Abstract
For this project, we have used new technologies to create a new channel of communication between doctors and patients in the treatment of mental disorders. We have created a web application using an adaptable design accessible from any mobile device, which allows doctors to adapt their patients’ therapy to real-time knowledge of their current condition. In turn, patients can express their mood state with respect to the component elements of their therapy.
Keywords
Introduction
Mental illnesses rank among those that cause the greatest impact to the patient and their family. One of the main shortcomings in the treatment of mental disorders is the lack of real-time information on the status of the patient. Through this project, we aim to provide a new channel of communication between doctors and patients, using the Internet and new technologies, to facilitate the adaptation of patient therapy to their needs by receiving real-time updates on their condition. These real-time updates on the mood state of the patient in relation to the component elements of their therapy will enable the doctor to perform an immediate adjustment to the therapy to improve patient outcomes.
This project was developed in the context of the public health system of the Autonomous Community of the Canary Islands. No similar tool is currently used by this health service. Only one system, the ‘drago system’, is used to obtain information on scheduled visits and view clinical and medication history.
In the private sector, there are various psychological care websites (none of them psychiatric) offering online emotional care (entire treatment) or a first consultation method. Email is also used frequently as a tool for monitoring and/or virtual consultations between two appointments that are very far apart.
Currently, various techniques based on new technologies are being employed in the field of health care. These include, specifically, the field of cognitive software, specialised in stimulating and enhancing mental skills associated with the processes of learning, visual memory or linguistic stimuli. This type of software permits the tests to be configured to parameters defined by the patient’s needs, taking into account aspects such as modality (visual or audible instructions), level of difficulty or response time. Some examples of cognitive software are telepsychology, virtual reality, augmented reality, video games, telecare or robots.
Related works
With the increasing use of Internet and information and communications technology (ICT) in recent years, it is natural to observe the union of health scientists with computer scientists in the research and development of technological solutions that advance the current state of global health.1,2 Indeed, a great deal of significant literature has already been published on the application of ICT to help treat and monitor people with mental disorders. Health information technology (HIT) and its subset, ICT, are increasingly being applied to facilitate communication between health-care provider and caregiver. 3 Following this line of research, we can highlight the work of Richards, 4 who reports on the use of the online counselling service at Trinity College Dublin, including its uptake and usage, the issues and benefits of online counselling to students and whether clients are satisfied with their experience of online counselling. Colder-Carras 5 examined the extent to which patients at an inner-city community psychiatry clinic had access to ICT and how they used those resources. They concluded that a majority of patients in that community psychiatry clinic sample use ICT. Greater access to and use of the Internet by those with mental illness has important implications for the feasibility and impact of technology-based interventions. Timpano et al. 6 focused on the use of telehealth in neurological practice, highlighting the potential benefits of also applying information and communication technology to psychosocial and educational aspects of the treatment of neurological diseases. They concluded that one of the main advantages in the application of ICT solutions to neurology is the ability to build relationships across families and care systems. Indeed, not only are the client and the health-care professional linked together but also others within the client community, such as family and other specialists and physicians. This ‘social network’ allows a multiple perspective evaluation: all the parties meet together and work towards a treatment plan based on specialist recommendations. Meiland et al. 7 explain the results of the European Rosetta Project. In this project, a user participatory design was adopted to develop an integrated system, which combines three previously developed assistive technology systems and is, in close cooperation with the target groups, adjusted to their needs and wishes. The three previously developed systems are the COGKNOW Day Navigator (CDN), 8 the EMERGE system 9 and the Unattended Autonomous Surveillance (UAS) system. 10 The functionality most often mentioned as relevant and useful by persons with dementia was help in cases of emergencies (with movement sensors). The functionalities most often preferred by carers were support with navigation outdoors and the calendar function. Other studies, such as those carried out by Lopez, 11 Mateu-Mateu and Navarro-Gómez 12 and Hu and Naseer, 13 show the advantages of ICT for social integration and clinical improvement of people with severe mental disorders (SMDs).
