Beliefs and Attitudes About the Dissemination and Implementation of Internet-Based Self-Care Programs in a Large Integrated Healthcare System

  • Eric D. A. HermesEmail author
  • Laura Burrone
  • Alicia Heapy
  • Steve Martino
  • Elliottnell Perez
  • Robert Rosenheck
  • Michael Rowe
  • Josef I. Ruzek
  • Carolyn Greene
Original Article


Behavioral intervention technologies (BITs) are online programs or mobile applications that deliver behavioral health interventions for self-care. The dissemination and implementation of such programs in U.S. healthcare systems has not been widely undertaken. To better understand these phenomena, we explored perspectives on BIT deployment in the Veterans Health Administration. Interviews from 20 providers, administrators, and policy makers were analyzed using qualitative methods. Eight themes were identified including the use of traditional healthcare delivery models, strategies for technology dissemination and implementation, internet infrastructure, leadership, health system structure, regulations, and strategic priorities. This research suggests policy, funding, and strategy development initiatives to promote the implementation and dissemination of BITs.


Cognitive behavioral therapy Internet-based therapy Health information technology Internet Veterans Implementation Dissemination 



The authors acknowledge and are grateful for the guidance of Mona Ritche, MSW, PhD in the use of the Atlas/ti. qualitative data analysis and management software. Interviews were transcribed by the VA HSR&D Centralized Transcription Services Program located at the VA Salt Lake City Healthcare System.


The research outlined here was supported by the Department of Veterans affairs, Veterans Health Affairs, HSR&D Career Development Award (Grant Number 119234740) to Eric Hermes, M.D. as well as the VA New England Mental Illness Research, Education, and Clinical Center and The VA Pain, Research, Informatics, Medical comorbidities, and Education (PRIME) Center. The funding sources had no role in the design, analysis or interpretation of data or in the preparation of the report or decision to publish.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the VA Connecticut Healthcare System and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Research Involving Animal and Human Participants

This article does not contain any studies with animals performed by any of the authors.


