An IT Platform Enabling Remote Therapeutic Interventions
Marc Schickler1, R¨
udiger Pryss1, Michael Stach1, Johannes Schobel1,
Winfried Schlee2, Thomas Probst1, Berthold Langguth2, Manfred Reichert1
1Institute of Databases and Information Systems, Ulm University, Germany
2Clinic and Policlinic for Psychiatry and Psychotherapy, University of Regensburg, Germany
1{marc.schickler, ruediger.pryss, michael.stach, johannes.schobel, thomas.probst, manfred.reichert}@uni-ulm.de
Abstract—The development of information systems, which
support homework in the context of therapeutic interventions,
has not been sufficiently addressed so far. However, both
therapists and patients crave for a mobile assistance managing
complex homework procedures. For example, smart mobile
devices can automatically inform therapists about corresbond-
ing outcomes, giving them the opportunity to timely adjust
homework if required. When realizing information systems that
integrate smart mobile devices, the common procedure of ther-
apeutic interventions in general and homework in particular
must be carefully captured by the system. Therefore, relevant
requirements were elicitated in real-world projects. Based on
these requirements, we realized the Albatros platform enabling
therapists to manage therapeutic interventions remotely. Using
the platform, homework can be created with a web-based
component and be performed by patients with the help of
smart mobile devices. In this paper, elicitated requirements for
realizing the platform as well as its features and architecture
are presented. Altogether, the Albatros platform enables ther-
apists as well as patients to manage therapeutic interventions
and homework more efficiently.
Keywords-Therapeutic intervention, mobile therapy, mobile
healthcare, mobile healthcare assistance
I. INTRODUCTION
Many studies have confirmed that therapeutic interven-
tions constitute a fundamental part of most therapies as
they increase their efficacy. The variety of therapeutic in-
terventions, in turn, ranges from simple medication intakes
up to complex behavioral therapies including homework,
which is assigned by a therapist to the patient. In partic-
ular, homework supports therapeutic progress and helps to
transfer therapeutic achievements from the clinical setting
to the real-life situation of the patient at home. Taking this
diversity into account, many therapists crave for a more
sophisticated IT support. In line with this trend, recent
studies (e.g., [1]) revealed that smart mobile devices are
demanded by therapists and can be used to obtain new
insights in clinical research. However, existing approaches
still come with several drawbacks. First, they mainly provide
specifically tailored applications and often do not cope
with the diversity of therapeutic interventions. Second, they
neither consider the execution context of homework properly
nor the provision of feedback. Third, existing solutions
focus on the therapist-patient relationship and, therefore,
Figure 1: IT Platform Challenges
neglect emerging opportunities (e.g., context-sensitive data)
in this context. Fourth, features provided by current smart
mobile devices (e.g., sensors) have seldomly been used for
therapeutic interventions.
Taking these shortcomings into account, Fig. 1 illustrates
the three major challenges addressed by the Albatros plat-
form. First, smart mobile devices need to be integrated.
Second, the capabilities offered by smart mobile device
sensors shall be utilized. Third, the therapist-patient rela-
tionship shall be extended to the therapist-patient-researcher
relationship. For this purpose, features must be provided that
enable the three stakeholders to collaborate. For example,
as therapists manage their individually created therapeutic
interventions digitally when using the Albatros platform,
they can easily make them available for researchers. As
a consequence, the therapist-researcher relationship can be
enhanced since researchers may evaluate the efficacy of
therapeutic interventions based on proper longitudinal data.
From a technical perspective, four aspects are crucial when
realizing the Albatros platform:
1) Insights into real-world therapies as well as a liter-
ature study are required to understand the common
procedure for managing therapeutic interventions.
2) The shortcomings of the identified procedure shall
be analyzed to elicitate requirements for the Albatros
platform.
3) These requirements, in turn, shall be addressed to help
evolve existing procedures for therapeutic interven-
tions. In particular, the contextual information as well
as the provision of feedback shall be included.
4) The Albatros architecture shall support the optimized
procedure to efficiently perform therapeutic interven-
tions.
