will encourage others to do similar analyses and report cost-effectiveness data in their research reports.

Background: The healthcare sector is a complex domain that faces challenges in effectively learning from practices and outcome data. The Learning Health System (LHS) has emerged as a potential framework to improve healthcare by promoting continuous learning. However, its adoption remains limited, often involving only a single clinical department or a part of the LHS cycle. There is a need to gain a better understanding of implementing LHS on a larger scale., Aim: To identify complete implementations of the LHS for providing recommendations into their implementation strategies, success factors, barriers, and outcomes., Methods: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Scopus databases. Data from the included papers were thematically categorized into four primary areas: (1) Scale of LHS Implementation; (2) Implementation strategies and the factors that facilitated the implementation of LHS; (3) LHS outcomes; and (4) Barriers /challenges related to the LHS implementation., Results: We identified 1,279 papers, of which 37 were included in the final analysis. Barriers to implementing LHS included interoperability, data integration, electronic health records (EHRs) challenges, organizational culture, leadership, and regulatory hurdles. Most LHS initiatives lacked discussion on long-term economic sustainability models, and only 16 papers provided objective measurements of performance changes. Drawing from the findings of the included studies, this paper offers recommendations for the effective implementation of the LHS., Conclusion: The establishment of sustainable LHS necessitates several key components. First, there is a need to develop long-term economic sustainability models. Secondly, governance at the national level should promote common Application Programming Interfaces (APIs) across LHS implementations, communication channels to share tacit knowledge, efficient Institutional Review Board, ethical approval processes, and connect various initiatives currently operating independently. Lastly, the success of LHS relies not only on technological infrastructure but also on the active participation of multidisciplinary teams in decision-making and sharing of tacit knowledge., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The Valkyrie project aims to develop a demonstration Federated Electronic Health Record for the use of mental health practitioners in Norway. Information for the record is drawn from existing records in Source Systems operating across primary and secondary care. Recording of information in any such system, in response to a healthcare event, triggers the generation of an Encrypted Token, containing summary metadata about the event, clinical coding indicating its clinical context and a locator that can be used to retrieve the full record of the event from the original Source System. The Valkyrie architecture consists of a number of interlinked Security Domains, each with its own private and public keys, through which the Encrypted Tokens are passed. Each Security Domain performs a specific function on a set of Tokens and only has access to the information within each Token that is necessary to perform that function. This paper describes the structure of the Encrypted Token, the function of each Security Domain and the orchestration of the flow of Tokens through the Domains. Together this allows a user to run a Valkyrie Session, in which they can view the content of a patient record, where all content has been drawn in real-time from heterogenous Source Systems (ISO13606- and openEHR-based) and is destroyed when the session terminates.

Despite learning health systems' focus on including the patients in improving healthcare services, research shows they are still considered participants, not partners. This article aims to provide practical guidance for recognizing and including the Voice of the Patient (VoP) as data in a continuous LHS by describing how the VoP can present itself, how it can be incorporated into the LHS and the barriers and enablers for doing so. Five key domains were identified to consider when including the patient perspective. The use of technology could be a facilitator for patients to provide their perspectives. However, there is a risk of increased health inequity by reducing the VoP of patients with low health or digital literacy.

Learning Health System (LHS) and integrated care are challenged due to a fragmented health data landscape. An information model is agnostic to the underlying data structures and can potentially contribute to mitigating some of the gaps. In a research project, Valkyrie, we are exploring how metadata can be organized and used to promote service coordination and interoperability across levels of care. An information model is viewed as central in this context and as a future integrated LHS support. We examined the literature regarding property requirements for data, information and knowledge models in the context of semantic interoperability and an LHS. The requirements were elicited and synthesized into five guiding principles as a vocabulary to inform the information model design of Valkyrie. Further research on requirements and guiding principles for information model design and evaluation are welcomed.

This study uses three case studies to investigate how the installed base affects Electronic Health Records (EHR) implementation in European hospitals: i) transition from paper-based records to EHRs; ii) replacement of an existing EHR with a similar system; and iii) replacing existing EHR system with a radically different one. Using a meta-analysis approach, the study employs the theoretical framework of Information Infrastructure (II) to analyze user satisfaction and resistance. Results show that the existing infrastructure and time factor significantly impact EHR outcomes. Implementation strategies that build upon the current infrastructure and offer immediate user benefits yield higher satisfaction rates. The study highlights the importance of considering the installed base and adapting implementation strategies to maximize EHR system benefits.

Learning Health Systems (LHS) are challenged by fragmented health data. In Valkyrie, information models (IM) are explored as translators for the underlying, fragmented data structures and can potentially extend to support a future LHS. In this paper, a literature review was performed to search for property requirements for semantic interoperable IMs in the context of an LHS. The literature was examined and property requirements elicited in the context of an LHS.

