Patients’ Experience of Patient-Reported Outcomes, Continuous Feedback, and a Solution-Focused Approach (Using DIALOG+) in Psychosis Care in Sweden

Patients’ Experience of Patient-Reported Outcomes, Continuous Feedback, and a Solution-Focused Approach (Using DIALOG+) in Psychosis Care in Sweden | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patients’ Experience of Patient-Reported Outcomes, Continuous Feedback, and a Solution-Focused Approach (Using DIALOG+) in Psychosis Care in Sweden Marcus Lundmark, Katarina Allerby, Andreas Gremyr, Ann-Christine Andersson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4579887/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Involving patients in their care and including them in continuous follow-up is a challenge. This challenge is often compounded by a lack of self-reported outcome measures. Incorporating such measures could aid healthcare professionals in collaboratively designing care plans and adjusting treatments as therapy progresses. Previous research highlights the positive impact of continuous feedback based on treatment outcomes and problem-solving methodology in routine psychiatric care. DIALOG + is a digitally supported conversational tool designed to enhance the therapeutic effectiveness of patient-clinician meetings by incorporating continuous self-reported outcomes and a solution-focused approach. The objective of this study was to investigate the disparities in patients' experiences when using DIALOG + compared to standard treatment and to examine the implications for clinical use within a Swedish setting. Methods A qualitative study was designed to describe patients’ experiences using DIALOG + in psychosis outpatient care in Sweden. A convenience sample of patients who used DIALOG + three times or more was included in the study. Individual semi-structured interviews were conducted with ten patients. The interviews were analysed using reflexive thematic analysis. Results The analysis identified two themes: 'The supportive features of DIALOG+' and 'Providing a constructive structure'. These themes consist of six sub-categories: Expanded the understanding of my health; Moving toward improvement; Provided memory support; Empowering participation; Distinguishing DIALOG + as a constructive complement, and Experiences of the digital tool. Conclusion The structure of DIALOG+, including continuous feedback and the solution-focused approach, seems to enhance person-centred care for patients with psychotic disorders, fostering shared decision-making and aiding memory support. It also facilitates a collaborative understanding of the patients’ health concerns and personal goals, which shows that DIALOG + could be useful as a tool to develop care plans that are more tailored to the patients’ needs. Despite some concerns about structured dialogues, DIALOG + holds promise for improving patient-clinician interactions and treatment outcomes in psychosis care in Sweden. Additional research is planned, which will include an exploration of clinicians' experiences with DIALOG + as well as observational and effectiveness studies. DIALOG+ Severe mental illness Psychotic Disorders Digital intervention Co-production Patient Reported Outcome Measures Routine outcome monitoring Continuous Feedback Problem-solving Figures Figure 1 Background Chronic illnesses, including mental health conditions, represent a significant and growing challenge in healthcare (Epping-Jordan et al., 2004 ). Severe mental illness, and psychotic disorders in particular, have a profound impact on the affected person’s life and have been shown to result in reduced quality of life (Saarni et al., 2010 ). A significant portion of individuals diagnosed with schizophrenia experience deterioration leading to inpatient care, and a high percentage of patients discontinue treatment (Tiihonen et al., 2017 ). Furthermore, this group has a reduced life expectancy compared to the general population (Crump et al., 2013 ). The care of persons with psychotic disorders, which are characterised by positive symptoms (such as hallucinations and delusions), negative symptoms (such as social withdrawal and flattened affect), and cognitive impairments, requires a nuanced and multifaceted approach, integrating medical, psychological, and social support strategies. Although patients want to participate in their own care (Hamann et al., 2005 ) and both national guidelines and Swedish law require patient participation (Patients' Act, 2014; Swedish Agency for Health Technology Assessment and Assessment of Social Services, 2012), symptom severity and treatment discontinuation pose challenges to involving patients in care during routine encounters. In recent years, there has been a surge in academic interest in patient involvement, particularly through "co-production", which reflects a fundamental change in the approach to patient care management (Elwyn et al., 2020 ; Masterson et al., 2022 ). Co-production involves a collaborative approach where patients and healthcare providers work together as equal partners, contributing jointly to the planning, development, and management of care. Understanding patients' well-being and their perceptions of care is a key challenge in facilitating care and support strategies that are designed in collaboration with patients. Co-production, which involves direct collaboration between service users and providers in the design, delivery, or evaluation of services, is recognised for its ability to enhance healthcare outcomes while improving service quality, user satisfaction, and empowerment (Masterson et al., 2022 ). Elwyn et al. ( 2020 ) outline an iterative co-production cycle consisting of the steps 'co-assess', 'co-decide', 'co-design', and 'co-deliver' to ensure that the patient is involved in the entire care process. Systematic attention to patient needs and supportive information systems are important for improving outcomes and satisfaction, and reducing healthcare costs (Wagner et al., 1996 ). This underscores the importance of a comprehensive approach to chronic illness management that emphasises personalised care and effective communication between providers and patients. There are several methods that seek to incorporate patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) within healthcare. Outcome management is an increasingly preferred method that involves continuous assessment and monitoring of a patient's progress during treatment to positively influence the overall treatment process (Lambert, 2013 ). This type of continuous, real-time feedback is particularly beneficial in addressing any unexpected challenges and ensuring that the treatment aligns with the patient's evolving needs, and it has been shown to be more effective than treatment as usual (Goodman et al., 2013 ; Lambert, 2017 ). Furthermore, the aggregation of PROM and PREM data has the potential to facilitate a deeper understanding of the real life effectiveness of interventions and areas requiring improvement. Such an approach, which is known as a Learning Health System (LHS), has shown promise in driving continuous quality improvement within mental health services for individuals diagnosed with severe mental illness (Gremyr et al., 2019 ). DIALOG + is a digital support tool that incorporates a self-assessment feature along with a problem-solving methodology. The method is designed to be utilised during routine encounters between patients and clinicians. The intervention involves a systematic process that begins with an assessment of the patient's satisfaction in eight life domains (PROMs) and three treatment domains (PREMs). The assessment helps the patient and the clinician to jointly identify areas that require further attention and support. The ratings can be compared with previous assessments, thus providing a longitudinal perspective on the patient's progress. During the session, the patient selects specific domains to discuss further, indicating areas where additional support is needed. This collaborative decision-making process seeks to empower patients by allowing them to prioritise their concerns and preferences, enabling them to lead discussions that are aligned with their needs. A solution-focused approach, which focuses on exploring potential solutions, setting goals, and reaching decisions on further actions, is employed to address the patient’s identified concerns. At the next DIALOG + session, agreed-upon decisions, along with new ratings, ensure ongoing patient feedback on how the therapy unfolds. [Fig. 1] Fig. 1. The Dialog + interface showing patient's ratings, where the current session ratings (top blue line) are compared to a selected previous session's ratings (bottom pink line). At far left each category for conversation is shown. Previous research has shown promising results when using DIALOG + in routine care, particularly for individuals diagnosed with psychosis. Studies have found that DIALOG + interventions are cost-effective while enhancing social outcomes, improving quality of life, and reducing unmet needs and general symptom levels (Priebe, 2013, 2015). Process evaluations involving patient and clinician feedback highlight the positive impact of DIALOG + on subjective quality of life, especially in areas like living situation and mental health (Omer et al., 2016 ). Pilot studies in Germany and evaluations in mental health trusts in East London have further demonstrated improvements in symptoms and patient satisfaction with life and treatment (Fichtenbauer et al., 2019 ; Mosler et al., 2020 ). Clinicians reported a high acceptability of using Dialog + for patients with chronic depression (Matanov et al., 2021 ). Research in low and middle income countries also supports the efficacy of DIALOG + in enhancing a holistic care of patients with psychosis (Jovanović et al., 2022 ). DIALOG + shows promising results in routine care, particularly for individuals diagnosed with psychosis, by enhancing social outcomes, improving quality of life, reducing unmet needs and general symptom levels, and demonstrating high acceptability among clinicians and patients across various settings. The aim of this study is to examine the experiences of patients participating in DIALOG + sessions in the Swedish healthcare system. It compares these sessions to standard routine encounters, focusing on aspects of co-production, as well as the utilisation of continuous feedback and a solution-focused approach. Method Study Design and Setting This study uses a qualitative design to explore patients' experiences of DIALOG + sessions. The study took place at the Department of Psychotic Disorders, Sahlgrenska University Hospital, in Gothenburg, Sweden. The department comprises seven outpatient clinics dedicated to serving approximately 3,000 patients, who collectively account for approximately 30,000 clinical encounters each year. The outpatient units specialising in psychosis care strive to adhere to the recommendations outlined in the Swedish national guidelines for psychosis care (Socialstyrelsen, 2018 ). This includes the implementation of a Case Management model and Flexible Assertive Community Treatment, with interdisciplinary teams comprising psychiatrists, nurses, specialised psychiatric assistant nurses, social workers, occupational therapists, psychologists, and physiotherapists or health coaches. The term 'clinicians' is used here to refer to healthcare professionals directly engaged in patient care. To improve the understanding of care content, its effects, patient involvement, and the consistency of care delivered, the department started a project in 2020 which focuses on the translation, design, and expert evaluation of DIALOG+ (Lindenfalk et al., 2022 ), along with pilot testing in 2021 (Lundmark, 2021 ). The comprehensive implementation of DIALOG + started in April 2022, with 111 