The remainder of the paper is structured as follows:
Section II discusses the common procedure for managing
therapeutic interventions as well as its current shortcomings
and elicitated requirements. Section III presents an opti-
mized procedure for the support of therapeutic interventions,
which meets these requirements. Section IV presents the
Albatros architecture, whereas Section V introduces the
implemented prototype. Section VI discusses related work
and Section VII concludes the paper with a summary.
II. COMMON THERAPEUTIC INTERVENTION PROCEDURE
The development of an IT platform supporting remote
therapeutic interventions necessitates insights into real-world
procedures. These insights were gathered by us through
an analysis of six scenarios from the real world; i.e., we
investigated six large-scale solutions supporting therapeutic
interventions with specifically tailored applications (cf. Table
I). This revealed that an appropriate IT support significantly
increases the efficacy of therapeutic interventions. For ex-
ample, in psychosomatic in-patient clinics, clinical support
tools increased the outcome for patients.
Fig. 2 shows how therapeutic interventions are usually
accomplished in the considered real-world scenarios. As the
Approach Country #STI Patient Cases
TrackYourTinnitus [2] World-Wide 12 1,500
Tinnitus Hearing Ability [3] Germany 10 120
Risk Factors during
Pregnancy [4]
Germany 12 410
PTSD in War Regions [5] Burundi 6 560
Supporting Parents after
Accidents of Children [6]
Switzerland,
Germany
6 80
Psychosomatic
in-patients clinics [7], [8]
Germany 23 25
Sum Σ59 2,870
STI = Number of Supported Therapeutic Interventions
Table I: Approaches Supporting Therapeutic Interventions
Figure 2: Common Therapeutic Intervention Procedure
depicted procedure is crucial for the design of the Albatros
platform, we summarize it in the following: the therapy
starts with a first personal meeting of the therapist and
the patient. During this meeting as well as the follow-up
sessions, the therapist creates a comprehensive anamnesis for
the case conceptualization, based on which the therapeutic
interventions (e.g., homework) are planned. If homework
becomes necessary, the therapist discusses it with the patient
and specifies exercises (e.g., relaxation techniques) that need
to be performed to successfully complete the homework (cf.
Fig. 2). In this context, exercises must be explained to the
patient (i.e., what, why, when, where, how, how often, with
whom). If homework is not explained to the patient in detail,
he might forget it in daily life or, especially when performing
complex exercises (e.g., cognitive restructuring). If exercises
are not performed as intended by therapists their efficacy is
potentially mitigated. Other shortcomings of current manual
therapeutic intervention procedures are as follows:
•Homework adjustments are only performed in personal
meetings of the therapist and the patient. Hence, ad-
justments might be ineffective.
•Homework cannot be monitored efficiently and, there-
fore, therapists are unable to adjust ongoing homework
timely.
•Patients have difficulties in providing detailed feedback
on the performed homework. Even if they have not, the
feedback might be biased, as sharing the experiences
with the therapist is only possible retrospectively at
personal meetings.
•Therapists cannot control the context in which home-
work is performed. If patients do not stick to a helpful
context, homework efficacy will be low.
•As crucial parts (e.g., complex exercises) of therapeutic
intervention procedures are not computerized, the reuse
of already existing homework is difficult.
•Therapists are unable to share homework schemes with
other therapists in a convenient manner. Accordingly,
the exchange of homework schemes within therapeutic
institutions is limited.
Considering these shortcomings, we elicitated technical
requirements to be met by the Albatros platform (cf. Table
II). We divide the requirements into four categories: (1)
Requirements related to exercises; e.g., therapists shall be
able to assign media elements to exercises, which are then
presented to patients on their smart mobile devices; (2)
requirements related to the context of an exercise. This
context shall enable the Albatros platform to cope with the
demands of therapists on one hand (e.g., a homework may
have to be performed after getting up) and to provide a
powerful tool for researchers to gather valuable context-
sensitive data on the other; (3) requirements related to
patient notifications; e.g., a patient shall be automatically
notified to perform the assigned homework; (4) requirements
related to feedback; e.g., therapists shall be able to create a
feedback schema using different question types. Altogether,
13 requirements were identified, which shall be met by the
Albatros platform.