There are a huge number of ICT tools for specific mental disorders. Lozano et al. 14 and Charitaki 15 studied software tools for teaching emotions to students with autism spectrum disorder. Romdhane et al. 16 presented an automatic video monitoring system for assessment of Alzheimer’s disease symptoms, and Robert et al. 17 gave some important recommendations for ICT use in Alzheimer’s disease assessment. Välimäki et al. 18 evaluated the effects of ICT in patient education and support for people with schizophrenia, and Van der Krieke et al. 19 presented a usability evaluation of a web-based support system for people with a schizophrenia diagnosis. There are also a lot of game tools to help in the diagnosis or treatment of different mental disorders. Tárrega et al. 20 proposed a videogame as an additional therapy tool for training emotional regulation and impulsivity control in severe gambling disorder, and Bagga et al. 21 discussed a framework for designing games for cognitive assessment. Some studies deal with the use of mobile phones as medical devices in mental disorder treatment. Gravenhorst et al. 22 discussed how mobile phones can support the treatment of mental disorders by (1) implementing human–computer interfaces to support therapy and (2) collecting relevant data from patients’ daily lives to monitor the current state and development of their mental disorders.
However, although there are many specific tools to aid the treatment of mental disorders, our article presents a complete, comprehensive tool without focusing on one specific pathology. The aim is to design a complementary, cross-cutting tool that makes it possible to
Establish continuity of care;
Address time constraints;
Bridge geographical barriers, a particularly critical aspect in the geographical context in which we propose to implement the system: the Canary Islands, where most of the specialised services are centralised on the two main islands (Gran Canaria and Tenerife), services which are, in many cases, non-existent on the smaller islands (Lanzarote, Fuerteventura, La Graciosa, La Gomera, El Hierro and La Palma).
Furthermore, in section ‘Case of use’, we describe the structure of the Canary Islands health system, where we aim to implement the proposed system and the metrics that we intend to use to evaluate its usefulness and impact once implemented.
eHealth
eHealth represents a change in our approach to health care. It is a technology at the service of everyone, so we can live a healthier life. We can monitor our vital signs and keep track of our treatments for better therapy compliance and even use remote medical consultation. This change is enabling data collection which, when analysed, will offer a more accurate and reliable diagnostic and therapeutic approach.
Mobile applications and new online communication tools are undergoing exponential growth as we seek immediate answers to all our health queries. The technologies that have been adopted to improve doctor–patient communication have brought some benefits, although they have also introduced new medical–legal and patient privacy risks.
One of the main advantages of eHealth is access to reliable quality information that helps resolve general queries about the health of the patient when they arise. The patient becomes the protagonist of the process and is able to store all information on his or her condition in his or her own medical history that he or she can share with the therapists.
Another advantage is the ability to stay in contact with therapists with waiting times that are shorter than under the current system. It reduces delays and unnecessary travel for all kinds of administrative tasks and consultations that can now be done online.
Finally, it facilitates learning so that the patients become increasingly autonomous in caring for their own health and for that of their dependants. Some of the advantages of eHealth are speed, low cost, asynchrony, accessibility, permanence, the absence of barriers and a reduction in unnecessary visits.
Design and development
In the analysis phase, we identified three different types of actors who interact with the web application. The most general user type is the ‘unregistered user’, all those who are not ‘registered users’. Within the registered users, we have the roles ‘Doctor’ and ‘Patient’:
Unregistered user. Users who access the application without identifying themselves. They may register if they want to see a doctor or login to identify themselves and access the corresponding features and be they doctor or patient.
Doctor. Uses the features provided by the Doctor module; has a profile with personal, professional and login information; is responsible for creating patient user profiles; and organises patient information, managing their history, treatment and clinical information.
Patient. Uses the features provided by the Patient module, can edit login information and some basic fields in their medical history through their profile and responds to events generated by his or her treating doctor and can generate others in turn through his or her emotional diary.
The design of the web application separates the system functions into three modules, each module covering the actions that can be performed by each user. The modules that have been developed are as follows:
Application. Contains the public part of the web application; displays information on the project features and some mental illnesses and their effects on the family; and has access to login area and, for doctor users, user account creation.
Doctor. Contains the private part intended for doctor users; permits administration of all information pertaining to patient records, clinical history and emotional diary; and contains psychological test editor.
Patient. Contains the private part intended for patient users. In this module, the patient can manage elements of his or her emotional diary and send feedback on elements of his or her therapeutic adherence (Figure 1).
