Backend Concept of the eSano eHealth Platform for Internet- and Mobile-based Interventions [original]

Backend Concept of the eSano eHealth Platform

for Internet- and Mobile-based Interventions*

Abdul Rahman Idrees1,2, Robin Kraft1,2, R¨

udiger Pryss3, Manfred Reichert2, Tran Nguyen1,

Lena Stenzel1and Harald Baumeister1

1Department of Clinical Psychology and Psychotherapy, Ulm University, Germany

2Institute of Databases and Information Systems, Ulm University, Germany

3Institute of Clinical Epidemiology and Biometry, University of W¨

urzburg, Germany

Abstract—Mental disorders represent an ongoing challenge

to global health and can affect anyone at any age from any

region in the world. The response of healthcare providers

to mental health disorders still lags behind that of other

diseases and a significant number of people who are affected

by mental health disorders do not receive adequate treatment.

The widespread usage of Internet-connected devices provides

new opportunities to deliver treatment to more people using

innovative approaches. The groundwork is being laid for the

adoption of Internet- and mobile-based interventions, providing

mental and behavioral health support to more people and

narrowing the treatment gap. This paper discusses the main

technical details of the backend API of the eSano eHealth

platform as an example for a complex and comprehensive IT-

framework for large-scale and flexible Internet- and mobile-

based interventions. An overview of eSano is provided and

the platform is compared with other technical solutions in the

field. In addition, the components of eSano are described and

further technical insights are elaborated in more detail. To this

end, the work at hand demonstrates the main requirements of

the backend API powering eSano, its concepts and the overall

developed solution. It will as such inform researchers and

practitioners about state-of-the-art backend API development

in the eHealth context.

Index Terms—eHealth-Platforms, eSano, Internet-

Interventions, Mental-Disorders, Behavior-Change

I. INTRODUCTION

Recent studies show that mental and behavioral disorders

are very common. Mental disorders represent 13% [1] of

the global burden of diseases. In a report published in

2010 [2], it was found that mental and behavioral disorders

increased by 37.6% over the course of two decades from

1990 to 2010. The report indicates that mental and behavioral

disorders are the main contributors to disability worldwide,

with depressive disorders representing 40.5% of this statistic.

More recently, according to [3], it was found that one in

three elderly people in Europe had experienced a mental

disorder in the previous year and one in four still lives with

one. Looking at other regions, 46% of the population of

the United States — approximately 150 million people —

experience a mental health disorder in their lifetime [4].

This research was partially funded by PSYCHOnlineTHERAPY and

CHIMPS-NET funded by the Innovation Committee of the Joint Federal

Committee (Gemeinsamer Bundesausschuss, gBA, no: 01NVF18036 and

01NVF18003) as well as ProTransition funded by the Ministry of Social

Affairs and Integration, Baden-W¨

urttemberg.

These numbers are likely to be low estimates, due to the

fact that some disorders were omitted from the survey [4].

70% of people with mental illness are not currently receiving

treatment [4]. These figures indicate that there is a significant

treatment gap. Additionally, this gap is even more noticeable

among ethnic minority groups [4]. Mental health treatment

gaps are a global issue. However, statistics vary among

regions and are illness-specific. In Europe, for example, the

treatment gap for late-life depression amounts to 79% [5]. In

developing countries, between 76% and 85% of people who

struggle with mental disorders did not receive treatment in

the previous year [6].

Novel approaches should be considered when trying to

overcome this issue. Recent developments have suggested

that Internet interventions may be a promising method of

delivering treatment to people who would otherwise fall into

the treatment gap [7]. Findings from [8] show that guided

interventions may yield similar outcomes when compared to

face-to-face therapy for several mental disorders. [8] indi-

cates that guided interventions are also effective in treatment

of depression and anxiety disorders. Baumeister et al. [9]

suggest that the eCoaching in Internet interventions by staff

with lower qualification standards than experienced clinicians

might provide similar effects, however, without implementa-

tion effects and potential adverse event prevention being well

studied in this context. Anyway, these aspects would mean

that such interventions could be provided to a wider number

of people. [10] also suggests that Internet- and mobile-

based interventions (IMIs) can reach potentially more and

— even more importantly — other people than traditional

treatments. Furthermore, it could reduce costs and increase

effectiveness when introduced alongside traditional treatment

activities [10]. A prerequisite of such IMI represents the IT-

framework necessary to run the interventions not only in

controlled environments such as randomized controlled trials

(RCTs) but also in routine care.