III. IT SUPPORTED INTERVENTION PROCEDURE
The development of the Albatros platform takes two major
aspects into account. The (1) technical requirements shown
in Table II are considered and (2) therapists are enabled
to exchange homework schemes with other therapists. To
properly address these two issues, the procedure shown in
Fig. 3 was developed.
Regarding exercises, four aspects become relevant:
(1) Exercises are stored in a repository (cf. Fig. 3, 1
).
This enables therapists of the same institute to share
exercises. Note that the Albatros platform also sup-
ports the exchange of exercises between healthcare
organizations, which is not further considered in this
paper.
No Title Description
Category I: Exercise
1Configuration Configure exercise (e.g., description)
2Versioning Create and manage exercise versions
3Reuse Use exercise for different scenarios
4Media Use media elements for exercise (e.g., videos)
Category II: Context
5Configuration Configure context (e.g., date, location)
6Versioning Create and manage context versions
7Reuse Use context for different scenarios
8Sensors Utilize sensors of smart mobile devices
Category III: Notification
9Schema Create context-sensitive notification schema
10 Patient Notify patient to perform exercise
Category IV: Feedback
11 Schema Create feedback schema
12 Media Upload media elements (e.g., videos, pictures)
13 Reuse Use feedback schema for different scenarios
Table II: IT Platform Requirements
Figure 3: IT Supported Therapeutic Intervention Procedure
(2) A set of parameters (e.g., number of repetitions, du-
ration) is provided in order to cope with the variety
of exercises (cf. Fig. 3, 2
). This parameter set can be
easily extended.
(3) To ease the reuse of exercises, a template feature
was developed (cf. Fig. 3, 3
); e.g., a template for
a breathing exercise, for which only the number of
repetitions needs to be set, may be defined.
(4) During most therapies, exercises need to be adjusted
to increase their efficacy over time. Therapists want to
track respective adjustments, necessitating the support
of multiple versions of an exercise (cf. Fig. 3, 4
).
Regarding the context, in which exercises are performed,
the following three aspects become relevant:
(1) For specifying the context, two kinds of parameters
are provided. Symbolic parameters (cf. Fig. 3, 5
)
describe facts to be ensured by the patients themselves
(e.g., doing a breathing exercise in the living room,
which represents the symbolic parameter). In turn,
sensory parameters (cf. Fig. 3, 6
) are automatically
evaluated by the smart mobile devices of the patients
(e.g., measuring the heart rate, which is considered as
sensory parameter).
(2) A template as well as a versioning concept (cf. Fig.
3, 7
) is provided for capturing contextual schemes.
(3) Context specifications (i.e., context schemes) shall be
reusable. In turn, this requires a context repository (cf.
Fig. 3, 8
).
Concerning the feature that enables patients to provide
feedback to their therapists, two aspects are important:
(1) For each exercise, a feedback questionnaire can be
defined (cf. Fig. 3, 9
). The latter consists of different
question types (e.g., single and multiple choice, Likert
scale).
(2) Patients may enrich feedback by uploading additional
elements (e.g., videos or spreadsheets).
Concerning the notification feature, a platform-specific
notification is automatically triggered based on the context
specified by therapists. Furthermore, therapists may cus-
tomize the user interface template of a notification (e.g.,
default color, font).
IV. ALBATROS ARCHITECTURE
Fig. 4 illustrates the Albatros architecture, which enables
the realization of the discussed therapeutic intervention
procedure. Although the concept is not restricted to specific
technologies, we realized the prototype using the Microsoft
.NET Framework and SQL Server. In turn, the mobile ap-
plication supporting patients with therapeutic interventions
at home is realized using Android.
