The results of a recent systematic review highlighted the benefits of HITs on the quality and efficacy of health care, partly by facilitating adherence to guidelines or protocol-based care with the aid of embedded electronic decision support functions [11]. Specific examples from the mental health field include consistent support for phone calls or short message service text messages about medications, resulting both in improved adherence and reductions in hospitalizations, as well as for the use of Web-based self-management tools to improve quality of life, mood, and social functioning [12]. Handheld devices to support health care consultations have also been shown to improve satisfaction with care [12]. Despite the unique and additive benefits of HITs to mental health service quality, previous studies have shown that a range of facilitators, barriers, and contextual conditions impact on implementation adoption and sustainment [13-16], potentially resulting in underutilization. Specifically, several recent reviews have documented potential barriers and facilitators to implementation processes [17-21], which can be divided into service-level, health professional, and individual factors. Notably, there is often a reciprocal relationship between facilitators and barriers, such that a facilitator that is not championed can quickly become a barrier and vice versa.

The importance of leadership from the senior service management, as well as at the local service level, is consistently highlighted as a potential facilitator to successful implementation [17,18,21,22]. Indeed, our experience implementing a prototype technology-enabled solution [23], described in detail below, across 5 youth mental health services highlighted the benefit of strong local leadership to promote service innovation, as well as R&D within a service [24]. Senior leaders help ensure alignment between the technology and the service mission and help foster an organizational culture that is open to change in the service model and receptive to the technology-enabled solution [17]. In this regard, involvement of local champions (ie, prominent and well-respected individuals in a service) in the co-design and co-development of the solution and its implementation is frequently emphasized as a facilitator of successful implementation [18,25]. In addition, executive sponsorship is essential to emphasize the organizational commitment and demonstrate support for service change and redevelopment, especially given that the underestimation of change management can also act as a barrier to successful implementation [17,20]. Service leaders engender a positive attitude toward change and encourage adoption of the technology-enabled solution by frontline staff and consumers. Contingencies need to be put in place to ensure that the local champion roles are always filled, regardless of staff turnover.

Consideration should also be given to the degree of alignment between conventional service models and workflows and the solution, as misalignment represents a barrier to successful implementation, with higher degrees of misalignment increasing the complexity of the implementation [26]. Furthermore, in a systematic review of electronic health implementations, workflow disruptions were found to be the most cited factor in determining the success or failure of an implementation [20]. Collaboration and R&D between researchers and service staff (eg, health professionals, administrators, and service managers), as well as consumers with lived experience and their families, in relation to the iterative co-design and co-development of the technology-enabled solution (including service model), are critically important components to implementation success and sustainability for mental health services reform [15,18,20,27,28].

Resource limitations, including lack of appropriate personnel and equipment, are routinely reported as barriers to implementation [17,21]. Interestingly, however, the availability of adequate resources within a service has not been found to be a specific facilitator of implementation. As summarized by Vis et al [21], reliable access to information and communications technology (ICT), as well as any required interoperability with other existing technology within the service, such as an electronic medical record or client management system, is a key determinant of implementation.

A number of factors related to health professionals have been identified as facilitators for successful implementation. For example, the co-design and configuration of the solution to fit the needs of health professionals foster buy-in and acceptance [18,21,22]. Successful implementation is also facilitated by effective education and training of health professionals, which nurtures self-efficacy and capacity in the context of continuous on-the-ground support [17,18,21,22]. Indeed, research indicates that learning outcomes are enhanced when initial education and training are supplemented with ongoing implementation support [29]. Several potential barriers to implementation at the level of health professionals have also been consistently reported in the literature, including negative staff attitudes, resistance to change, and changes to work practices [17,20-22].

Implementation theories consistently state the importance of considering consumers’ needs when designing any implementation processes intended to improve outcomes [30,31]. As such, the involvement of consumers with lived experience and their families in the co-design process is key to implementation success [20]. Consideration of consumer preferences for and disparities in the use of digital devices and modes of technology (eg, email, app, and website) to connect with health services is essential [32] when iteratively designing and developing technology-enabled solutions. Other identified facilitators include consideration of the convenience and appropriateness of the solution in addressing consumers’ health care needs [21], the user friendliness of the solution [22,33], and the appropriate adaptations (ie, configuration) of the solution to fit the specific cultural needs of the populations seeking care [18]. As drivers of acceptance [21,22] and empowerment for consumers with lived experience [20], the combination of these factors is likely to promote successful implementation. Conversely, individual resistance or nonparticipation, recruitment and retention issues, individual concerns about privacy, confidentiality, and information security, and a failure to adapt solutions over time to meet individual needs [17,20,22] are consistent barriers to successful implementation and, in turn, mental health services reform.