This paper provides a technical overview of the eHealth

platform eSano [11] as an example of a comprehensive and

complex IT-framework for delivering Internet- and mobile-

based interventions. More specifically, the requirements, de-

sign and implementation for the backend that powers the

eSano platform are described. Furthermore, it is explained

how the platform enables the use of therapeutically unguided

or guided interventions that can be used both as standalone

intervention or in a blended care scenario.

The remainder of this paper is organized as follows:

Section II gives an overview of related work including

similar platforms and compares these platforms to eSano.

Section III shows the concept of the eSano eHealth plat-

form, the overview of its structure, and how it operates.

Section IV discusses the main requirements of the platform

and the concepts used to implement the overall platform

solution. Section V provides more detailed descriptions of

the underlying implementations of the backend. Section VI

discusses the current uses of eSano and its shortcomings.

Finally, section VII provides an outlook for future plans and

a conclusion for the paper.

II. RELATED WORKS

Delivering health treatment over the Internet continues

to gain the attention of researchers [12]. Several research-

initiated platforms and applications already exist that aim

to improve the quality of life for their users and treat

mental disorders. Iterapi is a multilanguage Internet-based

platform developed by the Department of Behavioral Sci-

ences and Learning at Link¨

oping University in Sweden. The

goal of the app is to help users cope with their mental

and behavioral symptoms [13]. The platform is flexible

and allows treatment courses to be developed for a wide

range of psychological and health challenges [13]. Treatment

components include worksheets, text, audio and video com-

munications, a discussion forum and a questionnaire module.

Moodbuster is another platform that leverages the Internet

to deliver psychological treatments1. It was developed by

Vrije Universiteit Amsterdam. Currently, the platform offers

six online modules that use cognitive behavioral therapy

treatment to treat depression. Its content includes text and

videos. Users of the platform are also offered exercises and

home-works1[14]. As part of the Australian government

mission to promote eHealth, they developed an eHealth

platform named Mindspot. It has been made available to

adult Australian citizens who are suffering from symptoms

of anxiety and depression [15]. Mindspot offers online as-

sessments, information about local mental health support

and Internet-delivered cognitive behaviour therapy (ICBT)

guided by therapists [15]. Furthermore, several commer-

cial platforms are also readily available. Minddistric is a

web-based eHealth platform designed to contribute to the

prevention of mental illness and provide after-care2[16].

The platform offers a Content Management System (CMS)

to enable health care providers to create and customize

interventions based on their specific needs. They can also

monitor patient progress via the dashboard. Other features

include video sessions, social support, plan design and pa-

tient questionnaires2. SilverCloud3and online-therapy4are

1https://www.moodbuster.science/

2https://www.minddistrict.com/

3https://www.silvercloudhealth.com/

4https://www.online-therapy.com/

two examples of commercially available platforms, without

much information available about their internal components.

Table I shows a comparison between the features of each

of the platforms mentioned above. It can be seen that eSano

already provides most of the features available on the other

platforms. Furthermore, eSano enables researchers to develop

new interventions for mental disorders, as well as chronic

somatic diseases and health behaviour risk factors, without

being bound by commercial requirements or boundaries

of existing projects [11]. In addition, the flexible platform

allows the development, integration and investigation of

new, innovative eHealth approaches without the need to

make any changes or updates to the source code, thanks

to the accessibility of the CMS. Additionally, eSano allows

text communication between intervention supervisors and

participants and it provides a journal feature which enables

participants to keep a regular journal of their activities. It

also comes with multilanguage support which means that

interventions can be provided in different languages. Since

eSano is a research-based platform, there is a lot of room

for research and experimentation with new concepts. For

example, social support elements are already implemented

and could be integrated into eSano interventions with the

intention of increasing user motivation and engagement with

the participants’ app. Gamification is also another concept

that has been integrated into eSano. Both of these two

features will be evaluated and tested soon. Moreover, new

features for eSano will be added (see Section VI for more

details).