Taking the elaborated requirements into account, several
aspects of the architecture need to be discussed. First, as
many stakeholders are involved, a robust access control is
required. For this purpose, we implemented a sophisticated
authorization & authentication service (cf. Fig. 4 1
), taking
contemporary security and data protection concepts into
account. Second, as an additional demand of therapists, the
invitation service (cf. Fig. 4 2
) was implemented. To be
more precise, a therapist must be able to invite patients
by using an anonymized and unique invitation code. The
latter can be easily created by the Albatros platform. Third,
we implemented a notification service (cf. Fig. 4 3
) being
Figure 4: Albatros Architecture
able to send e-mails to patients and push notifications to the
patients’ smart mobile devices. Fourth, we implemented a
RESTful web service (cf. Fig. 4 4
) to manage the entire
communication with the smart mobile devices. In addition,
the communication required for the HTML5 application used
by therapist is managed through the web service as well.
In this context, the web service offers features for multi-
lingualism (cf. localization web service component shown
in Fig. 4 5
). Fifth, we designed a feasible data model (cf.
Fig. 4 6
) to cope with the relationships between therapeutic
interventions, homework, exercises, context, feedback, and
notifications. Subsequently, we implemented an advanced
business logic (cf. Fig. 4 7
) and a data access layer that
incorporates the defined data model.
V. PROOF-OF-CONCEPT PROTOTYPE
We implemented a proof-of-concept prototype, which is
briefly discussed in the following. Inspired by the insights
from the QuestionSys project and its modeling component
[9]–[11], fundamental components of the presented proto-
type were developed. Currently, the prototype consists of an
HTML5 application and a mobile application for the An-
droid mobile operating system. The HTML5 application, in
turn, provides the modeling component as well as the com-
ponent to manage therapeutic interventions by therapists. To
provide an impression of the prototype, Fig. 5 shows the
therapists’ view to manage patient cases. More precisely, all
therapeutic interventions, the personal appointments, and the
therapy history are managed using this view. In turn, Fig.
6 depicts the view in which therapists may configure all
possible homework features, e.g., required media elements
for performing a homework. Finally, Fig. 7 shows the list
of already created context schemes as well as details of one
context schema.
Two issues are finally mentioned that emerged when
using the Albatros platform in practice. First, the therapeutic
intervention procedure as well as the identified requirements
are sufficiently considered by the realized platform. Second,
the resulting complexity for therapists to create and manage
Figure 5: Therapy Details
Figure 6: Homework Details
Figure 7: Context Repository
therapeutic interventions is still challenging for them. In
this context, insights from the QuestionSys project help to
reduce the overall configuration complexity through the use
of concepts known from end-user development. Therefore, a
large-scale experiment is currently conducted with the goal
to identifiy the factors that may reduce the complexity.
VI. RELATED WORK
Three categories of related work are relevant in the context
of this paper.
Approaches providing IT platforms for therapeutic in-
terventions. Online-supported therapeutic interventions and
evaluations of the efficacy of respective interventions com-
pared to traditional ones are presented in [12]–[16]. How-
ever, only few approaches providing IT support for thera-
peutic interventions can be found. Commercial software so-
lutions dealing with e-health and Internet-based therapeutic
interventions, in turn, are discussed in [17], [18]. None of
these solutions provides support as the Albatros platform
does.
Approaches dealing with mobile therapies. Several studies
that use mobile phones as a motivating factor for teenagers to
record their mental health symptoms are presented in [19]. In
this context, recordings are discussed with clinicians. In turn,
[20] presents approaches using smartphones in the context
of personal healthcare. Recent works, e.g., [21], revealed
that mobile applications can be used to properly perform
therapeutic interventions. In addition, there exist IT-driven
approaches that may be configured by domain experts to
increase the efficacy of psychotherapy [22]. In line with
[20], [1] elaborates the benefits of mobile technology with
respect to the efficacy of psychotherapy in detail. However,
none of these approaches presents technical solutions for
therapeutic interventions, as the Albatros platform does. [23]
presents three clinical studies in which mobile technology
was used for mobile interventions. For each study, a specif-
ically tailored mobile application was realized. Although
[23] emphasizes the usefulness of mobile interventions in
the considered case studies, no generic technical solution is
presented.