clinicians undergoing a one-day training to ensure the correct use of DIALOG + during routine patient meetings. This study was conducted during the Covid-19 pandemic, and face-to-face meetings with patients were at times difficult to arrange. Therefore, patients were offered a combination of in-person and virtual DIALOG + sessions. In the virtual meetings, screen share mode was utilised to ensure that patients could access the content. Participants A convenience sampling approach was used to recruit participants from three outpatient units. The inclusion criteria for participants were 1) engagement in three or more DIALOG + sessions (to ensure enough experience to provide comprehensive information about DIALOG+) and 2) being in active treatment with at least one clinician meeting every two months. Fifteen patients met the inclusion criteria; all were asked to participate, of which three declined. Two patients were excluded due to difficulties with the Swedish language or not meeting the inclusion criteria. The final sample consisted of 10 patients, of which six were women. The overall age range of the sample varied from 31 to 63 years. These patients received DIALOG + sessions from seven clinicians (nurses and mental health nurses) with experience working in outpatient care ranging from 2 to 26 years. Nine patients had contact with the respective outpatient unit for over one year. In the past 12 months, these patients met with their clinician on average 32 times. Eight patients were diagnosed with schizophrenia spectrum and other psychotic disorders, and two with mood disorders (World Health Organization, 2019 ). Three patients used DIALOG + through video meetings and one used a mix of video and in-person meetings. All other patients used DIALOG + through in-person meetings. All participants provided informed consent prior to their involvement in the study. Data Collection Data were collected through individual interviews from December 2021 to January 2023. The interviews were conducted by the first author using a semi-structured interview guide. The structure and questions of the interview guide were inspired by a focus group study conducted by Priebe et al. ( 2017 ). The interview focused on participants’ experiences of Dialog + and their interactions with clinicians. It began with questions about the duration of contact with psychiatric care and experiences of Dialog + sessions. Participants described how meetings were conducted before and after Dialog + was introduced, discussing the topics covered, decision-making processes, and the focus of conversations. They were asked about their experiences with self-rated well-being and the structure of Dialog + sessions, as well as how topics for further discussion were decided upon. The interview also explored the four-step approach to discussing problems, participants' experiences with the Dialog + software, and overall thoughts on using Dialog + in therapy sessions, including any changes in the relationship with the therapist and preferences for using Dialog+. The interviews took place at the participants’ outpatient clinic (n = 7) or via video meetings (n = 3) and lasted between 20–45 min. All interviews were audio-recorded after obtaining the consent of participants. Audio recordings were subsequently transcribed verbatim for analysis. After the interviews, data was securely stored and de-identified to protect participants´ identities and maintain confidentiality. Data Analysis The data analysis was conducted using reflexive thematic analysis, following the steps described by Braun and Clarke ( 2022 ). The method aimed to generate an understanding of patterns, themes, and meanings from textual data, while acknowledging the researchers’ reflexivity and subjectivity in the analysis process. Nvivo (version 14) was used to manage data during the analysis. The analysis began with the reading of transcripts, followed by an initial open coding where codes were formulated inductively, without preconceived categories, in order to facilitate the discovery of unexpected themes. This led to the generation of numerous codes, which were then thoroughly reviewed and refined through discussions between the coders. The subsequent phase focused on identifying themes within the dataset. The researchers placed significant emphasis on maintaining thematic consistency and coherence, ensuring a representative portrayal of diverse perspectives within the data, and ensuring that the analysis level matched the importance of the themes. Illustrative quotes were selected to provide examples of each theme, ensuring transparency and supporting the credibility of the findings. Two of the authors (ML and KA) conducted the analysis collaboratively. The researchers remained attentive to their subjectivities and biases throughout the analysis, engaging in reflexive practices. This included regular discussion of thoughts, feelings, and preconceptions that inform the analysis and influence the interpretation of the findings. This self-reflection aimed to ensure transparency and acknowledge the potential influence of the researcher's perspectives on the analysis. Discrepancies in coding and theme development were discussed until consensus was reached . Results The analysis resulted in two themes: 'The supportive features of DIALOG+' and 'Providing a constructive structure'. The first theme illuminates the participants' experiences in relation to specific features of DIALOG+, while the second theme explores participants’ perceptions of the digital tool and differences between DIALOG + and traditional routine encounters. [Table 1 ] Themes and sub-themes Table 1 Themes and sub-themes Theme 1: The supportive features of DIALOG+ Theme 2: Providing a constructive structure Expanded understanding of my health Distinguishing DIALOG + as a constructive complement Moving toward improvement Experiences of the digital tool Provided memory support Empowering participation Theme 1: The supportive features of DIALOG+ Participants described how different aspects of the DIALOG + session helped them, and these features collectively support a process towards improved health. The features of DIALOG + guided participants in an exploratory process that helped them gain an ‘understanding’ of their health, which was an important first step towards improvement. The enhanced understanding prompted a movement towards improvement through the deliberate selection of areas for further discussion. Identifying concrete problems or goals, and planning corresponding actions were key features that allowed participants to achieve control and work towards improvement. Memory support was provided in various ways, which was considered valuable and enhanced the result of the other features. The encouragement of participation and individual choice had an empowering effect, further strengthening the participants’ engagement. Expanded understanding of my health Two aspects assisted participants in achieving a more comprehensive understanding of their health: the rating feature and the holistic approach provided by the various areas rated. Several participants mentioned that actively rating different health areas helped them get an overview of their overall well-being, highlighting areas of both strength and concern. The rating process served as the basis for reflection and discussion of what influenced the participants’ ratings in different areas. This process transformed the more abstract notion of 'how I feel' into a concrete reflection on the factors that actually impact well-being, allowing participants to understand the numerous aspects that contribute to their emotional state. It becomes a visualisation ... making my well-being status more concrete. (p8) I felt that with DIALOG+, it was more mapped out, the feelings you have and how you behave in different situations. You could see that in the rating, on that particular day, I must have felt a bit worse or a bit better. It's interesting to know what affects such things, that you sometimes feel worse. Being able to look at the different variables was good. (p6) Comparing current ratings with previous ratings also contributed to an overall picture of well-being and changes over time. The ability to track changes in ratings over time added a layer of insight into the participants’ understanding of their own health. This also allowed them to draw conclusions and to understand underlying causes. It helps to have the overall picture, like how it was then compared to how it is now. (p10) ... the function seems good, because then you can clearly see if you have improved in any area. (p2) Moreover, it serves the purpose of acknowledging the potential for change; participants could explicitly see improvements or periods of lower satisfaction, fostering a sense of hope. Several participants also linked this feature to an area of discussion, suggesting that an expanded understanding of one's health is an important initial step in identifying relevant areas for further discussion and prioritisation of actions. It was interesting that the way you feel could change so much, from feeling very bad at one time to feeling much better the next time. You could identify why you felt like that. Sometimes it could be that something had happened, and sometimes it was just my mood on that particular day. (p6) DIALOG+'s coverage of ratings across 11 different domains provided several participants with a more holistic perspective on their health. They were able to gain insight into areas of health that they may have otherwise overlooked or that they had not thought about bringing up for discussion. One participant also reported that she felt more respected, as the use of DIALOG + made the clinician aware of additional areas that affected her, providing a fuller picture of her life situation and challenges. I think DIALOG + gives a more holistic perspective. You get the whole picture of mental health. And it's everything from social factors, and specifically the psychiatric, if you have any psychotic symptoms or similar. (p10) Moving toward improvement Participants described how DIALOG + helped them move forward by giving them the opportunity to choose relevant areas for further discussion, identify problems, and plan for action. The opportunity to choose specific areas for further discussion and support in DIALOG + was highly valued by most participants. It was viewed as a straightforward and concrete way to identify relevant areas where support was needed. The range of areas identified suggested what could be addressed and allowed for the exploration of difficult topics that might not otherwise be explored. This allowed participants to explore specific topics in more depth, addressing issues more directly compared to previous unstructured conversations. It is a very straightforward model. When you have a conversation [before using DIALOG+], it takes a while before you start talking about certain things. You may need to meet a few times. This model highlights different areas, that's what I mean by saying it's more straightforward. You choose areas and then we dig deeper into what you need to talk about. (p3) The ratings helped to address areas in need of improvement, and some participants expressed that this was important when deciding on what area to address during the encounter. Accessing the results of the ratings was also helpful, since areas in need of improvement also became clearer for the clinician. The option to work on areas with lower satisfaction ratings encouraged some participants and clinicians to confront and address challenging issues that might have otherwise been overlooked. It was very concrete that you had to choose which areas you wanted more support and help, that you can bring up a topic and go into it a bit deeper, gather your thoughts around it. It was helpful to