III. CONCEPT

The eSano platform provides tools to enable researchers

and clinicians to develop a wide range of behavioral and/or

mental health IMI in a variety of possible implementation

scenarios and to provide these interventions to users (pa-

tients, people with prevention and health promotion demands,

health care professionals, researchers etc.). As mentioned

by [11], the platform is comprised of three parts that are

connected together through one central backend. The three

parts are: a CMS, an eCoach platform, and the participant

application. The CMS and the eCoach platform are both web

applications that can be accessed via any web browser, such

as Google’s Chrome or the Mirosoft’s Edge. The participant

application is a cross-platform app that runs as a web app

and also on Android and iOS platforms. The platform is

empowered by one backend that enables communications

to run smoothly between the three parts of the platform.

Furthermore, the backend relies on one central database to

store the data of the platform. The participant app is used

to provide users access to their intervention courses. Users

of the participant app are not required to have knowledge

of the rest of the platform and all their interactions happen

exclusively through this app. The CMS is where clinicians

and researchers develop their interventions — possibly across

the whole spectrum of mental- and behavioral health in-

terventions — which are then made available through the

platform. Finally, the eCoach platform is where eCoaches

TABLE I

PLATFORM COMPARISON

Feature/Platform eSano Iterapi Moodbuster Mindspot Minddistrict SilverCloud online-therapy

Evidence-based Yes Yes Yes Yes Yes Yes No

Course design Flexible Flexible Flexible Not flexible Flexible N/A N/A

Multi-language Yes Yes Yes No Yes No No

Video sessions No Yes No No Yes No Yes

Text communication Yes Yes No N/A Yes Yes Yes

Journals Yes Yes No No Yes No Yes

Commercial No No Yes No Yes Yes Yes

Platform Web/mobile Web N/A Web/mobile Web/mobile Web/mobile Web/mobile

Availability Globally Globally Globally Australia Globally Globally Globally

manage the treatment courses of their participants. Through

the eCoach platform, guidance can be offered to users.

eCoaches, in turn, can then monitor the progress of each

of their users and provide them with feedback and support.

Communication between the three applications of the

platform and the backend is compatible with the REpre-

sentational State Transfer (REST) architectural style. The

principles of the REST architectural style were firstly intro-

duced by Roy Fielding in his work ”Architectural Styles and

the Design of Network-based Software Architectures” [17].

REST architecture principles serve as standards to help sys-

tems communicate with each other in a stateless manner [17].

Such communications are performed by using RESTful APIs

(application programming interfaces), which are interfaces

for the services. These APIs hide the complexity of the

underlying functionalities from the clients; for eSano, for the

CMS, the eCoach platform and the participant application.

This enables the clients to perform the various required

functionalities by simply communicating with the backend

via the APIs.

IV. REQUIREMENTS

It was essential for the eSano backend to be flexible and

scalable in order to have a prototype that is even ready

for its practical use and to enable continuation/scaling of

the development of the eSano platform. One even more

challenging aspect of eSano’s development was to provide

researchers and clinicians with the ability to develop new

interventions themselves and publish them for users without

the need for any adjustments or changes to the source code.

To the lack of space, in Table II, only the major functional

requirements of the eSano platform are presented in terms

of their API endpoints. These requirements are discussed in

more detail within this section.