Patient user functions.
Information access control
Since this web application handles highly sensitive data, we chose to use various systems that guarantee the privacy of patients’ personal data and their treatments. These systems include restricted access via personal login that asks the users to identify themselves when accessing the application’s database and an access control list (ACL).
The ACL enables us to define a range of user roles and grant or remove permission to access certain parts of the application. This means that the list is a tool that controls information access for the corresponding user. To properly define the ACL, we first need to clarify two concepts:
Resources. Access-restricted objects;
Roles. Subjects that will request access to a resource.
In simple terms, roles request access to resources. A well-defined ACL will enable an application to control which roles have access to each resource.
This web application has three types of users:
Visitor. Users who have not identified themselves on the system and can only access public content;
Doctor. Role assigned to doctors, who can access the functions available in the Doctor module;
Patient. The role assigned to the patients, who can access the functions available in the Patient module (Figure 2).
ACL code.
Psychological test editor
One of the most salient features of this project is the psychological test editor that allows the doctor to create and modify tests adapted to the needs of each patient. With this editor, the doctor can create tests with various types of questions: simple, yes or no, true or false, relationship or cause or Likert scale. The editor has other features such as creating private entries for the doctor or a system to evaluate the test results, either as a whole or the individual answer to each question.
After the more general pre-diagnostic tests, and after assessment and diagnosis of the patient, this tool may be used to ascertain the patient’s new needs that result from the changes brought about by adherence to a therapy. Being able to measure progress on a regular basis supplies us with information on these changes, and we can also, therefore, provide the patient with this same information (goals achieved and those yet to be attained). Furthermore, the language of the tests may be adapted to the mental capacity of the patient, adapting them to their reality.
To obtain the parameters for the online psychological test editor, we drew on the work by Bobes et al., 23 which contains a compilation of all test types used in psychology as well as their objectives and types of questions used. By studying the questionnaires in this book, we gained an idea of the kinds of questions required to create the tests. Table 1 shows the questionnaires that were analysed and the objectives that they pursue.
Types of questionnaire analysed.
PTSD: post-traumatic stress disorder; MALT: Munich Alcoholism Test; AUDIT: Alcohol Use Disorders Identification Test.
Bibliotherapy
The therapeutic function resides in the healing, restorative and preventive effects of reading. Reading encourages a change of individual behaviour not only at the time of the crisis but also in individual routines. It assists the patient in developing the faculty of self-criticism and prompts a desire to make changes to help them adapt to their customary environment. Autonomous learning linked to experience is what, therefore, motivates them to constantly update and review their conduct and its repercussions beyond intentions without defined goals or personal statements and situations.
Workshop monitoring
Workshop monitoring is another tool for improving the behaviour of individuals engaging in activities to achieve the objectives proposed in therapy (socially proactive, search for alternative solutions, time management, information about toxic products, etc.).
Doctor–patient communication model – implementation
Doctor–patient communication conforms to several models that define how to handle conversations involving situations related to the patient’s health and how to make them see the reality that surrounds them.
To carry out these communications, various models have been defined that determine how the doctor achieves this reality approach when establishing contact with the patient.
Following these models, we can define this relationship as a meeting between two people, one of them the patient who needs help to recover his or her health and the other the doctor who is trained to provide this help. This relationship depends on the cultural, scientific and technical circumstances of each time and place.
Of all the models of doctor–patient communication, we have selected the Veatch 24 model for the purposes of this project. This model considers that the contract to be established is a consensus or agreement based on the theme that motivates the meeting: the health of the patient.
The diagnosis is made by the doctor, but the responsibility for the therapy is shared. There is respect for the autonomy of the patient who is informed in order to be able to make an informed choice.
This model is the one that seems best suited to the nature of this project; when attending therapy, doctor and patient can agree on the steps to be taken, but the doctor cannot force the patient to follow them as directed. Another significant aspect of this model of communication is the importance that is given to the feedback that the patient gives to the doctor with respect to the therapy, an essential aspect in reinforcing the rationale of the project: real-time therapy adjustments according to the patient’s needs.