  1. Baker, R., Camosso-Stefinovic, J., Gillies, C., Shaw, E. J., Cheater, F., Flottorp, S., … Eccles, M. P. (2015). Tailored interventions to address determinants of practice. The Cochrane Library, 29, CD005490.Google Scholar
  2. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.CrossRefGoogle Scholar
  3. Campbell, A. N., Nunes, E. V., Matthews, A. G., Stitzer, M., Miele, G. M., & Polsky, D. (2014). Internet-delivered treatment for substance abuse: A multisite randomized controlled trial. American journal of psychiatry, 171(6), 683–690.CrossRefGoogle Scholar
  4. Common Mental Health Problems: Identification and Pathways to Care. (2011). London: National Institute for Health and Care Excellence (NICE). (Clinical Guideline 123). Retrieved from
  5. Demakis, J. G., McQueen, L., Kizer, K. W., & Feussner, J. R. (2000). Quality Enhancement Research Initiative (QUERI): A collaboration between research and clinical practice. Medical Care 38(6), I-17–I-25.Google Scholar
  6. England, M. J., Butler, A. S., & Gonzalez, M. L. (2015). Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-based standards. Washington, DC: National Academy Press.Google Scholar
  7. Evans, D. C., Nichol, W. P., & Perlin, J. B. (2006). Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration. Health Economics, Policy and Law, 1(2), 163–169.CrossRefGoogle Scholar
  8. Fleming, T., Bavin, L., Lucassen, M., Stasiak, K., Hopkins, S., & Merry, S. (2018). Beyond the trial: Systematic review of real-world uptake and engagement with digital self-help interventions for depression, low mood, or anxiety. Journal of Medical Internet Research, 20(6), e199.CrossRefGoogle Scholar
  9. Fortney, J. C., Burgess, J. F., Bosworth, H. B., Booth, B. M., & Kaboli, P. J. (2011). A re-conceptualization of access for 21st century healthcare. Journal of General Internal Medicine, 26(2), 639–647.CrossRefGoogle Scholar
  10. Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. T. (2016). A tipping point for measurement-based care. Psychiatric Services, 68(2), 179–188.CrossRefGoogle Scholar
  11. Gilbody, S., Littlewood, E., Hewitt, C., Brierley, G., Tharmanathan, P., Araya, R., … Gask, L. (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): Large scale pragmatic randomised controlled trial. British Medical Journal, 351, h5627.CrossRefGoogle Scholar
  12. Grol, R., Wensing, M., Eccles, M., & Davis, D. (Eds.)., (2013). Improving patient care: The implementation of change in health care. Hoboken: Wiley.Google Scholar
  13. Hermes, E., Burrone, L., Perez, E., Martino, S., & Rowe, M. (2018). Implementing internet-based self-care programs in primary care: Qualitative analysis of determinants of practice for patients and providers. JMIR Mental Health, 5(2), e42.CrossRefGoogle Scholar
  14. Jha, A. K., Perlin, J. B., Kizer, K. W., & Dudley, R. A. (2003). Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. New England Journal of Medicine, 348(22), 2218–2227.CrossRefGoogle Scholar
  15. Kaltenthaler, E., Sutcliffe, P., Parry, G., Beverley, C., Rees, A., & Ferriter, M. (2008). The acceptability to patients of computerized cognitive behaviour therapy for depression: A systematic review. Psychological Medicine, 38(11), 1521–1530.CrossRefGoogle Scholar
  16. Mair, F. S., May, C., O’Donnell, C., Finch, T., Sullivan, F., & Murray, E. (2012). Factors that promote or inhibit the implementation of e-health systems: An explanatory systematic review. Bulletin of the World Health Organization, 90, 357–364.CrossRefGoogle Scholar
  17. Mohr, D. C., Burns, M. N., Schueller, S. M., Clarke, G., & Klinkman, M. (2013). Behavioral intervention technologies: Evidence review and recommendations for future research in mental health. General Hospital Psychiatry, 35(4), 332–338.CrossRefGoogle Scholar
  18. Mojtabai, R., Olfson, M., Sampson, N. A., Jin, R., Druss, B., Wang, P. S., … Kessler, R. C. (2011). Barriers to mental health treatment: Results from the National Comorbidity Survey Replication. Psychological Medicine, 41(8), 1751–1761.CrossRefGoogle Scholar
  19. Nelson, K. M., Helfrich, C., Sun, H., Hebert, P. L., Liu, C.-F., Dolan, E.,.. . Hernandez, S. E. (2014). Implementation of the patient-centered medical home in the Veterans Health Administration: Associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Internal Medicine, 174(8), 1350–1358.CrossRefGoogle Scholar
  20. Quanbeck, A., Gustafson, D. H., Marsch, L. A., Chih, M. Y., Kornfield, R., McTavish, F., … Shah, D. V. (2018). Implementing a mobile health system to integrate the treatment of addiction into primary care: A hybrid implementation-effectiveness study. Journal of Medical Internet Research, 20(1), e37.CrossRefGoogle Scholar
  21. Quinn, C. C., Clough, S. S., Minor, J. M., Lender, D., Okafor, M. C., & Gruber-Baldini, A. (2008). WellDoc™ mobile diabetes management randomized controlled trial: Change in clinical and behavioral outcomes and patient and physician satisfaction. Diabetes Technology & Therapeutics, 10(3), 160–168.CrossRefGoogle Scholar
  22. Sander, L., Rausch, L., & Baumeister, H. (2016). Effectiveness of Internet-based interventions for the prevention of mental disorders: A systematic review and meta-analysis. Journal of Medical Internet Research - Mental Health, 3(3), e38.Google Scholar
  23. Schueller, S. M., Tomasino, K. N., & Mohr, D. C. (2017). Integrating human support into behavioral intervention technologies: The efficiency model of support. Clinical Psychology: Science and Practice, 24(1), 27–45.Google Scholar
  24. Tang, P. C., & Smith, M. D. (2016). Democratization of health care. Journal of the American Medical Association, 316(16), 1663–1664.CrossRefGoogle Scholar
  25. Titov, N., Dear, B. F., Staples, L. G., Bennett-Levy, J., Klein, B., Rapee, R. M., … Nielssen, O. B. (2017). The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives. Australian & New Zealand Journal of Psychiatry, 51(12), 1227–1239.CrossRefGoogle Scholar
  26. Tsai, J., & Rosenheck, R. A. (2012). Use of the internet and an online personal health record system by US veterans: Comparison of Veterans Affairs mental health service users and other veterans nationally. Journal of the American Medical Informatics Association, 19(6), 1089–1094.CrossRefGoogle Scholar
  27. Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of information technology: Toward a unified view. MIS quarterly, 27, 425–478.Google Scholar
  28. Veterans’ A. Choice and Accountabilaity Act of 2014. (H.R. 3230; P.L. 113–146). Retrieved from
  29. Warmerdam, L., Smit, F., van Straten, A., Riper, H., & Cuijpers, P. (2010). Cost-utility and cost-effectiveness of internet-based treatment for adults with depressive symptoms: Randomized trial. Journal of Medical Internet Research, 12(5), e53.CrossRefGoogle Scholar
  30. Wasserman, J., Ringel, J., Wynn, B., Zwanziger, J., & Ricci, K. (2001). An analysis of the veterans equitable resource allocation (VERA) system (No. RAND/MR-1419-DVA). Santa Monica: Rand National Defense Research Institute.Google Scholar
  31. West, A., & Weeks, W. B. (2006). Physical and mental health and access to care among nonmetropolitan Veterans Health Administration patients younger than 65 years. The Journal of Rural Health, 22(1), 9–16.CrossRefGoogle Scholar
  32. Wicklund, E. (2018). VA finalizes ‘Anywhere to Anywhere’ telehealth program for vets. mHealth Intellignece. Retrieved from

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply  2019

Authors and Affiliations

  1. 1.VA Connecticut Health Care SystemWest HavenUSA
  2. 2.Department of PsychiatryYale University School of MedicineNew HavenUSA
  3. 3.VA Pain Research, Informatics, Multi-Morbidities, and Education (PRIME) CenterVA Connecticut Health Care SystemWest HavenUSA
  4. 4.Program for Recovery and Community Health, Department of PsychiatryYale University School of MedicineNew HavenUSA
  5. 5.Dissemination and Training DivisionVA National Center For PTSD Department of Veterans Affairs, VA Palo Alto Healthcare SystemMenlo ParkUSA
  6. 6.Center for m2 HealthPalo Alto UniversityPalo AltoUSA
  7. 7.Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordUSA
  8. 8.Office of Mental Health and Suicide PreventionDepartment of Veterans Affairs, Central OfficeWashingtonUSA

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