An authorization mechanism is used to control what data

each user is allowed to access. APIs are organized into

groups and an authorization middleware is used to control

which users are allowed to access which APIs. Further-

more, inside each API, another protection layer filters the

coming requests based on what permissions the user has

on the requested resources (Req. 1). Adding new users to

the platform is done via the admins or the eCoaches. An

invitation is sent to people who are interested in participating

in a certain intervention via an email with more details on

TABLE II

MAJOR REQUIREMENTS OF ESANO IN TERMS OF API ENDPOINTS

ID Requirements APIs

authentication

and

authorization

mechanisms

POST auth/login

Users

Accounts

Manage-

ments

POST admin/auth/assign/register

POST ech/auth/register

POST admin/auth/reactivate

POST admin/users/{ID}

DELETE ech/users/nonverified

3Interventions

Development

POST editor/interventions

PATCH /editor/interventions/{ID}

POST editor/interventions/{ID}/questionnaires

POST questionnaires/{ID}/elements

Intervention

Configura-

tion

POST ech/interventions/instances

PATCH ech/interventions/instances/{ID}

PATCH ech/interventions/instances/unlock

5 Monitoring

GET e/members/{ID}/interventions/instances

GET ech/interventions/instances/{ID}/activities

PATCH ech/interventions/instances/{ID}/state

PATCH ech/interventions/instances/{ID}/feedback

PATCH ech/interventions/instances/unlock

User-eCoach

Communica-

tion

POST e/messages/threads

GET ech/interventions/instances/{ID}/threads

GET ech/messages/folders/inbox

GET messages/threads/{ID}

POST /messages/threads

7 Reminders POST ech/users/{ID}/email

GET ech/users/{ID}/unread/feedback

how to activate their accounts and how to further proceed

(Req. 2). The platform enables clinicians and researchers to

create new interventions inside the platform. Interventions

are created inside groups and each intervention can contain

a different number of lessons, while each lesson contains a

different number of elements of different types. Intervention

developers can add lessons to interventions and adjust the

contents of the lessons. The content can contain text, audio,

images, videos or a combination of these, with different

styling options (Req. 3). Furthermore, conditional elements

are also available, which can only be used conditionally,

based on certain answers provided by the users throughout

the intervention course [11]. eCoaches also have the option

to adapt an intervention to the specific needs of each user

(before and during the treatment) (Req. 4). User supervision

is another available feature. Patients progress in the inter-

vention can be supervised and supported by one or more

eCoaches when the intervention is designed to be guided

(Req. 5). Communication between a user and their eCoach(s)

is possible. Users can start a thread and exchange messages

with an eCoach, who is supervising their treatment. eCoaches

can also communicate with their users whenever required

(Req. 6). eSano also provides eCoaches with the possibility

to send reminders via email and push notifications to remind

their users of certain activities to keep them engaged with the

application (Req. 7). On top of the functional requirements,

eSano also has to comply with non-functional requirements,

such as the safety and security of data, online availability,

performance, interoperability, multilingualism, to mention

only the most important ones [11].

V. TECHNICAL APPROACH

Interventions in eSano are placed under groups. Users are

given access to each intervention based on what permissions

they have for each group. Permissions are a set of permitted

actions that certain users may perform, based on their role

in a group. Figure 1 shows a simplified version of an eSano

entity relationship (ER) diagram. It can be seen that all the

entities descend directly or indirectly from groups. Users

are also connected to groups and to the interventions via

intervention instances. An intervention contains the lessons

that were designed by the intervention developers. When

a participant starts a treatment course, a new intervention

instance is created especially for them. This instance contains

a copy of the intervention itself, except that this copy is

modified to suit the specific needs of this participant. This

means that a participant can only access lessons that are

part of their assigned interventions. If this intervention is

supervised, then at least one eCoach is assigned to monitor

the progress of the participant via the intervention instance.

Figure 1 shows another entity called diary that inherits

directly from the group entity. A key concept in cognitive

behavioral therapy (CBT), for example, is the use of self-

monitoring [18]. According to [19], self-monitoring can be

used as a homework tool to encourage patients to monitor

their daily mood. Patients may be asked to write down any

positive or negative experience that influenced their mood.