Communication models follow several phases as the therapy progresses, according to renowned doctor Laín Entralgo. 25 These phases are summarised as follows:
Cognitive moment. Stage at which the link between doctor and patient is established. The interest that binds both sides of this relationship is represented by the desire to recover health, but the person suffering from the condition is the patient, not the doctor.
In this interaction, the doctor employs scientific knowledge to name, describe and set out what ails the patient; at the same time, the patient contributes with his or her ideas and emotions. The result is a medical diagnosis.
Operative moment. Refers to the therapeutic activity of the doctor, from empathic listening at the start until the final send-off.
Therapeutic action begins when the patient decides to seek medical advice, before the actual appointment, and does not end until final discharge. The moment of diagnosis is also therapeutic.
Affective moment. The author argues that there are two forms of affectional bonding between the doctor and the patient.
Medical camaraderie. Both the doctor and the patient seek to remedy the condition and achieve good health but with little personal commitment. The patient, if cured, is grateful and becomes emotionally attached to the doctor, albeit not very deeply, because of the service provided.
Medical friendship. Characterised by trust whereby the patient can confide their innermost thoughts and emotions in the doctor.
The most important element for the doctor is the principle of bioethics: the intention to ‘do good’ for the patient, bearing in mind that the sought-after good is their health. The relationship in this case is both technical and affectional.
In this project, we may observe the following three stages described above:
Cognitive moment. Applicable to all communication between doctor and patient. Recovery of the patient’s health via the doctor’s knowledge is enhanced whenever communication is established through the application, primarily through the doctor’s messages and feedback from the patient as they follow the steps indicated by the doctor during therapy.
Operative moment. Developed throughout the patient’s therapy, from the first contact between doctor and patient, through the use of the application as a tool during therapy, to patient discharge and the end of the relationship with the doctor.
Affective moment. Reflected in the use of the application itself, as the aim to improve communication between doctor and patient presupposes an intention between both parties to work on the affectional aspect of therapy. This improvement in communication between doctor and patient develops the spirit of both medical camaraderie and medical friendship, as described above.
The following sections will describe aspects of the application that reflect and use the aforementioned doctor–patient communication model.
Emotional diary
This is another tool that is normally included in a wider package of measures to help patients express their emotions in their daily lives. The aim of this diary is to enable the patient, after a period of learning in which they relate emotions to physical stimuli and cognitions, to be able to recognise their own emotions, both primary and secondary. They will thus be able to, if need be, curb ill-adapted conduct and will learn to redirect their thoughts and put into practice learnt relaxation techniques to control and stimulate their own impulses in order to better adapt to the situation. The goal is to learn how to channel expressions of emotion and feeling in a healthier way by understanding, managing and using them to grow psychologically.
The emotional diary is a very useful tool to complement the therapy of a patient suffering from a mental disorder. It is an extra resource that helps to resolve certain problems that are emotional or have their origins in emotion. The purpose of this record is not to provide a solution to every feeling but to identify it and give it its exact name (Figure 3).
Primary emotions.
The emotional diary aims to elicit pure emotional expression, as this allows patients to better understand themselves in order to build self-assurance, reduce their fears and anxiety in new situations, learn to resolve problems and understand how to identify and self-regulate emotions.
Writing down these experiences will increase the patient’s perception of different situations and the correct way to deal with them because it will enable them to recognise what they are feeling in certain situations and create behavioural patterns that they will then analyse so that they can decide how to act or react. It also provides the doctor, over time, with relevant information about the patient’s evolving management of their emotions.
To reflect the emotional diary on the web application, the patient is provided with a range of features to express their mood state using three methods:
Write a diary entry. As if it were a physical diary, the patient has a section in which they can type up an entry in their emotional diary. As with a normal diary, the patient can add the date, title and development to the diary entry.
Create new mood state. Another addition to the emotional diary is an indication of mood state. When the patient suffers any mood change and wants to communicate it to the doctor, they can do so in this section. Options are available here to indicate when the mood arose, give it a name, define what primary emotion most adequately describes their emotions, describe its intensity and explain the whole episode by reporting it.