be able to do that. This makes it stricter and more concrete and tackles the problem. Otherwise, it's easy to not talk about what's difficult and avoid it. (p2) Several participants went on to describe how DIALOG + helped them pinpoint problems and decide on actions to solve them or to create goals and plan actions to reach set goals. This process provided a sense of growth, especially when participants achieved their goals. Most of the participants’ statements regarding defining problems or goals and ways to address these were related to the built-in solution-focused method. Participants’ referred to the approach helping them maintain focus, working together to find solutions, agreeing on actions, and being motivated to enact the plan while deciding on follow-up measures. Some statements suggested that the DIALOG + feature helped participants solve problems that were difficult to solve before. The problem-solving feature also encouraged some participants to consider involving others (e.g. family members) in their support network and helped them seek out care and support. Statements suggest that DIALOG + increased the participants’ engagement and involvement in their own care. From the second session, we agreed on various actions, which I call some kind of goals. I've actually reached several of them since then. The next time, we sort of started from scratch, but we also looked back at how things looked before. And then we set new goals. And I think it helps me a lot, like... to find some kind of... well, way forward and some balance in life. (p10) I feel that this [DIALOG+] is more concrete because here you find the weaknesses in a completely different way, simpler, I think. That's how it feels to me. It feels like I can get things I'm unhappy with fixed in a more concrete way. (p7) Not all participants reported the same degree of success in agreeing on actions or working on the agreed upon actions. One participant pointed to time constraints during the session, namely, that filling in the required information was time-consuming, limiting or completely eliminating the time allocated to discussing the problem and creating agreed actions. Others reported that it was difficult to take action due to ill health or other unknown reasons. However, such failures could be the starting point for a new round of problem-solving and action-planning. Sometimes I did what we had agreed on, and sometimes not. The interesting thing is why it turned out that way. (p6) Provided memory support Several participants touched on different ways in which DIALOG + assisted their memory. Through its range of features, DIALOG + seems to support patients in retaining, organising, and recalling important information. It incorporates multiple modalities, such as written transcripts, visualisation of results, structured discussions, and consistent follow-up. The memory support was helpful both in more concrete activities, such as choosing topics from a list, and in abstract tasks, such as gaining an understanding of one's well-being over time. Regular use of DIALOG + was also mentioned as helpful in remembering previous responses and discussions, which is particularly beneficial for patients with short-term memory issues. I think it can be quite good to get a printout. I get one to remember what we have talked about. And it becomes a way for me to look at and go back to and think about what I should do to achieve my goals. (p10) I think that it's good actually, just that you have... we've been doing it regularly now and so on, it means that you might remember why you answered a certain thing and so on. And then you remember, so it doesn't just disappear, so to speak....from your memory. (p8) Empowering participation Several participants described how they could make their own choices with the support of DIALOG+. Statements indicated that the participants’ ability to choose topics for further discussion and being encouraged to find their own solutions in the problem-solving structure contributed to feelings of empowerment. Participants valued the ability to make their own choices and generate their own solutions. Several participants touched on the importance of being the one who actually makes the decisions, which offered a sense of self-confidence and independence. Their statements also showed that the clinician sometimes needed to participate more actively in problem-solving and support participants to find the right solution. Furthermore, active participation in decision-making and topic selection can enhance an individual’s sense of autonomy, fostering mutual respect in the therapeutic relationship. I thought it was very good that the patient independently gets to choose in what areas they want more help or support. I think it's good that people can choose themselves and feel more independent, because when you have a psychotic disorder, you can feel very independent. (p2) I definitely felt that I was involved when I tested DIALOG+. I was involved in developing these different parts that were needed to come up with ideas on how to solve my problems. (p6) Theme 2: Providing a constructive structure Participants distinguished DIALOG + from traditional routine encounters by highlighting its structured yet flexible approach and its effectiveness in promoting proactive health management. While participants appreciated the usefulness of DIALOG+'s structure, they also expressed preferences for the conversational flexibility in encounters where DIALOG was not used. Therefore, many participants suggested that a combination of encounters with and without DIALOG + could be used to optimise their healthcare experience. Additionally, the participants’ feedback on the use of the digital tool suggested that it was user-friendly and supportive, although some encountered challenges with the design of the interface and navigating the tool. Overall, this theme suggested that DIALOG + has the potential to empower patients in managing their own health by providing a constructive structure for discussion and decision-making. Distinguishing DIALOG + as a constructive complement Through descriptions of the supportive structure of DIALOG + and reflections on how DIALOG + should best be used, this subtheme captures how participants distinguish DIALOG + as a constructive complement to routine encounters with their clinician. Participants provided varied depictions of routine encounters with no standardised structure. These depictions contributed to the theme by highlighting qualitative differences in routine encounters, where the quality of the encounter is dependent on the skill of the clinician and the therapeutic relationship. Some described more traditional, medically oriented meetings where the clinician would lead the conversation and focus primarily on medication and symptoms. It was different. It was very much about how are your medications going? And how are your symptoms [traditional routine encounters]? And they just focused on that. (p10) When you're mentally ill, the clinician takes over in a way, and I might have had other things that I wanted to talk about. They see the illness, that you don’t see yourself. You talk about things that the clinician wants to talk about. (p4) Other participants reflected that during routine encounters (not using DIALOG+), the clinician encouraged them to participate, inviting them to decide on what topics to discuss or taking a more whole-life perspective when asking questions regarding health. When these conversations were described as beneficial, the relationship with the clinician was an important factor, and participants described a good, well-established relationship. Although participants highlighted the importance of a good dialogue, they also highlighted the risk that some topics would be overlooked. Previously, I used to get asked whether there was anything special I wanted to address and how different things were working out, for example, my medication. Sometimes you miss things that you don't talk about. (p2) It was more like ‘How are you?’ We talked superficially about whatever came to mind, and then we might forget about different areas. (p4) DIALOG + was described as a structured yet flexible approach, in contrast to traditional free-form conversations in routine encounters. The model's structure was seen to enable a more focused and efficient dialogue while maintaining the freedom to explore topics in depth. Furthermore, it was seen as a way to ensure that critical areas of concern were addressed in a systematic way. Participants indicated that DIALOG + facilitated dialogue, as it was structured in a way that provided valid questions for discussion and steered the conversation towards the most important topics, especially in the early stages of the therapeutic relationship. Additionally, DIALOG + appears to assist patients in discussing areas they may not otherwise address, thus providing an opportunity for patients to open up more quickly. There is a clear difference when we’ve used DIALOG+. It's mostly the structure of the conversation. Well, we speak very freely about the topic even when we use DIALOG+, but it's still this thing that you have a follow-up, you get to think about the different ratings and things like that. It sort of creates a structure in the conversation and helps maintain focus. (p8) DIALOG + was appreciated for its interactive and collaborative nature, providing a platform for patients to develop and share their own ideas while receiving constructive feedback. This aspect was seen as crucial as it helped participants evaluate the viability of their ideas and contributed to a more dynamic and supportive interaction. You help each other, and it's very good that there is this room to come up with your own ideas, and at the same time, you can get very good feedback on whether it's constructive or not. (p2) The use of DIALOG + early in the therapeutic process was seen as particularly effective, allowing for prompt identification and discussion of key issues, potentially leading to reduced therapy duration. I felt I got a lot out of it. It covered important areas and so on, but I would have appreciated if we could have used it a lot earlier. I might have been able to leave certain things behind much sooner. Certain things that might be more difficult to talk about would have been pinpointed in a much earlier stage. (p3) Although almost all participants described the usefulness of the structure provided by DIALOG+, several participants stated that traditional routine encounters were also needed. Others suggested that a different structure could be used, where helpful features of DIALOG+ (e.g. choosing topics) are used but where the dialogue could then depart from the DIALOG + format, making the conversation more “free” within the DIALOG + session. Some patients also reported time constraints, regarding agreeing on actions at the end of the session. Others pointed out that the ability to observe changes in health over time or monitor the achievement of established goals requires a timespan of several weeks between DIALOG + sessions, and emphasised the significance of employing DIALOG + over an extended period. Experiences of the digital tool Participants provided feedback on their experiences of the digital tool. Their statements described their perceptions of and interactions with the user interface in the digital tool, including its design, ease of use, and overall usability. The statements suggest that the participants found the digital tool to be user-friendly and easy to understand. They appreciated the visual presentation of results and felt that it provided valuable support, even for individuals who struggle with the use of technology. Some participants viewed DIALOG + as an effective and accessible self-analysis tool that offered a more comfortable experience than