Approaches dealing with homework in the context of
psychotherapy. Numerous works deal with homework in
the context of psychotherapy [19], [24], [25]. However,
respective approaches mainly address the results of the
conducted studies with no particular focus on technical
issues. Moreover, no technical solution is presented that
applies contemporary mobile technology. In turn, all studies
reveal that homework should be a fundamental component
of most psychotherapies.
Altogether, existing work has proven that homework is
crucial for many therapies. The development of a generic
technical solution that supports homework in particular
and therapeutic interventions in general is currently less
considered.
VII. SUMMARY AND OUTLOOK
This paper presented an IT platform enabling therapists
to provide therapeutic interventions to their patients with
the help of smart mobile devices. We discussed fundamental
requirements elaborated in real-world projects to capture the
common therapeutic intervention procedure with the Alba-
tros platform. Thereby, four major aspects are particularly
considered: (1) the creation of exercises, (2) the specification
of a context, (3) the provision of a feedback feature, and (4) a
notification feature. In this context, we showed the developed
procedure that combines these four aspects, the developed
architecture as well as the implementation of the prototype.
Overall, an approach supporting therapeutic interventions
with the use of smart mobile devices becomes increasingly
important. In current work, we focus on the modeling
component, which we evaluate through an experiment. In
addition, we will consider legal aspects of the platform.
Altogether, the support of therapeutic interventions on smart
mobile devices constitutes an important step towards more
effective therapies.
REFERENCES
[1] O. Lindhiem, C. Bennett, D. Rosen, and J. Silk, “Mobile
technology boosts the effectiveness of psychotherapy and
behavioral interventions a meta-analysis,” Behavior modifi-
cation, vol. 39, no. 6, pp. 785–804, 2015.
[2] R. Pryss, M. Reichert, B. Langguth, and W. Schlee, “Mobile
Crowd Sensing Services for Tinnitus Assessment, Therapy
and Research,” in IEEE 4th Int’l Conf on Mobile Services.
IEEE Computer Society Press, 2015.
[3] M. Schickler, R. Pryss, M. Reichert, J. Schobel, B. Langguth,
and W. Schlee, “Using Mobile Serious Games in the Context
of Chronic Disorders - A Mobile Game Concept for the
Treatment of Tinnitus,” in 29th IEEE Int’l Symp on Computer-
Based Medical Systems, 2016, pp. 343–348.
[4] M. Ruf-Leuschner, N. Brunnemann, M. Schauer, R. Pryss,
E. Barnewitz, M. Liebrecht, W. Kratzer, M. Reichert, and
T. Elbert, “The KINDEX-App - an Instrument for Assessment
and Immediate Evaluation of Psychosocial Risk Factors in
Pregnant Women in Daily Practice by Gynecologists, Mid-
wives and in Gynecological Hospitals,” Verhaltenstherapie,
vol. 26, no. 3, pp. 171–181, 2016.
[5] J. Schobel, R. Pryss, and M. Reichert, “Using Smart Mobile
Devices for Collecting Structured Data in Clinical Trials:
Results From a Large-Scale Case Study,” in 28th IEEE Int’l
Symposium on Computer-Based Medical Systems. IEEE
Computer Society Press, 2015.
[6] “Kidtrauma,” https://kidtrauma.com/en/, 2017, [Online; ac-
cessed 19-April-2017].
[7] T. Probst, M. Lambert, T. Loew, R. Dahlbender, R. G¨
ollner,
and K. Tritt, “Feedback on patient progress and clinical sup-
port tools for therapists: Improved outcome for patients at risk
of treatment failure in psychosomatic in-patient therapy under
the conditions of routine practice,” Journal of Psychosomatic
Research, vol. 75, no. 3, pp. 255–261, 2013.
[8] T. Probst, M. Lambert, R. Dahlbender, T. Loew, and K. Tritt,
“Providing patient progress feedback and clinical support
tools to therapists: Is the therapeutic process of patients
on-track to recovery enhanced in psychosomatic in-patient
therapy under the conditions of routine practice?” Journal of
psychosomatic research, vol. 76, no. 6, pp. 477–484, 2014.