Create new mood state associated with an image. The patient is provided with this alternative way of describing a mood state. In this case, a mood is also described with the aforementioned features, but the explanation is reinforced by uploading an image. This caters to those patients who cannot write, or who are disorientated and have difficulties maintaining a coherent conversation due to the stage of their illness or their life situation, or for whom it is tedious and arduous to name or label their emotions. They are, however, capable of recognising their physical symptoms and the thoughts associated with the various mood states. They are provided with simple drawings that reflect them (Figure 4).
Mood state symbols.
Guidelines to remember
There is no point in keeping an emotional diary if the doctor does not adjust the therapy after seeing the reactions of the patient. It is, therefore, important that the doctor develops guidelines to remember, which will enable the patient to recognise the emotions or situations that trigger an emotional crisis. Thus, they will be able to adequately channel events. Using these behaviour guidelines, the patient will be able to act correctly when these delicate moments arise and overcome their emotional deficiencies.
Therapeutic adherence
In addition to following medical advice, a number of changes in patient habits, lifestyle, thoughts and abilities are required to increase the efficacy of the treatment and obtain a better quality of life as the outcome. This combined approach is called ‘therapeutic adherence’.
The web application project seeks to group all elements of the patient’s therapy in one place. All elements of the patient’s therapy can be managed under the label of therapeutic adherence (consultations, medication, tests, workshops and bibliotherapy).
Feedback
In all the aforementioned sections, once the doctor has read the patient’s message, they can send a reply if they consider it appropriate. The patient, in turn, can send a message to his or her doctor about any element of his or her therapy whenever necessary. Both actors will be notified by the system of any entry or reply.
Feedback on therapies, visits and medication improves ongoing doctor–patient communication between appointments, which are often too far apart. It gives continuity to the information and consequently allows the treatment to be adapted to the changing needs of the patient. Moreover, a closer bond is forged with the family social unit (primary caregivers) which generates information that is useful when making timely changes to the therapy.
Event system
All this therapy monitoring would be impossible without a system that supports real-time communication between doctor and patient.26,27 To this end, we have developed an event system that notifies users if they have any pending action to attend to. These notifications are displayed on the user’s main screen. When a user creates a new action, an event is automatically generated together with a notifying email (Figure 5).
Controllers involved in the creation of an event.
When the main controller – either the Doctor or Patient module – creates a new activity, it invokes the associated controller, and this second controller is responsible for creating the activity in the database, invoking the controller that manages the events and receives the emails.
As shown in Figure 5, if the doctor creates a new medication for the patient, the action is inserted into the medication table of the database and a medication type event is generated, and if the patient has notifications enabled in his or her profile, an email with information about the event is sent to him or her. Once the process is finished, we return to DoctorController, which will display the patient’s list of medications with this latest medication already recorded.
The status of an event may vary over time, following a ‘now the ball is in your court’ approach, that is, when a user generates an event with an action, for them the status of this event is ‘terminated’, while the other user now has a ‘new event’ status. The aim is that when a doctor or patient generates an activity, the event informs the other so that they know they should attend to it (Figure 6).
Event system flow.
This method has been developed with two status fields on the table that stores the events in the database: one reflecting event status for the doctor and one for the patient. An illustration of the changes that an event may undergo during use of the web application is shown in Figure 6; in this figure, it is the doctor who creates a new activity.
Interface
The interface is designed to be simple and user-friendly. The main actions that the user can perform are located in a horizontal bar at the top of the screen. Overloading the screen with elements will be avoided, while maintaining the maximum amount of information in the horizontal space. To avoid the user having to scroll vertically whenever possible, several systems have been designed:
Paginated tables. Non-detailed information is displayed in paginated tables with up to five rows. If the table has more entries, these will be moved to a new page (Figure 7).
Search filters. The user can filter search results through a system of filters. All they need to do is select the desired filter and apply it to their search (Figure 8).
Tab system. The information is divided by a tabbed browsing system. Each tab represents an information category, hiding the other categories until the user wishes to consult them. Each time the user returns from a detailed view of an event, the system remembers the last selected tab (Figure 9).
Paginated tables.
Search filters.
Tab system.