traditional paper-based methods. Some downsides were reported. One participant encountered difficulties navigating the digital interface during the self-rating task, particularly when changing questions or topics and choosing areas for further support, while another participant needed support from the clinician due to limited computer skills. One participant suggested that the design could be more user-friendly and intuitive, with larger icons. I think it was a great idea (with the DIALOG + program on a computer) actually, because it's not like staring over a piece of paper and not finding the answer. (p1) I think this seems to be easy to work with. Now I get support from my therapist all the time, because I am so unsure about computers and technology. It seems to be good; I get a good impression of it. Pretty easy to understand for someone who has difficulty understanding computers, so it was easy to understand at the time. (p9) Statements regarding the use of DIALOG + through video meetings were generally positive. Screen-sharing enhanced clarity, enabling participants to follow and engage with the content. I think it worked very well, using DIALOG + during video meetings. It was perhaps even easier to do it that way than usual. It makes things more concrete. I'm not a very tech-savvy person, so what you see on a screen feels kind of not real, even though I know that the person I'm talking to through the screen feels a bit strange and distant. DIALOG + makes it more concrete when you meet through a screen. (p2) Discussion The findings of this study suggest that the use of DIALOG + during clinical encounters had a positive impact on participants’ experiences of patient-clinician meetings in Swedish psychosis care. Participants reported feeling empowered through joint decision-making and had a better understanding of their health and improved engagement in proactive health management. DIALOG + was perceived as a valuable tool in facilitating structured yet flexible discussions, where patients and clinicians could identify areas for improvement related to the patient’s health and other areas of life while setting achievable goals. Clinical encounters with and without DIALOG+ While routine encounters without DIALOG + often lacked structure and sometimes overlooked important topics, the use of DIALOG + provided a structure that enabled focused discussions and the exploration of a variety of health domains based on the patient’s needs. In encounters where DIALOG + was not used, some participants reported that the clinician dominated the conversation and primarily discussed medications and symptoms. Moreover, the use of DIALOG + offered valuable memory support tools through various features, such as written transcripts, visualisation of results, and consistent follow-up, which helped participants retain, organise, and recall important information. Such cognitive compensatory interventions have been associated with improvements in functioning for patients with psychotic disorders (Allot et al., 2020). Even though all participants were satisfied with the structure within DIALOG+, some participants were not able to generate solutions during the sessions due to time constraints. Additionally, some participants suggested combining DIALOG + sessions with less structured routine encounters to optimise the healthcare experience. Support for co-production The participants seemed to value the visualization of their health status and the structured way of evaluating their treatment. Choosing topics for further discussion appeared to help patients make preference-based decisions, sometimes leading to a care plan aligned with their goals. The subsequent DIALOG + sessions included discussions on how the patient could actively contribute to their care with the support of healthcare professionals. The supportive features of DIALOG + seem to align with Elwyn's iterative co-production cycle, which consists of the steps 'co-assess', 'co-decide', 'co-design', and 'co-deliver' to ensure that the patient is involved in the entire care process (Elwyn et al., 2020 ). This is also consistent with the findings of Omer et al. ( 2016 ), who demonstrated that DIALOG + enhances an individual’s sense of competence across various life domains. Continuous Feedback and solution-focused approach The use of continuous patient-reported ratings of well-being and experiences of care is a key feature of DIALOG+. This continuous feedback loop seems to enhance the therapeutic process in multiple ways and enables longitudinal tracking of the patient's progress over time. Patients suggested that the ratings can serve as indicators of whether intended actions have actually resulted in improvements. If not, patients and clinicians can collaborate to explore solutions. Furthermore, the patients’ ratings can help identify signs of deterioration, which otherwise can be difficult to predict (Lambert, 2017 ). This type of continuous measurement aligns with continuous feedback methods known as Routine Outcome Monitoring (ROM) and Progress Monitoring (PM), which have also shown positive effects on treatment lengths while reducing care costs (Goodman et al., 2013 ). The problem-solving methodology in DIALOG + is designed to work to address identified problems in a structured way. Through the problem-solving process, patients and clinicians collaborate to explore potential solutions and agree on options and suitable actions. The result of this study suggests that this type of collaborative approach seems to foster a sense of ownership and empowerment among patients, as they play an active role in decision-making in their own treatment. Furthermore, patients suggested that the problem-solving approach seems to promote structure, helping patients and clinicians maintain their focus during the clinical encounter. Previous studies have demonstrated that problem-solving interventions can significantly enhance patient outcomes, especially in mental health settings. These interventions have been shown to reduce the risk of deterioration and increase recovery rates compared to standard routine encounters (Lambert, 2017 ). Overall, the results of this study support the claim that the continuous feedback and solution-focused approaches integrated into D + facilitate the achievement of co-produced care. Practical Implications DIALOG + could serve as a method to facilitate co-production in healthcare, establishing a foundation for placing the patient in the role of a decision-maker. Furthermore, DIALOG + enables longitudinal tracking of the patient's progress over time, providing a comprehensive view of the patient's journey and allowing for the evaluation of treatment effectiveness on an individual level. Through the use of continuous feedback and a problem-solving approach, DIALOG + also has the potential to facilitate tailored care plans based on the patient's needs. Beyond using DIALOG + on an individual level, aggregated patient rating data can enable the identification of strategies and areas for improvement at various levels within the healthcare system, contributing to quality improvement initiatives that ultimately enhance overall care and outcomes for individuals with severe mental illness (Gremyr et al., 2019 ). Dialog + also appears to be suitable for use during video meetings, which aligns with previous research on videoconferencing interventions for patients with schizophrenia-spectrum disorders (Santesteban-Echarri et al., 2020 ). Future research In an ongoing study conducted in psychosis outpatient care settings in Sweden, clinicians' experiences with DIALOG + are being investigated. Understanding clinicians' perspectives, attitudes, and experiences when using DIALOG + is crucial for implementation and sustained use. This research also examines the perceived usefulness of DIALOG+, its integration into existing workflows, and challenges or barriers encountered. Furthermore, observational studies could offer valuable insights into the interaction between patients and clinicians during DIALOG + sessions. Observing these interactions in real time can provide valuable insights into how Dialog + is used, the communication dynamics between patients and clinicians, the impact of the tool on clinical encounters, and its contribution to co-production. There is also a potential to utilise various Patient-Reported Outcome Measures (PROMs) to enhance healthcare systems so that they become learning health systems, fostering greater patient involvement through self-reported measures. This integration allows for the seamless utilisation of aggregated data to drive quality improvement initiatives, thereby optimising patient outcomes and system efficiency (Green et al., 2014 ). Further research could investigate the potential of DIALOG + as a tool to facilitate the transition to a learning health system. Limitations This study was conducted in the early stage of implementation, resulting in a limited pool of patients eligible for participation. In order to efficiently collect data under these circumstances, a convenience sampling method was used (Taherdoost, 2016 ). Participants were selected based on their availability and willingness to participate. Therefore, the patients included in this study may not necessarily be representative of the entire population. On the other hand, the included patients were mainly patients with psychotic disorder and the mix of age and gender, and the richness of data in interviews and analysis, still provides valuable insights into how patients with psychotic disorders experience the use of DIALOG+. Conclusions The findings suggest that DIALOG + could serve as a tool to establish an iterative co-produced care process during routine encounters, empowering patients through shared decision-making that places them at the centre of the conversation. Furthermore, DIALOG + seems to enhance patients' understanding of their health and facilitate the journey toward improvement. The continuous feedback loop, driven by patient ratings, contributes to addressing unspoken concerns and providing a comprehensive view of well-being. Moreover, the built-in solution-focused approach appears to aid patients in maintaining focus during conversations, which increases the understanding of patient concerns while aiding in the establishment of achievable goals. This highlights the potential of DIALOG + as a tool that can be used to tailor care plans according to patient-specific needs. Additionally, DIALOG + seems to provide built-in memory support features, which is particularly important for patients with cognitive impairments. Despite the concerns some participants raised about the structured meeting format and time constraints, DIALOG + seems promising as a means to improve patient-clinician interactions and treatment outcomes in Swedish psychosis outpatient care. Declarations Ethical Considerations Ethical approval was obtained from the Swedish Ethical Review Board prior to data collection (Dnr 2020–03653). Informed consent was obtained from all participants, and participants were informed of the voluntary nature of their participation and their right to withdraw at any time without consequences. The confidentiality of the participants was maintained throughout the study by assigning pseudonyms and ensuring secure data storage. Author Contribution Authors ML, AG, and ACA designed the study, and ML developed the interview guide with contributions from AG and ACA. ML conducted patient interviews and conducted the qualitative analysis along with KA, and discussed the results with the other authors. ML was mainly responsible for drafting the manuscript with contributions from all authors. All authors, ML, KA, AG and ACA, critically reviewed the analysis and approved the final manuscript. Acknowledgement We want to extend our sincere gratitude to the patients