[9] J. Schobel, R. Pryss, W. Wipp, M. Schickler, and M. Reichert,
“A Mobile Service Engine Enabling Complex Data Collection
Applications,” in 14th Int’l Conf on Service Oriented Com-
puting, ser. LNCS, 2016, pp. 626–633.
[10] J. Schobel, R. Pryss, M. Schickler, M. Ruf-Leuschner,
T. Elbert, and M. Reichert, “End-User Programming of Mo-
bile Services: Empowering Domain Experts to Implement
Mobile Data Collection Applications,” in 5th IEEE Int’l Conf
on Mobile Services, 2016, pp. 1–8.
[11] J. Schobel, R. Pryss, M. Schickler, and M. Reichert, “A
Configurator Component for End-User Defined Mobile Data
Collection Processes,” in Proc 14th Int’l Conf on Service
Oriented Computing, October 2016.
[12] A. Barak, B. Klein, and J. Proudfoot, “Defining internet-
supported therapeutic interventions,” Annals of Behavioral
Medicine, vol. 38, no. 1, pp. 4–17, 2009.
[13] V. Spek, P. Cuijpers, I. Nykl´
ıcek, H. Riper, J. Keyzer, and
V. Pop, “Internet-based cognitive behaviour therapy for symp-
toms of depression and anxiety: a meta-analysis,” Psycholog-
ical medicine, vol. 37, no. 03, pp. 319–328, 2007.
[14] S. Walters, J. Wright, and R. Shegog, “A review of computer
and internet-based interventions for smoking behavior,” Ad-
dictive behaviors, vol. 31, no. 2, pp. 264–277, 2006.
[15] A. Barak, L. Hen, M. Boniel-Nissim, and N. Shapira, “A com-
prehensive review and a meta-analysis of the effectiveness
of internet-based psychotherapeutic interventions,” Journal of
Technology in Human services, vol. 26, no. 2-4, pp. 109–160,
2008.
[16] M. Lambert, “Progress feedback and the OQ-system: The past
and the future.” Psychotherapy, vol. 52, no. 4, p. 381, 2015.
[17] “Minddistrict,” https://www.minddistrict.com, 2017, [Online;
accessed 19-April-2017].
[18] E. AbuKhousa, N. Mohamed, and J. Al-Jaroodi, “e-health
cloud: opportunities and challenges,” Future Internet, vol. 4,
no. 3, pp. 621–645, 2012.
[19] D. J. Cox, D. A. Tisdelle, and J. Culbert, “Increasing ad-
herence to behavioral homework assignments,” Journal of
behavioral medicine, vol. 11, no. 5, pp. 519–522, 1988.
[20] K. Wac, “Smartphone as a personal, pervasive health infor-
matics services platform: literature review,” arXiv preprint
arXiv:1310.7965, 2013.
[21] A. Aguilera and F. Muench, “There’s an app for that: In-
formation technology applications for cognitive behavioral
practitioners,” The Behavior therapist/AABT, vol. 35, no. 4,
p. 65, 2012.
[22] S. Watts, A. Mackenzie, C. Thomas, A. Griskaitis,
L. Mewton, A. Williams, and G. Andrews, “Cbt for depres-
sion: a pilot rct comparing mobile phone vs. computer,” BMC
psychiatry, vol. 13, no. 1, p. 49, 2013.
[23] C. Depp, B. Mausbach, E. Granholm, V. Cardenas,
D. Ben-Zeev, T. Patterson, B. Lebowitz, and D. Jeste, “Mobile
interventions for severe mental illness: design and preliminary
data from three approaches,” The Journal of nervous and
mental disease, vol. 198, no. 10, p. 715, 2010.
[24] N. Kazantzis, C. Whittington, and F. Dattilio, “Meta-analysis
of homework effects in cognitive and behavioral therapy: A
replication and extension,” Clinical Psychology: Science and
Practice, vol. 17, no. 2, pp. 144–156, 2010.
[25] T. Neben, A. Seeger, T. Kramer, and A. White, “Regaining
Joy of Life: Theory-Driven Development of Mobile Psy-
chotherapy Support Systems,” 2015.