Case of use
The aim of the tool that we have developed is to improve mental health care in the Canary Islands. More specifically, the tool is intended to obtain more and better patient information through improved communication between the patient and the doctor. Although the tool may be used with patients capable of managing ICT resources, it could be a particularly effective resource for young patients because of the interest that this sector of the population shows in ICT tools. To contextualise the impact of the tool, we have provided an overview of the organisation, resources and activities of health-care provision for mental disorders in the public health network of the Canary Islands. We then propose a case of use for the tool and the metrics to be used to assess the impact of the tool in improving patient care, and we consider a proposal for a pilot project to assess its impact.
Mental health care in the Canary Islands is provided by a network of centres, of which there are two types: outpatient units and inpatient units. The use of our proposed system makes the most sense in outpatient units; hence, the following brief description of their structure and information relating to relevant activities.
Mental health care in the public health system of the Canary Islands: outpatient units
Outpatient units are distributed throughout the Canary Islands, and there are currently 31 such units. This network of centres covers 100 per cent of the population, once they have been seen by the corresponding primary care centre. These units are, in turn, divided into three types:
Community Mental Health Units (CMHU). These units serve the entire population, and there are 24 such units.
Community Child Mental Health Units. These are specific units to treat patients under 18 years. They have specific teams of physicians, and there are five units of this type.
Child Day Hospitals. Currently, there are two units of this type, consisted of psychiatrists, psychologists, paediatricians specialised in neuropsychiatry, nurses, nursing assistants, occupational therapists, psychomotor specialists, social workers, special education teachers, porters and administrative assistants.
With regard to human resources in mental health outpatient units, these are organised into multidisciplinary teams. Table 2 shows the number of professionals assigned.
Human resources assigned to mental health outpatient units of the public health system in the Canary Islands.
With regard to the provision of care in these units, Table 3 shows activity for the Community Mental Health Units during 2011–2015. The most prevalent diagnoses in these units in 2015 are as follows:
Schizophrenia and other psychoses;
Affective disorders;
Anxiety and somatic symptom disorders;
Behavioural and emotional disorders with onset usually occurring in childhood and adolescence.
Provision of care related to mental health in outpatient units of the public health network of the Canary Islands, since 2011.
Mental health-care provision from 2011 onwards for the population aged under 18 years is shown in Table 4.
Provision of care related to mental health for the population aged under 18 years in the public health network of the Canary Islands, since 2011.
For patients under 18, the most frequent diagnosis in 2015 was by far for behavioural and emotional disorders with onset usually occurring in childhood and adolescence, with 4684 cases diagnosed.
Planned case of use: metrics to evaluate usefulness
The tool that we developed is a resource that enables practitioners to gather information about the mood state and emotions of their patients, complemented with the information gathered during consultations in health centres in order to monitor patient outcomes. Another feature of the tool is that it helps the patient recognise and express their emotions, facilitating the development of emotional intelligence in young patients with pathologies that affect their social skills. The usefulness of the tool will be evaluated by considering two sources of information that it provides:
The patient’s diary entries. This source of information will reveal to what extent the tool provides relevant information on the patient’s history: information related to the patient’s ability to represent and control their mood and the effects of the therapies.
Communications between the patient and the doctor. This source of information will measure the impact of the tool in improving communication with the patient, insofar as it prevents unnecessary travel by the patient to the health-care facilities.
With regard to the indicators used to measure the relevant information provided by the tool, these are obtained by analysing the entries made by patients in their diaries. Specifically, these indicators are as follows:
Number of entries created by the patient: This indicator measures whether patient trust and fluency with their doctor improves. In addition, sudden changes in the number of entries may be symptoms of patient status changes due to stages of worsening or crisis.
Number of mood changes noted by the patient: This indicator reports the effects of treatments and also indicates worsening or crisis patient situations.
Number of new mood states created by the patient: This indicator is used to detect improvements in patient status since it is able to identify their mood states and monitor them when they manifest new mood states.
Effect of the therapies, analysing the correlation between the number and type of entries made by the patient and the prescribed therapies.
To assess how the tool enables improvement in the quality of life of patients, those entries in their diary that indicate better emotional control or represent their mood states are analysed. Indicators associated with improved patient quality of life are as follows:
Entries that indicate the acquisition of new social skills or development thereof. These are related to social proactivity or the ability to find solutions to everyday situations.
Diary entries that indicate changes in habits and lifestyle.
