Table 3 Themes regarding use of digital intervention to address mental health in the orthopedic care setting

Feasibility

Appealing: The ease of referring a patient to an app is appealing to orthopedic clinicians and clinical support staff, especially if the added resource reduces how much the patient needs to navigate mental health and pain challenges through the orthopedic office. Ideally, the app could be somewhat customized to the orthopedic patient population, even to the relevant body part or surgery (e.g., post-operative precautions, activity progression).

“I think an app like this would be amazing for a huge portion of the patients that we have.” (Medical assistant)

“I’m not saying to a patient, ‘I’m treating your depression with this.’ I’m telling the patient, ‘This is a resource that we have, that we use as an option to help improve the patient’s well-being.’” (Physician)

“This, to me, would not be very difficult to discuss and just provide the information. Like, ‘Here’s an app. This is a platform you can use, and we highly recommend it. By no means do you have to use it.’ I mean, it’s a conversation piece. It’s not like we’ve got to spend 30 minutes discussing this…And quite honestly, we spend a lot of time talking to patients about their pain and about how it’s affecting their lifestyle. And it may even take some of that off of us because now they’re using their app versus us.” (Nurse)

Persistent implementation concerns: Potential barriers to delivering a mental health app in the orthopedic care setting include: (1) out-of-pocket costs for patients, and (2) the concern for added medicolegal liabilities and responsibilities out of the scope of practice for orthopedic clinicians and team members.

“I’m on a fixed income, so any increase in my healthcare cost, I’ve got to monitor pretty closely. I’ve seen people on social security who budget – they don’t have an extra $5 to spare.” (Patient, 44-year-old White man)

“[Maybe] you can get it from your health insurance, and they pay for it.” (Patient, 40-year-old White woman)

“My first thought is that this would probably be a nice resource for patients. My second thought is, if you initiate some intervention or application, what kind of legal responsibility do you have based on that output? What I don’t want to do, personally, is increase my medicolegal risk on being responsible for intervening or providing outputs to patients where I have no knowledge base or expertise.” (Physician)

Acceptability

Digital advantages: The app was appealing to orthopedic patients who: (1) were interested in self-help resources, (2) did not feel ready or interested in reaching out to a person for mental health assistance, and (3) wanted convenient access to on-demand resources.

“I think this is excellent because people have access and the ability to look it up and say, ‘Oh, I’m getting stressed out about this. What exercises do I do?’” (Patient, 71-year-old Asian man)

“I believe with the app, it’s a safety for those that choose not to get out to see someone face-to-face. Because even me going to counseling, I didn’t want the stigma of having to go to therapy… I had a family member that just said that she wouldn’t mind doing therapy if she can do it through text. And I was like, ‘How deep is that?’ Because a lot of things, sometimes people can’t verbalize or vocalize what it is they’re feeling, but they can write it down to you.” (Patient, 31-year-old Black woman)

“Online resources are sometimes the only thing that patients have. I was in a wheelchair for months, and I just couldn’t go places. I was in so much pain. You go by what you can find online.” (Patient, 43-year-old White woman)

“I love that they have times available that are really late. Because sometimes with my schedule, by the time I can actually sit down and focus on something, it’s 10:00 PM.” (Patient, 40-year-old White woman)

“I think the app will be very helpful to have when it’s late or when it’s early morning and you’re not getting any sleep or something.” (Patient, 60-year-old White man)

“For it to be here waiting for me, not having to try to navigate getting into a shrink and all of that nonsense with my primary – just any chance to introduce more mental healthcare, I think is good, honestly.” (Patient, 44-year-old White man)

Tech savviness dependent: Orthopedic patients, clinicians, and clinical support staff agreed that digital interventions such as smartphone apps are preferred by many patients. They tend to be more preferred by young and middle-aged adults and less appealing to patients who are not “tech savvy,” including many (but not all) older adults. Estimates for the proportion of clinicians’ patient populations who might be interested in a digital intervention ranged from 5–70% and clustered around 20–25%.