The purpose of this is to help patients to understand the

connection between mood and behavior and to support the

goals of the treatment [19]. In eSano, this is implemented

through the use of the diaries. In cases where participants are

assigned a weekly challenge or homework, such homework

can also be documented in the diaries. Participants can work

on a diary once a diary instance is assigned to them. In the

case where a diary is part of an intervention, a diary instance

is created after an intervention instance is assigned to the

participant. Diaries are linked via an attribute that is available

in an intervention or a lesson. Each diary points to a set of

elements. Diaries can be seen in Fig. 1. As with interventions,

diaries are also organised under a certain group.

Another thing to notice in the diagram is the translation

entities. These provide support for different languages, which

Fig. 1. Simplified eSano ER diagram

Fig. 2. Intervention Instance Finite State Machine

makes eSano a multilingual platform. For each intervention,

lesson, element and diary, a translation entity is available that

can contain an arbitrary number of translations.

To help participants and eCoaches work smoothly with

the intervention instance, the concept of the instance state

has been added to each intervention instance. The state of

the instance identifies the current progress of the instance.

This enables certain actions to be achieved, such as sending

reminders to patients or eCoaches, based on the current

state of the instance. For each state, only certain actions are

allowed. For example, when the state is active, participants

can interact with the available lessons. However, when the

state is at awaiting next lesson, the participant is neither ex-

pected nor permitted to go through any lessons. New lessons

will be available either according to a certain time/date or

when they are made available by the eCoach. Table IV

shows the possible states of any intervention instance and

a description of each state, which have been identified from

the prototypical use of eSano and similar systems in several

(feasibility) studies and interviews with healthcare experts.

The transitions from each state to another are depicted in

Fig. 2. Each state in Fig. 2 is given a number according

to Table IV. For example, state configuration is S0, state

active is S1, and so forth. Each arrow in Fig. 2 represents a

state transition from one state to another. At the beginning,

when the instance is being created, it is assigned the state

configuration. Once the instance configuration is complete,

the state transitions to either active or awaiting next lesson.

From there on, several options are available. Table III shows

all the possible transitions and the inputs for each one.

For each transition, several inputs have to be considered as

TABLE III

INTERVENTION INSTANCE STATE TRANSITIONS

T# Current State Available Lesson Finished Lessons Feedback Required Feedback Provided Feedback Read To

T1 configuration +1 - False null null active

T2 configuration 0 - False null null awaiting next lesson

T3 active 0 All False null null completed

T4 active 0 - True False False feedback required

T5 feedback required 0 - False True False feedback provided

T6 feedback provided +1 - - - - active

T7 feedback provided 0 - - - - awaiting next lesson

T8 awaiting next lesson +1 - - - - active

T9 active 0 - - - - awaiting next lesson

T12 paused 0 - - - - awaiting next lesson

T13 paused +1 - - - - active

T16 paused 0 - True - - feedback required

T22 paused 0 - False True - feedback provided

T23 feedback provided 0 All - True True completed

TABLE IV

STATES OF AN INTERVENTION INSTANCE

ID State Description

S0 configuration

The intervention instance is being con-

figured and participants cannot start the

treatment yet

S1 active The intervention instance is available

S2 awaiting next lesson No lessons are available for the partic-

ipant

S3 feedback required The eCoach supervising the participant

is invited to provide a feedback

S4 feedback provided

The eCoach supervising the participant

has provided a feedback and the partic-

ipant is invited to read it

S5 paused

The eCoach supervising the patient has

paused the instance. Temporary, the

participant cannot access any lesson

S6 canceled The intervention instance is canceled

by the eCoach

S7 completed The patient has finished all the avail-

able lessons

follows:

•Current state of the intervention instance.

•Number of available lessons.

•Number of finished lessons.

•Whether an eCoach’s feedback is required.

•Whether feedback was provided or not.