who generously participated in the interviews for this study. Your contributions have been invaluable to our research. We also thank Sahlgrenska University Hospital and the Department of Psychotic Disorders for providing the support and resources necessary to conduct this study. Your collaboration and dedication to advancing medical research are greatly appreciated. References Allott, K., Van-Der-El, K., Bryce, S., Parrish, E. M., McGurk, S. R., Hetrick, S., ... & Velligan, D. (2020). Compensatory interventions for cognitive impairments in psychosis: a systematic review and meta-analysis. Schizophrenia bulletin , 46 (4), 869-883. Braun, V., & Clarke, V. (2022). Thematic analysis: A practical guide . Sage Crump, C., Winkleby, M. A., Sundquist, K., & Sundquist, J. (2013). Comorbidities and mortality in persons with schizophrenia: a Swedish national cohort study. American Journal of Psychiatry , 170 (3), 324-333. Elwyn, G., Nelson, E., Hager, A., & Price, A. (2020). Coproduction: when users define quality. BMJ quality & safety , 29 (9), 711-716.Gremyr, A., Malm, U., Lundin, L., & Andersson, A. C. (2019). A learning health system for people with severe mental illness: a promise for continuous learning, patient coproduction and more effective care. Digital Psychiatry , 2 (1), 8-13. Epping-Jordan, J. E., Pruitt, S. D., Bengoa, R., & Wagner, E. H. (2004). Improving the quality of health care for chronic conditions. BMJ Quality & Safety , 13 (4), 299-305. Fichtenbauer, I., Priebe, S., & Schrank, B. (2019). The German Version of DIALOG plus for Patients with Psychosis-A Pilot Study. Psychiatrische Praxis . Goodman, J. D., McKay, J. R., & DePhilippis, D. (2013). Progress monitoring in mental health and addiction treatment: a means of improving care. Professional Psychology: Research and Practice , 44 (4), 231. Green, C., Estroff, S. E., Yarborough, B. J. H., Spofford, M., Solloway, M. R., Kitson, R. S., & Perrin, N. A. (2014). Directions for future patient-centered and comparative effectiveness research for people with serious mental illness in a learning mental health care system. Schizophrenia bulletin , 40 (Suppl 1), 1-94. Gremyr, A., Malm, U., Lundin, L., & Andersson, A. C. (2019). A learning health system for people with severe mental illness: a promise for continuous learning, patient coproduction and more effective care. Digital Psychiatry , 2 (1), 8-13. Hamann, J., Cohen, R., Leucht, S., Busch, R., & Kissling, W. (2005). Do patients with schizophrenia wish to be involved in decisions about their medical treatment?. American Journal of Psychiatry , 162 (12), 2382-2384. Jovanović, N., Russo, M., Pemovska, T., Francis, J. J., Arenliu, A., Bajraktarov, S., ... & Marić, N. P. (2022). Improving treatment of patients with psychosis in low-and-middle-income countries in Southeast Europe: Results from a hybrid effectiveness-implementation, pragmatic, cluster-randomized clinical trial (IMPULSE). European Psychiatry , 65 (1), e50. Lambert, M. J. (2013). Outcome in psychotherapy: the past and important advances. Lambert, M. J. (2017). Maximizing psychotherapy outcome beyond evidence-based medicine. Psychotherapy and psychosomatics , 86 (2), 80-89. Lindenfalk, B., Gremyr, A., Lundmark, M., & Jacobsson, T. (2022). Digitally Mediated Schizophrenia Care-A Swedish Case of Translating, Designing and Expert Evaluation of Dialog. Studies in Health Technology and Informatics , 290 , 882-886. Lundmark, M. (2021). Psykosvård på patientens villkor. Ökad delaktighet med DIALOG+? [Examensarbete/Masteruppsats, Hälsohögskolan i Jönköping]. DiVA. https://www.diva-portal.org/smash/record.jsf?pid=diva2:1596447 Masterson, D., Areskoug Josefsson, K., Robert, G., Nylander, E., & Kjellström, S. (2022). Mapping definitions of co‐production and co‐design in health and social care: a systematic scoping review providing lessons for the future. Health Expectations , 25 (3), 902-913. Matanov, A., McNamee, P., Akther, S., Barber, N., & Bird, V. (2021). Acceptability of a technology-supported and solution-focused intervention (DIALOG+) for chronic depression: views of service users and clinicians. BMC psychiatry , 21 (1), 263. Mosler, F., Priebe, S., & Bird, V. (2020). Routine measurement of satisfaction with life and treatment aspects in mental health patients–the DIALOG scale in East London. BMC Health Services Research , 20 , 1-12. Omer, S., Golden, E., & Priebe, S. (2016). Exploring the mechanisms of a patient-centred assessment with a solution focused approach (DIALOG+) in the community treatment of patients with psychosis: a process evaluation within a cluster-randomised controlled trial. PLoS One , 11 (2), e0148415. Patients' Act (Patientlagen) 2014. Svensk författningssamling (SFS 2014:821). Socialdepartementet. https://www.riksdagen.se/sv/dokumendokument-och-lagar/dokument/svensk-forfattningssamling/patientlag-2014821_sfs-2014-821/ Priebe, S., Kelley, L., Golden, E., McCrone, P., Kingdon, D., Rutterford, C., & McCabe, R. (2013). Effectiveness of structured patient-clinician communication with a solution focused approach (DIALOG+) in community treatment of patients with psychosis–a cluster randomised controlled trial. BMC psychiatry , 13 (1), 1-7. Priebe, S., Kelley, L., Omer, S., Golden, E., Walsh, S., Khanom, H., Kingdon, D., Rutterford, C., McCrone, P. and McCabe, R. (2015). The effectiveness of a patient-centred assessment with a solution-focused approach (DIALOG+) for patients with psychosis: a pragmatic cluster-randomised controlled trial in community care. Psychotherapy and psychosomatics , 84 (5), 304-313. Priebe, S., Golden, E., Kingdon, D., Omer, S., Walsh, S., Katevas, K., McCrone, P., Eldridge, S. and McCabe, R. (2017). Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design. Programme Grants for Applied Research , 5 (6). Saarni, S. I., Viertiö, S., Perälä, J., Koskinen, S., Lönnqvist, J., & Suvisaari, J. (2010). Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders. The British Journal of Psychiatry , 197 (5), 386-394. Santesteban-Echarri, O., Piskulic, D., Nyman, R. K., & Addington, J. (2020). Telehealth interventions for schizophrenia-spectrum disorders and clinical high-risk for psychosis individuals: A scoping review. Journal of telemedicine and telecare , 26 (1-2), 14-20. Socialstyrelsen. (2018). Nationella riktlinjer för vård och stöd vid schizofreni och schizofreniliknande tillstånd. (Artikelnummer 2018-9-6). https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/nationella-riktlinjer/2018-9-6.pdf Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU). (2012). Schizofreni: Läkemedelsbehandling, patientens delaktighet och vårdens organisation. En systematisk översikt (Schizophrenia: Pharmacological treatment, patient involvement and the organization of care. A systematic review) (213). Retrieved from Statens Beredning för Medicinsk och Social Utvärdering: http://sbu.se/en/publications/sbu-assesses/schizophrenia–pharmaceutical-treatments-patient Taherdoost, H. (2016). Sampling methods in research methodology; how to choose a sampling technique for research. How to choose a sampling technique for research (April 10, 2016) . Tiihonen, J., Mittendorfer-Rutz, E., Majak, M., Mehtälä, J., Hoti, F., Jedenius, E., ... & Taipale, H. (2017). Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29 823 patients with schizophrenia. JAMA psychiatry , 74 (7), 686-693. Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. The Milbank Quarterly , 511-544. World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/ Additional Declarations No competing interests reported. Supplementary Files InterviewguidePatientsexperiences.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4579887","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":314429468,"identity":"53b007e4-caef-4f9c-b359-89a655ddfd12","order_by":0,"name":"Marcus Lundmark","email":"data:image/png;base64,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","orcid":"","institution":"Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden","correspondingAuthor":true,"prefix":"","firstName":"Marcus","middleName":"","lastName":"Lundmark","suffix":""},{"id":314429469,"identity":"d410a441-0ca6-47b7-820c-417f4d4a829b","order_by":1,"name":"Katarina Allerby","email":"","orcid":"","institution":"Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden","correspondingAuthor":false,"prefix":"","firstName":"Katarina","middleName":"","lastName":"Allerby","suffix":""},{"id":314429470,"identity":"1e372f45-b3d2-4044-9eaf-2373b934b975","order_by":2,"name":"Andreas Gremyr","email":"","orcid":"","institution":"Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Gremyr","suffix":""},{"id":314429471,"identity":"930cbeea-eeb6-4ae7-a7e9-1839273f9030","order_by":3,"name":"Ann-Christine Andersson","email":"","orcid":"","institution":"Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden","correspondingAuthor":false,"prefix":"","firstName":"Ann-Christine","middleName":"","lastName":"Andersson","suffix":""}],"badges":[],"createdAt":"2024-06-14 06:34:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4579887/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4579887/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59872834,"identity":"eee31d3b-bafd-4b17-b091-917a51b11af3","added_by":"auto","created_at":"2024-07-08 17:15:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":869117,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Dialog+ interface showing patient's ratings, where the current session ratings (top blue line) are compared to a selected previous session's ratings (bottom pink line). At far left each category for conversation is shown.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4579887/v1/707f854f0582f27758d9416f.png"},{"id":62843867,"identity":"9edc2d6c-bf44-4b16-a14b-8c4516013f29","added_by":"auto","created_at":"2024-08-20 07:02:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1342380,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4579887/v1/fc74aa4c-5dbe-4eea-9d19-32651b3acc8f.pdf"},{"id":59872832,"identity":"c01b060a-6007-4e99-9857-27d0dcc7d0c2","added_by":"auto","created_at":"2024-07-08 17:15:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24587,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewguidePatientsexperiences.docx","url":"https://assets-eu.researchsquare.com/files/rs-4579887/v1/319146739e058b239c445cd4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patients’ Experience of Patient-Reported Outcomes, Continuous Feedback, and a Solution-Focused Approach (Using DIALOG+) in Psychosis Care in Sweden","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic illnesses, including mental health conditions, represent a significant and growing challenge in healthcare (Epping-Jordan et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Severe mental illness, and psychotic disorders in particular, have a profound impact on the affected person\u0026rsquo;s life and have been shown to result in reduced quality of life (Saarni et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). A significant portion of individuals diagnosed with schizophrenia experience deterioration leading to inpatient care, and a high percentage of patients discontinue treatment (Tiihonen et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Furthermore, this group has a reduced life expectancy compared to the general population (Crump et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The care of persons with psychotic disorders, which are characterised by positive symptoms (such as hallucinations and delusions), negative symptoms (such as social withdrawal and flattened affect), and cognitive impairments, requires a nuanced and multifaceted approach, integrating medical, psychological, and social support strategies. Although patients want to participate in their own care (Hamann et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) and