The high investments in deploying a new Electronic Health Record (EHR) make it necessary to understand its effect on usability (effectiveness, efficiency, and user satisfaction). This paper describes the evaluation process related to user satisfaction over data gathered from three Northern Norway Health Trust hospitals. A questionnaire gathered responses about user satisfaction regarding the newly adopted EHR. A regression model reduces the number of satisfaction items from 15 to nine, where the result represents user EHR Features Satisfaction. The results show positive satisfaction with the newly introduced EHR, a result of proper EHR transition planning and the previous experience of the vendor with the hospitals involved.

Background: Patient accessible electronic health records (PAEHR) hold the potential to increase patient empowerment, especially for patients with complex, long-term or chronic conditions. However, evidence of its benefits for patients who undergo mental health treatment is unclear and inconsistent, and several concerns towards use of PAEHR emerged among health professionals. This study aimed at exploring the impact of PAEHR among mental health professionals in terms of patient-provider relationship, changes in the way of writing in the electronic health records and reasons for denying access to information., Methods: In-depth qualitative interviews with health professionals working in two mental health outpatient clinics at Helgelandssykehuset in Northern Norway, one of the first hospitals in Norway to implement the PAEHR in 2015. The interviews were conducted by phone or videoconferencing, audio recorded and transcribed verbatim. Data were analyzed by a multidisciplinary research team using the Framework Method., Results: A total of 16 in-depth qualitative interviews were conducted in April and May 2020. The PAEHR implemented in Norway was seen as a tool to increase transparency and improve the patient-provider relationship. The PAEHR was seen to have negative consequences only in limited situations, such as for patients with severe mental conditions, for child protective services when parents access their children's journal, or for patients with abusive partners. The functionality to deny access to the journal was used rarely. A more common practice for making information not immediately available was to delay the final approval of the notes. The documentation practices changed over the years, but it was not clear to what extent the changes were attributable to the introduction of the PAEHR. Health professionals write their notes keeping in mind that patients might read them, and they try to avoid unclear language, information about third parties, and hypotheses that might create confusion., Conclusions: The concerns voiced by mental health professionals regarding the impact of the PAEHR on the patient-provider relationship and practices to deny access to information were not supported by the results of this study. Future research should explore changes in documentation practices by analysing the content of the electronic health records., (© 2022. The Author(s).)

Background: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom., Methods: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683., Findings: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components., Interpretation: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package., Funding: Japan Society for the Promotion of Science., Competing Interests: Declaration of interests TAF reports grants from Japan Society for Promotion of Science, during the conduct of the study; grants and personal fees from Mitsubishi-Tanabe, personal fees from MSD, grants and personal fees from Shionogi, outside the submitted work; a patent 2018-177688 concerning smartphone CBT apps pending; and an intellectual properties for Kokoro-app licensed to Tanabe-Mitsubishi. AC reports personal fees from Italian Network for Paediatric Trials and CARIPLO Foundation; and grants and personal fees from Angelini Pharma, outside the submitted work. EGO reports personal fees from Angelini Pharma, outside the submitted work. PCa reports personal fees from Osmond Foundation and Sandoz, outside the submitted work. JD is co-owner of Behavioral Activation Tech LLC, a small business that develops and evaluates mobile app-based treatments for depression and co-occurring disorders. DDE has served as a consultant to or on the scientific advisory boards of Sanofi, Novartis, Minddistrict, Lantern, Schoen Kliniken, Ideamed, German health insurance companies (BARMER, Techniker Krankenkasse), and a number of federal chambers for psychotherapy; is a stakeholder of the Institute for health training online (GET.ON), which aims to implement scientific findings related to digital health interventions into routine care. NRF is an employee of AbleTo. JPK reports grants and personal fees from Servier; personal fees from Beltz, Elsevier, Hogrefe, and Springer, outside the submitted work; funding for clinical trials (German Federal Ministry of Health and Servier); payments for presentations on internet interventions (Servier); and payments for workshops and books (Beltz, Elsevier, Hogrefe, and Springer) on psychotherapy for chronic depression and on psychiatric emergencies. BM is an employee of GAIA AG. DCM reports personal fees from Apple, Pear Therapeutics, and Otsuka Pharmaceuticals and has an equity interest in Adaptive Health, outside the submitted work. JMM is supported by a Wellcome Trust Grant (104908/Z/14/Z). SN is an employee of GET.ON Institut. DR is an employee of SilverCloud Health. LBS is an employee of Influents Innovations. PZ reports grants and non-financial support from Techniker Krankenkasse (German public health insurance company), outside the submitted work. CK reports personal fees from Oberbergklinik and Servier; and grants and non-financial support from Techniker Krankenkasse, outside the submitted work. MH reports grants and non-financial support from Techniker Krankenkasse, outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Importance: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them., Objective: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information., Data Sources: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019., Study Selection: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization., Data Extraction and Synthesis: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression., Main Outcomes and Measures: Patient Health Questionnaire-9 (PHQ-9) scores., Results: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9., Conclusions and Relevance: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.