•Whether feedback was read or not.

For example, in transition number three (T3), the state

moves from active (S1) to completed (S7). This only occurs

when there are no more available lessons for the participant,

the participant has already finished all the lessons, and

feedback is not required by the eCoach. This can be seen

in Fig. 2, in the transitions T0, T1, and T3. Additionally,

Table III does not show transitions from any state to either

paused (S5) or canceled (S6) (T10, T11, T14, T15, T17,

T18, T19, T20 and T21). This is because these transitions are

triggered manually by an eCoach and do not get calculated

automatically.

VI. LIMITATIONS AND CURRENT PRACTICAL USE

Although eSano has already fulfilled many of the initial

functional and non-functional requirements, there is still

room for improvements. Interoperability and scalability are

two challenges that still await solutions. eSano is not yet

able to communicate with other health systems to via Fast

Healthcare Interoperability Resources (FHIR) standard. Scal-

ability is another challenge facing eSano. Since the app

has a central database, this could potentially lead to a

dropdown in performance when the data exceeds a certain

limit. One solution would be to employ microservices and

organize the data over several smaller databases. eSano also

still relies on eCoaches to send reminders to their users

manually if, for example, the user did not go through a

lesson that was made available after a certain amount of

time has passed. Automatic reminders should be imple-

mented to detect such cases and send reminders to users

who have activated the reminders option in their profile.

Other limitations include the lack of a mechanism to collect

more data on the users via smart sensing. Such data can

provide an understanding of the user experience and deliver

better behavioral health treatments [20] [21]. Furthermore,

the introduction of just-in-time adaptive interventions (JITAI)

to eSano is still in its early stages and more research is

needed before such interventions can be made available for

users. However, eSano is already being used to improve

the well-being of its users. An example of such use is

the development of PSYCHOnlineTherapie (POT) [22] for

the (accompanying) treatment of depressive disorders and

anxiety disorders. The online modules of POT are based

on cognitive behavioral therapy. The intervention contains

lessons for depression, different anxiety disorders and other

transdiagnostic modules (e.g., on loneliness, perfectionism,

gratitude, sleep, physical activity). iCHIMPS is another IMI

developed and delivered via eSano. This IMI aims to support

adolescent children of parents struggling with mental health

disorders. A cluster-randomized controlled trial (cRCT) is

already planned to evaluate the clinical effectiveness as well

as cost-effectiveness of iCHIMPS against that of traditional

treatment models [23]. Currently, there are already over 500

active users on the platform who have worked on more than

2800 unique answer sheets.

VII. SUMMARY & OUTLOOK

This paper has discussed one possible solution to the

global mental health treatment gap, in the form of an online

mental health treatment tool. More specifically, it described

the development of the backend powering eSano, which is

an eHealth platform for Internet- and mobile-based interven-

tions that could be utilized as a remote and easily accessible

treatment tool for mental health disorders worldwide. The

general workflow and concepts of the platform were pre-

sented. In addition, the key functional requirements of eSano

were discussed, as well as the technical approaches, main

interfaces and underlying features that were implemented in

the backend to fulfill these requirements. Most importantly,

the data model behind the platform and the concept of

intervention instances were presented in more detail. Finally,

technical and conceptual limitations of the platform were

discussed and it was described how eSano is currently used

in practice.

For future versions of eSano, some of the limitations (see

Section VI) of the platform are planned to be addressed.

These include the addition of new features, such as interfaces

to external eHealth systems (e.g., via FHIR), personalization

options and automatic reminders, as well as the integra-

tion of new scientific developments such as just-in-time

adaptive interventions, smart sensing, and persuasiveness.

Furthermore, the platform should be optimized in terms of

scalability and privacy. Finally, when it comes to mental

disorder interventions, user engagement is often an important

factor. Therefore, as eSano continues to be developed, it is

intended to focus on approaches that engage users and to

create a convenient, easy-to-use, and trusted platform for

patients, clinicians, and researchers.

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