both national guidelines and Swedish law require patient participation (Patients' Act, 2014; Swedish Agency for Health Technology Assessment and Assessment of Social Services, 2012), symptom severity and treatment discontinuation pose challenges to involving patients in care during routine encounters. In recent years, there has been a surge in academic interest in patient involvement, particularly through \"co-production\", which reflects a fundamental change in the approach to patient care management (Elwyn et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Masterson et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Co-production involves a collaborative approach where patients and healthcare providers work together as equal partners, contributing jointly to the planning, development, and management of care. Understanding patients' well-being and their perceptions of care is a key challenge in facilitating care and support strategies that are designed in collaboration with patients. Co-production, which involves direct collaboration between service users and providers in the design, delivery, or evaluation of services, is recognised for its ability to enhance healthcare outcomes while improving service quality, user satisfaction, and empowerment (Masterson et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Elwyn et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) outline an iterative co-production cycle consisting of the steps 'co-assess', 'co-decide', 'co-design', and 'co-deliver' to ensure that the patient is involved in the entire care process. Systematic attention to patient needs and supportive information systems are important for improving outcomes and satisfaction, and reducing healthcare costs (Wagner et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). This underscores the importance of a comprehensive approach to chronic illness management that emphasises personalised care and effective communication between providers and patients. There are several methods that seek to incorporate patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) within healthcare. Outcome management is an increasingly preferred method that involves continuous assessment and monitoring of a patient's progress during treatment to positively influence the overall treatment process (Lambert, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This type of continuous, real-time feedback is particularly beneficial in addressing any unexpected challenges and ensuring that the treatment aligns with the patient's evolving needs, and it has been shown to be more effective than treatment as usual (Goodman et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Lambert, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Furthermore, the aggregation of PROM and PREM data has the potential to facilitate a deeper understanding of the real life effectiveness of interventions and areas requiring improvement. Such an approach, which is known as a Learning Health System (LHS), has shown promise in driving continuous quality improvement within mental health services for individuals diagnosed with severe mental illness (Gremyr et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDIALOG\u0026thinsp;+\u0026thinsp;is a digital support tool that incorporates a self-assessment feature along with a problem-solving methodology. The method is designed to be utilised during routine encounters between patients and clinicians. The intervention involves a systematic process that begins with an assessment of the patient's satisfaction in eight life domains (PROMs) and three treatment domains (PREMs). The assessment helps the patient and the clinician to jointly identify areas that require further attention and support. The ratings can be compared with previous assessments, thus providing a longitudinal perspective on the patient's progress. During the session, the patient selects specific domains to discuss further, indicating areas where additional support is needed. This collaborative decision-making process seeks to empower patients by allowing them to prioritise their concerns and preferences, enabling them to lead discussions that are aligned with their needs. A solution-focused approach, which focuses on exploring potential solutions, setting goals, and reaching decisions on further actions, is employed to address the patient\u0026rsquo;s identified concerns. At the next DIALOG\u0026thinsp;+\u0026thinsp;session, agreed-upon decisions, along with new ratings, ensure ongoing patient feedback on how the therapy unfolds.\u003c/p\u003e \u003cp\u003e \u003cb\u003e[Fig.\u0026nbsp;1] Fig.\u0026nbsp;1. The Dialog\u0026thinsp;+\u0026thinsp;interface showing patient's ratings, where the current session ratings (top blue line) are compared to a selected previous session's ratings (bottom pink line). At far left each category for conversation is shown.\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePrevious research has shown promising results when using DIALOG\u0026thinsp;+\u0026thinsp;in routine care, particularly for individuals diagnosed with psychosis. Studies have found that DIALOG\u0026thinsp;+\u0026thinsp;interventions are cost-effective while enhancing social outcomes, improving quality of life, and reducing unmet needs and general symptom levels (Priebe, 2013, 2015). Process evaluations involving patient and clinician feedback highlight the positive impact of DIALOG\u0026thinsp;+\u0026thinsp;on subjective quality of life, especially in areas like living situation and mental health (Omer et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Pilot studies in Germany and evaluations in mental health trusts in East London have further demonstrated improvements in symptoms and patient satisfaction with life and treatment (Fichtenbauer et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Mosler et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Clinicians reported a high acceptability of using Dialog\u0026thinsp;+\u0026thinsp;for patients with chronic depression (Matanov et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Research in low and middle income countries also supports the efficacy of DIALOG\u0026thinsp;+\u0026thinsp;in enhancing a holistic care of patients with psychosis (Jovanović et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). DIALOG\u0026thinsp;+\u0026thinsp;shows promising results in routine care, particularly for individuals diagnosed with psychosis, by enhancing social outcomes, improving quality of life, reducing unmet needs and general symptom levels, and demonstrating high acceptability among clinicians and patients across various settings.\u003c/p\u003e \u003cp\u003eThe aim of this study is to examine the experiences of patients participating in DIALOG\u0026thinsp;+\u0026thinsp;sessions in the Swedish healthcare system. It compares these sessions to standard routine encounters, focusing on aspects of co-production, as well as the utilisation of continuous feedback and a solution-focused approach.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study uses a qualitative design to explore patients' experiences of DIALOG\u0026thinsp;+\u0026thinsp;sessions. The study took place at the Department of Psychotic Disorders, Sahlgrenska University Hospital, in Gothenburg, Sweden. The department comprises seven outpatient clinics dedicated to serving approximately 3,000 patients, who collectively account for approximately 30,000 clinical encounters each year. The outpatient units specialising in psychosis care strive to adhere to the recommendations outlined in the Swedish national guidelines for psychosis care (Socialstyrelsen, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This includes the implementation of a Case Management model and Flexible Assertive Community Treatment, with interdisciplinary teams comprising psychiatrists, nurses, specialised psychiatric assistant nurses, social workers, occupational therapists, psychologists, and physiotherapists or health coaches. The term 'clinicians' is used here to refer to healthcare professionals directly engaged in patient care. To improve the understanding of care content, its effects, patient involvement, and the consistency of care delivered, the department started a project in 2020 which focuses on the translation, design, and expert evaluation of DIALOG+ (Lindenfalk et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), along with pilot testing in 2021 (Lundmark, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The comprehensive implementation of DIALOG\u0026thinsp;+\u0026thinsp;started in April 2022, with 111 clinicians undergoing a one-day training to ensure the correct use of DIALOG\u0026thinsp;+\u0026thinsp;during routine patient meetings. This study was conducted during the Covid-19 pandemic, and face-to-face meetings with patients were at times difficult to arrange. Therefore, patients were offered a combination of in-person and virtual DIALOG\u0026thinsp;+\u0026thinsp;sessions. In the virtual meetings, screen share mode was utilised to ensure that patients could access the content.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eA convenience sampling approach was used to recruit participants from three outpatient units. The inclusion criteria for participants were 1) engagement in three or more DIALOG\u0026thinsp;+\u0026thinsp;sessions (to ensure enough experience to provide comprehensive information about DIALOG+) and 2) being in active treatment with at least one clinician meeting every two months. Fifteen patients met the inclusion criteria; all were asked to participate, of which three declined. Two patients were excluded due to difficulties with the Swedish language or not meeting the inclusion criteria. The final sample consisted of 10 patients, of which six were women. The overall age range of the sample varied from 31 to 63 years. These patients received DIALOG\u0026thinsp;+\u0026thinsp;sessions from seven clinicians (nurses and mental health nurses) with experience working in outpatient care ranging from 2 to 26 years. Nine patients had contact with the respective outpatient unit for over one year. In the past 12 months, these patients met with their clinician on average 32 times. Eight patients were diagnosed with schizophrenia spectrum and other psychotic disorders, and two with mood disorders (World Health Organization, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Three patients used DIALOG\u0026thinsp;+\u0026thinsp;through video meetings and one used a mix of video and in-person meetings. All other patients used DIALOG\u0026thinsp;+\u0026thinsp;through in-person meetings. All participants provided informed consent prior to their involvement in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData were collected through individual interviews from December 2021 to January 2023. The interviews were conducted by the first author using a semi-structured interview guide. The structure and questions of the interview guide were inspired by a focus group study conducted by Priebe et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The interview focused on participants\u0026rsquo; experiences of Dialog\u0026thinsp;+\u0026thinsp;and their interactions with clinicians. It began with questions about the duration of contact with psychiatric care and experiences of Dialog\u0026thinsp;+\u0026thinsp;sessions. Participants described how meetings were conducted before and after Dialog\u0026thinsp;+\u0026thinsp;was introduced, discussing the topics covered, decision-making processes, and the focus of conversations. They were asked about their experiences with self-rated well-being and the structure of Dialog\u0026thinsp;+\u0026thinsp;sessions, as well as how topics for further discussion were decided upon. The interview also explored the four-step approach to discussing problems, participants' experiences