To measure the impact on patient care, patient–doctor communication records will be used to temporarily analyse said communications and entries to assess the effect of these communications.
To evaluate the tool, we propose developing a pilot project with a sample of young patients aged between 12 and 16 years with diagnosed disorders associated with behavioural and emotional disorders with onset usually occurring in childhood and adolescence. The reason for choosing this group of patients is that young people are a sector of the population that normally show interest in ICT and more easily acquire the ICT skills necessary to manage the application. In addition to the intervention of patients and doctors, this trial will require the collaboration of their teachers and tutors to check the findings of the indicators related to the development of new skills (social proactivity, finding solutions to everyday situations and changes in habit and lifestyle). Moreover, as initial data for each participating patient, their mental age will be obtained by performing a standardised test for this purpose. Based on this initial information, there will be a learning phase on how to use the tool, taking into account the characteristics of each patient. Once patients have mastered the use of the tool, it will be used during the school year in order to check the evolution of the patient with their tutors and parents.
Conclusion
The web application we have developed provides a number of essential tools for functional improvement of communication between doctors and patients. Some of the most salient features are psychological test editor, doctor–patient communication system, emotional diary and combining medical and clinical history.
The tool represents an advance in patient proximity and provides more continuous monitoring outside doctor visits. It offers the possibility of adjusting or changing medical and psychological treatment in a simple, fast way that reinforces patient autonomy.
Despite this being a tool that will enhance therapy, there are certain types of patients with whom it should not be used. Patients who may potentially suffer from using this tool are those who suffer from certain obsessive compulsive disorders, who are exhibiting signs of severe depression or patients with symptoms of paranoia.
The proposed tool can be used by all patients receiving any psychological therapy including cognitive behavioural counselling, systemic therapy, humanistic therapy … all apart from psychodynamic therapy. Furthermore, it could also be used in psychiatry by doctors and liaison nurses who are mental health specialists in home care programmes and day care units.
The web application could be used by patients with severe psychopathologies who remain under the care of their families; in these cases, the latter would have access to this channel of communication with health professionals in order to provide information on changes and/or new requirements that arise between scheduled visits. This would improve one of the major shortcomings of the Canary Islands health system, in particular, but one that also affects health care nationally: overlong waiting times between doctor–patient visits as a result of an overloaded health system.
In short, the development of all the tools described above facilitates, on one hand, the work of the professionals (more and better access to the experiences of the patient through the information that they and their family have reported); on the other hand, it promotes adherence to therapy through closer monitoring by the health professional and, finally, brings relatives closer to the therapeutic exchange that their loved one is undergoing.
Moreover, although it is not an essential requirement, the system provides benefits to the patient if used with mobile devices since there are several features of the web application that benefit from the use of this technology.
The patient can use the camera on their mobile device (mobile phone or tablet) to take a picture that describes a feeling better than any text in their emotional diary.
Another useful option that using the application on mobile devices offers is the ability to communicate with their doctor in real time in case they want to express some feeling they think is appropriate or indicate the trigger for a crisis once it has been identified, thanks to the guidelines to remember that were defined in therapy. The way in which the patient perceives many of these feelings may be affected over time if the patient has to wait for the next appointment to discuss them with their doctor. The immediacy of the platform on a mobile device is, therefore, vital.
Future work
After the current phase of system development, the first step would be to implement it in the Canary Islands health system, so that we may obtain the metrics described in section ‘Case of use’ and evaluate the real impact of the system.
The web application developed for this project has many features that can be expanded upon and improved. Instead of opting to use an adaptable design, a native mobile application could be developed for both Android and iOS. This would enhance the functionality of the system. For example, the representation of a mood in the emotional diary via an image would benefit from mobile device geolocation. Currently, patient information and treatment is stored in a database developed in SQL. A way could be found to export patient information by creating a format that presents the information in such a way that it may easily be transferred to another professional. Similarly, it would be useful to add a feature that allows the sharing of information on therapies or to create a method by which a psychologist can make an online inquiry to another colleague if they have any doubts about a patient’s therapy. Finally, new stakeholders can be added to the system. As noted above, in some therapies, it is convenient to receive the active support of relatives or social workers, and they could be introduced to the system under new roles and functions.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.