The primary objective of Phase 1 is to determine the fit between the aims of the potential mental health service partner and the quality improvement goals supported by the technology-enabled solution. To begin with, it is essential to ensure that the service leadership is invested in quality improvement at the individual level and to demonstrate the relationship between this aim and the components of the technology-enabled solution. Our protocol emphasizes the importance of engaging organizational leaders from the earliest steps of the process. Furthermore, it is crucial to understand the basic attributes of the service, including the following: the characteristics of the consumers who access the service for care, the qualifications and occupancy of the service health professionals, administrators and service managers, and the current hardware and ICT infrastructure (eg, electronic medical record, client management system, and availability of Wi-Fi). It is also important to identify those persons who will be responsible for facilitating the implementation process at the service, including making decisions related to configuration and customization of the technology-enabled solution and overseeing change management processes (eg, changes to the clinical pathway, user journey, and workflows) on the ground. Provided the key tasks outlined in the scoping and feasibility phase are addressed, transition to Phase 2 then occurs. Alternatively, the service may choose to address the internal service gaps identified in this phase before proceeding to the next phase.

A key feature of the technology is that the functionality and content are configurable, which allows it to adapt easily to local contexts, as well as specialist clinical and population groups, and it thus meets the person-centered care needs of a wider range of people presenting to diverse mental health providers. The primary objective of this phase is to utilize novel and innovative co-design methodologies to develop the technology-enabled solution and service model, as well as to user (acceptance) test these solutions for mental health services reform.

Phases 1 and 2 are seen as critical to successful implementation, as they foster buy-in and commitment from stakeholders to the principles of co-design and quality improvement, and they should lead to a point where all stakeholders feel heard and are able to participate in the change process. As far as possible, all known barriers and facilitators to implementation, as they apply to the local context, have been identified at this stage, with a mitigation strategy identified for each. Despite this, new barriers and facilitators may be uncovered, which were previously unknown or underestimated; thus, having clearly established processes and identified persons to support the service through the change is key to address issues as they arise. Providing on-the-ground support to service users and staff is valuable in the early weeks or months of implementation. Furthermore, gathering feedback from all user groups, as they use the technology-enabled solution in practice, refines the technology and service model, but more importantly, the workforce and structural changes required to improve service quality (Figure 2). As illustrated in Figure 1, ongoing feedback from service staff (eg, health professionals, administrators, and service managers) is collected via Web-based surveys, semistructured interviews, and workshops to evaluate and monitor the impact of embedding the technology-enabled solution in the service, including (1) service-level changes in outcomes and processes, as well (2) as the digital readiness and competence of service staff, (3) quality, usability, and acceptability of the solution, and (4) social return on investment of embedding the solution in the service. In addition, feedback from both staff and consumers about existing and newly designed functionality is captured through quarterly user testing sessions. The fortnightly Implementation Officer Logs are also used to gather data from service staff, including anonymous commentary and feedback provided by individuals with lived experience, including consumers and their families or supportive others, who are engaging with the solution as part of care, which are then fed back through to R&D processes to inform the iterative design and development of the technology-enabled solution. This feedback may include technical difficulties, as well as comments in relation to the user experience and clinical aspects of the solution. Google Analytics is also embedded within the solution to allow back-end analysis of user behavior, including details regarding the features of solution that consumers use most consistently, as well as those features with which they disengage most quickly. Of note, in the absence of a 24-hour monitoring protocol to ensure the safety of all users at this time, there is no option for consumers to provide free text feedback.

Importantly, it is generally accepted in digital mental health research that the technology-enabled solution will be iteratively developed, designed, and refined during implementation. The expected outcome of Phase 3 is for the technology to be embedded and integrated within the service, such that it is seen as a vital piece of standard care, enabling and maintaining ongoing service quality improvement and reform.

In accordance with Lennox et al [39], the primary objective of Phase 4 is the continuation and maintenance of our technology-enabled solutions and their associated outcomes within a health service, as well as the iterative process of evaluation and design, to address problems and emerging needs and demands of the service, individual populations, and the broader context [15]. To achieve this aim, prospective approaches are employed throughout the preceding phases to build relationships with and foster buy-in from key stakeholders (ie, consumers with lived experience and their families, health professionals, administrators, and service managers), as well as to iteratively design and refine the technology-enabled solution to adapt to the changing needs of the stakeholders and service [39]. Employing these processes helps to ensure the continued effectiveness of the technology-enabled solution, including improved access to care and resources to promote mental health and well-being, the integration of the technology within the service, and community ownership of the solution [40]. When taken together, this reflects the primary outcome of Phase 4, namely technology-enabled mental health services reform.

Furthermore, the objective of Phase 4 is to leave a configurable technology-enabled solution in place for ongoing and continued benefit to the service, following the replacement of a locally available Implementation Officer with a more sustainable supporting resource that is readily available remotely.