with the Dialog\u0026thinsp;+\u0026thinsp;software, and overall thoughts on using Dialog\u0026thinsp;+\u0026thinsp;in therapy sessions, including any changes in the relationship with the therapist and preferences for using Dialog+. The interviews took place at the participants\u0026rsquo; outpatient clinic (n\u0026thinsp;=\u0026thinsp;7) or via video meetings (n\u0026thinsp;=\u0026thinsp;3) and lasted between 20\u0026ndash;45 min. All interviews were audio-recorded after obtaining the consent of participants. Audio recordings were subsequently transcribed verbatim for analysis. After the interviews, data was securely stored and de-identified to protect participants\u0026acute; identities and maintain confidentiality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data analysis was conducted using reflexive thematic analysis, following the steps described by Braun and Clarke (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The method aimed to generate an understanding of patterns, themes, and meanings from textual data, while acknowledging the researchers\u0026rsquo; reflexivity and subjectivity in the analysis process. Nvivo (version 14) was used to manage data during the analysis. The analysis began with the reading of transcripts, followed by an initial open coding where codes were formulated inductively, without preconceived categories, in order to facilitate the discovery of unexpected themes. This led to the generation of numerous codes, which were then thoroughly reviewed and refined through discussions between the coders. The subsequent phase focused on identifying themes within the dataset. The researchers placed significant emphasis on maintaining thematic consistency and coherence, ensuring a representative portrayal of diverse perspectives within the data, and ensuring that the analysis level matched the importance of the themes. Illustrative quotes were selected to provide examples of each theme, ensuring transparency and supporting the credibility of the findings. Two of the authors (ML and KA) conducted the analysis collaboratively. The researchers remained attentive to their subjectivities and biases throughout the analysis, engaging in reflexive practices. This included regular discussion of thoughts, feelings, and preconceptions that inform the analysis and influence the interpretation of the findings. This self-reflection aimed to ensure transparency and acknowledge the potential influence of the researcher's perspectives on the analysis. Discrepancies in coding and theme development were discussed until consensus was reached .\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe analysis resulted in two themes: 'The supportive features of DIALOG+' and 'Providing a constructive structure'. The first theme illuminates the participants' experiences in relation to specific features of DIALOG+, while the second theme explores participants\u0026rsquo; perceptions of the digital tool and differences between DIALOG\u0026thinsp;+\u0026thinsp;and traditional routine encounters.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] Themes and sub-themes\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 1: The supportive features of DIALOG+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheme 2: Providing a constructive structure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpanded understanding of my health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistinguishing DIALOG\u0026thinsp;+\u0026thinsp;as a constructive complement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoving toward improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiences of the digital tool\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvided memory support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpowering participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eTheme 1: The supportive features of DIALOG+\u003c/h2\u003e \u003cp\u003eParticipants described how different aspects of the DIALOG\u0026thinsp;+\u0026thinsp;session helped them, and these features collectively support a process towards improved health. The features of DIALOG\u0026thinsp;+\u0026thinsp;guided participants in an exploratory process that helped them gain an \u0026lsquo;understanding\u0026rsquo; of their health, which was an important first step towards improvement. The enhanced understanding prompted a movement towards improvement through the deliberate selection of areas for further discussion. Identifying concrete problems or goals, and planning corresponding actions were key features that allowed participants to achieve control and work towards improvement. Memory support was provided in various ways, which was considered valuable and enhanced the result of the other features. The encouragement of participation and individual choice had an empowering effect, further strengthening the participants\u0026rsquo; engagement.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eExpanded understanding of my health\u003c/h2\u003e \u003cp\u003eTwo aspects assisted participants in achieving a more comprehensive understanding of their health: the rating feature and the holistic approach provided by the various areas rated. Several participants mentioned that actively rating different health areas helped them get an overview of their overall well-being, highlighting areas of both strength and concern.\u003c/p\u003e \u003cp\u003eThe rating process served as the basis for reflection and discussion of what influenced the participants\u0026rsquo; ratings in different areas. This process transformed the more abstract notion of 'how I feel' into a concrete reflection on the factors that actually impact well-being, allowing participants to understand the numerous aspects that contribute to their emotional state.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIt becomes a visualisation ... making my well-being status more concrete. (p8)\u003c/h2\u003e \u003cp\u003e \u003cem\u003eI felt that with DIALOG+, it was more mapped out, the feelings you have and how you behave in different situations. You could see that in the rating, on that particular day, I must have felt a bit worse or a bit better. It's interesting to know what affects such things, that you sometimes feel worse. Being able to look at the different variables was good. (p6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eComparing current ratings with previous ratings also contributed to an overall picture of well-being and changes over time. The ability to track changes in ratings over time added a layer of insight into the participants\u0026rsquo; understanding of their own health. This also allowed them to draw conclusions and to understand underlying causes.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt helps to have the overall picture, like how it was then compared to how it is now. (p10)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e... \u003cem\u003ethe function seems good, because then you can clearly see if you have improved in any area. (p2)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMoreover, it serves the purpose of acknowledging the potential for change; participants could explicitly see improvements or periods of lower satisfaction, fostering a sense of hope. Several participants also linked this feature to an area of discussion, suggesting that an expanded understanding of one's health is an important initial step in identifying relevant areas for further discussion and prioritisation of actions.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt was interesting that the way you feel could change so much, from feeling very bad at one time to feeling much better the next time. You could identify why you felt like that. Sometimes it could be that something had happened, and sometimes it was just my mood on that particular day. (p6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDIALOG+'s coverage of ratings across 11 different domains provided several participants with a more holistic perspective on their health. They were able to gain insight into areas of health that they may have otherwise overlooked or that they had not thought about bringing up for discussion. One participant also reported that she felt more respected, as the use of DIALOG\u0026thinsp;+\u0026thinsp;made the clinician aware of additional areas that affected her, providing a fuller picture of her life situation and challenges.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think DIALOG\u0026thinsp;+\u0026thinsp;gives a more holistic perspective. You get the whole picture of mental health. And it's everything from social factors, and specifically the psychiatric, if you have any psychotic symptoms or similar. (p10)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMoving toward improvement\u003c/h2\u003e \u003cp\u003e Participants described how DIALOG\u0026thinsp;+\u0026thinsp;helped them move forward by giving them the opportunity to choose relevant areas for further discussion, identify problems, and plan for action. The opportunity to choose specific areas for further discussion and support in DIALOG\u0026thinsp;+\u0026thinsp;was highly valued by most participants. It was viewed as a straightforward and concrete way to identify relevant areas where support was needed. The range of areas identified suggested what could be addressed and allowed for the exploration of difficult topics that might not otherwise be explored. This allowed participants to explore specific topics in more depth, addressing issues more directly compared to previous unstructured conversations.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt is a very straightforward model. When you have a conversation [before using DIALOG+], it takes a while before you start talking about certain things. You may need to meet a few times. This model highlights different areas, that's what I mean by saying it's more straightforward. You choose areas and then we dig deeper into what you need to talk about. (p3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e The ratings helped to address areas in need of improvement, and some participants expressed that this was important when deciding on what area to address during the encounter. Accessing the results of the ratings was also helpful, since areas in need of improvement also became clearer for the clinician. The option to work on areas with lower satisfaction ratings encouraged some participants and clinicians to confront and address challenging issues that might have otherwise been overlooked.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt was very concrete that you had to choose which areas you wanted more support and help, that you can bring up a topic and go into it a bit deeper, gather your thoughts around it. It was helpful to be able to do that. This makes it stricter and more concrete and tackles the problem. Otherwise, it's easy to not talk about what's difficult and avoid it. (p2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Several participants went on to describe how DIALOG\u0026thinsp;+\u0026thinsp;helped them pinpoint problems and decide on actions to solve them or to create goals and plan actions to reach set goals. This process provided a sense of growth, especially when participants achieved their goals. Most of the participants\u0026rsquo; statements regarding defining problems or goals and ways to address these were related to the built-in solution-focused method. Participants\u0026rsquo; referred to the approach helping them maintain focus, working together to find solutions, agreeing on actions, and being motivated to enact the plan while deciding on follow-up measures. Some statements suggested that the DIALOG\u0026thinsp;+\u0026thinsp;feature helped participants solve problems that were difficult to solve before. The problem-solving feature also encouraged some participants to consider involving others (e.g. family members) in their support network and helped them seek out care and support. Statements suggest that DIALOG\u0026thinsp;+\u0026thinsp;increased the participants\u0026rsquo; engagement and involvement in their own care.