“[Patients] are on their phones a lot more. Everything’s going to their phones. Even when they’re in pain or if they’re miserable or something, their phones are a lot more accessible than a laptop or a piece of paper. I give them a whole packet and they’ll say, ‘I know you gave me some stuff and I wrote it down somewhere, but I don’t know where I put it.’” (Medical assistant)

“We have an online database for a particular surgery that we do, and I think 30% of my patients request paper surveys. Which is insanely high. For every other person in my division, it’s like 5–15%. So, it just tends to be my geographic location, I think, because it’s a lot of people from rural areas. They maybe don’t really like using their smartphone, so it’s a challenge. I think it’s going to be less of a challenge, and there are more and more elderly people that are used to these things, but that’s going to be your toughest population to hit with any kind of digital intervention – the elderly.” (Physician)

“I would give it a shot because, like I say, we’re getting older, and we need to know how to mentally deal with our aches and pains. We really do.” (Patient, 70-year-old Black man)

“I don’t know that I would use my phone that way.” (Patient, 67-year-old white woman)

Patient situation dependent: Patients expressed particular interest in a mental health app that addressed their coexisting orthopedic pain and limitations. Patients anticipated using a mental health app more frequently if they found it to be helpful, if they were having a flare of pain or depressed or anxious thoughts, and if the app’s interventions were short and succinct. Some, but not all, of patients also appreciated reminder notifications within the app, and some, but not all, desired their input into the app to be linked back to their medical record.

“I can think of so many people I know with chronic pain that would love this app, actually.” (Patient, 47-year-old Black woman)

“Ultimately, it’ll be whether I continue to see results from it. But right now, I’m actually pretty excited. I’ve been waiting for something like this to link my mental health with the pain that I’m in. So yeah, I’m gung ho.” (Patient, 44-year-old White man)

“Notifications, to be honest. And then also when I’m just experiencing pain, that’s when I think I would use it more.” (Patient, 64-year-old White woman)

Evidence dependent: Before recommending a mental health app to patients, orthopedic clinicians want details on the content and delivery of the actual intervention, and they want to be reassured of the quality of the intervention and how patients will perceive it. There is some concern regarding reliance on a chatbot to deliver an intervention.

“The big question that I would have is, ‘How does this compare to seeing a ‘real person’?’’ But this is presumably going to be better than nothing.” (Physician)

“I feel like people still want to talk to people. I think having a licensed provider on the other end to chat with them is better than a bot.” (Physician)

Facilitators for implementation: Facilitators reported by orthopedic patients and clinicians for delivering a mental health app to orthopedic patients include: (1) a printed informational “Getting started” handout for patients, (2) centralized phone support to assist patients in onboarding to the app, and (3) clear liability policies and a support path which does not filter mental health related questions or crises to the orthopedic clinician.

“It’s not like [our staff] are going to go through it and help put the app on the patient’s phone and go through that. Anything extensive like that might be like, ‘Oh gosh, we don’t have time to set it all up and to actually get them going with it and that type of thing.’ So yeah, I think being able to have a printed ‘How-to’ thing – to give that to them would be, I think, helpful.” (Nurse practitioner)

As an older person, I learn more through visuals. I’m finding that if I hear and see it, I can retain it better. If somebody talks to me and tells me how to get through the app, then that would be better for me. The verbal, as well as the instructional handout, would be great.” (Patient, 71-year-old Black woman)

“I’m assuming there’s a back-end to this app with someone monitoring it…We’re treating the patient and they’re putting information out there that we’re not receiving or monitoring. And what happens if this app captures a problem?” (Physician)

Usability

Varied proficiency: Although not universally true, some older and even middle-aged orthopedic patients expressed interest in using the app but had more difficulty than they anticipated navigating through the app. In contrast, some patients had no difficulty at all navigating to tools within the app, although these patients tended to be younger.

“It seemed pretty self-explanatory….Nothing was confusing.” When asked to schedule a session with the human coach: “I wouldn’t know how to get to that… I’m not sure how I got here, but I guess I just keep going back.” (Patient, 78-year-old White woman)

“It’s actually pretty clear, pretty cut and dry, which is good.” (Patient, 47-year-old Black woman)

Password recall: The most common barrier to patients using the app was that many iOS (Apple iPhone) users could not remember their App Store password and therefore could not immediately download the app, even though the download was free.

“I think they want me to enter…my Apple ID? I think I will have to go home and check it.” (Patient, 71-year-old Asian man)