\u003c/p\u003e \u003cp\u003e\u003cem\u003e From the second session, we agreed on various actions, which I call some kind of goals. I've actually reached several of them since then. The next time, we sort of started from scratch, but we also looked back at how things looked before. And then we set new goals. And I think it helps me a lot, like... to find some kind of... well, way forward and some balance in life. (p10)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eI feel that this [DIALOG+] is more concrete because here you find the weaknesses in a completely different way, simpler, I think. That's how it feels to me. It feels like I can get things I'm unhappy with fixed in a more concrete way. (p7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Not all participants reported the same degree of success in agreeing on actions or working on the agreed upon actions. One participant pointed to time constraints during the session, namely, that filling in the required information was time-consuming, limiting or completely eliminating the time allocated to discussing the problem and creating agreed actions. Others reported that it was difficult to take action due to ill health or other unknown reasons. However, such failures could be the starting point for a new round of problem-solving and action-planning.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSometimes I did what we had agreed on, and sometimes not. The interesting thing is why it turned out that way. (p6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eProvided memory support\u003c/h2\u003e \u003cp\u003e Several participants touched on different ways in which DIALOG\u0026thinsp;+\u0026thinsp;assisted their memory. Through its range of features, DIALOG\u0026thinsp;+\u0026thinsp;seems to support patients in retaining, organising, and recalling important information. It incorporates multiple modalities, such as written transcripts, visualisation of results, structured discussions, and consistent follow-up. The memory support was helpful both in more concrete activities, such as choosing topics from a list, and in abstract tasks, such as gaining an understanding of one's well-being over time. Regular use of DIALOG\u0026thinsp;+\u0026thinsp;was also mentioned as helpful in remembering previous responses and discussions, which is particularly beneficial for patients with short-term memory issues.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think it can be quite good to get a printout. I get one to remember what we have talked about. And it becomes a way for me to look at and go back to and think about what I should do to achieve my goals. (p10)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eI think that it's good actually, just that you have... we've been doing it regularly now and so on, it means that you might remember why you answered a certain thing and so on. And then you remember, so it doesn't just disappear, so to speak....from your memory. (p8)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEmpowering participation\u003c/h2\u003e \u003cp\u003eSeveral participants described how they could make their own choices with the support of DIALOG+. Statements indicated that the participants\u0026rsquo; ability to choose topics for further discussion and being encouraged to find their own solutions in the problem-solving structure contributed to feelings of empowerment. Participants valued the ability to make their own choices and generate their own solutions. Several participants touched on the importance of being the one who actually makes the decisions, which offered a sense of self-confidence and independence. Their statements also showed that the clinician sometimes needed to participate more actively in problem-solving and support participants to find the right solution. Furthermore, active participation in decision-making and topic selection can enhance an individual\u0026rsquo;s sense of autonomy, fostering mutual respect in the therapeutic relationship.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI thought it was very good that the patient independently gets to choose in what areas they want more help or support. I think it's good that people can choose themselves and feel more independent, because when you have a psychotic disorder, you can feel very independent. (p2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eI definitely felt that I was involved when I tested DIALOG+. I was involved in developing these different parts that were needed to come up with ideas on how to solve my problems. (p6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Providing a constructive structure\u003c/h2\u003e \u003cp\u003eParticipants distinguished DIALOG\u0026thinsp;+\u0026thinsp;from traditional routine encounters by highlighting its structured yet flexible approach and its effectiveness in promoting proactive health management. While participants appreciated the usefulness of DIALOG+'s structure, they also expressed preferences for the conversational flexibility in encounters where DIALOG was not used. Therefore, many participants suggested that a combination of encounters with and without DIALOG\u0026thinsp;+\u0026thinsp;could be used to optimise their healthcare experience. Additionally, the participants\u0026rsquo; feedback on the use of the digital tool suggested that it was user-friendly and supportive, although some encountered challenges with the design of the interface and navigating the tool. Overall, this theme suggested that DIALOG\u0026thinsp;+\u0026thinsp;has the potential to empower patients in managing their own health by providing a constructive structure for discussion and decision-making.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDistinguishing DIALOG\u0026thinsp;+\u0026thinsp;as a constructive complement\u003c/h2\u003e \u003cp\u003eThrough descriptions of the supportive structure of DIALOG\u0026thinsp;+\u0026thinsp;and reflections on how DIALOG\u0026thinsp;+\u0026thinsp;should best be used, this subtheme captures how participants distinguish DIALOG\u0026thinsp;+\u0026thinsp;as a constructive complement to routine encounters with their clinician. Participants provided varied depictions of routine encounters with no standardised structure. These depictions contributed to the theme by highlighting qualitative differences in routine encounters, where the quality of the encounter is dependent on the skill of the clinician and the therapeutic relationship. Some described more traditional, medically oriented meetings where the clinician would lead the conversation and focus primarily on medication and symptoms.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt was different. It was very much about how are your medications going? And how are your symptoms [traditional routine encounters]? And they just focused on that. (p10)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen you're mentally ill, the clinician takes over in a way, and I might have had other things that I wanted to talk about. They see the illness, that you don\u0026rsquo;t see yourself. You talk about things that the clinician wants to talk about. (p4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Other participants reflected that during routine encounters (not using DIALOG+), the clinician encouraged them to participate, inviting them to decide on what topics to discuss or taking a more whole-life perspective when asking questions regarding health. When these conversations were described as beneficial, the relationship with the clinician was an important factor, and participants described a good, well-established relationship. Although participants highlighted the importance of a good dialogue, they also highlighted the risk that some topics would be overlooked.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePreviously, I used to get asked whether there was anything special I wanted to address and how different things were working out, for example, my medication. Sometimes you miss things that you don't talk about. (p2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eIt was more like \u0026lsquo;How are you?\u0026rsquo; We talked superficially about whatever came to mind, and then we might forget about different areas. (p4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDIALOG\u0026thinsp;+\u0026thinsp;was described as a structured yet flexible approach, in contrast to traditional free-form conversations in routine encounters. The model's structure was seen to enable a more focused and efficient dialogue while maintaining the freedom to explore topics in depth. Furthermore, it was seen as a way to ensure that critical areas of concern were addressed in a systematic way. Participants indicated that DIALOG\u0026thinsp;+\u0026thinsp;facilitated dialogue, as it was structured in a way that provided valid questions for discussion and steered the conversation towards the most important topics, especially in the early stages of the therapeutic relationship. Additionally, DIALOG\u0026thinsp;+\u0026thinsp;appears to assist patients in discussing areas they may not otherwise address, thus providing an opportunity for patients to open up more quickly.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThere is a clear difference when we\u0026rsquo;ve used DIALOG+. It's mostly the structure of the conversation. Well, we speak very freely about the topic even when we use DIALOG+, but it's still this thing that you have a follow-up, you get to think about the different ratings and things like that. It sort of creates a structure in the conversation and helps maintain focus. (p8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDIALOG\u0026thinsp;+\u0026thinsp;was appreciated for its interactive and collaborative nature, providing a platform for patients to develop and share their own ideas while receiving constructive feedback. This aspect was seen as crucial as it helped participants evaluate the viability of their ideas and contributed to a more dynamic and supportive interaction.\u003c/p\u003e \u003cp\u003e \u003cem\u003eYou help each other, and it's very good that there is this room to come up with your own ideas, and at the same time, you can get very good feedback on whether it's constructive or not. (p2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe use of DIALOG\u0026thinsp;+\u0026thinsp;early in the therapeutic process was seen as particularly effective, allowing for prompt identification and discussion of key issues, potentially leading to reduced therapy duration.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI felt I got a lot out of it. It covered important areas and so on, but I would have appreciated if we could have used it a lot earlier. I might have been able to leave certain things behind much sooner. Certain things that might be more difficult to talk about would have been pinpointed in a much earlier stage. (p3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Although almost all participants described the usefulness of the structure provided by DIALOG+, several participants stated that traditional routine encounters were also needed. Others suggested that a different structure could be used, where helpful features of DIALOG+ (e.g. choosing topics) are used but where the dialogue could then depart from the DIALOG\u0026thinsp;+\u0026thinsp;format, making the conversation more \u0026ldquo;free\u0026rdquo; within the DIALOG\u0026thinsp;+\u0026thinsp;session. Some patients also reported time constraints, regarding agreeing on actions at the end of the session. Others pointed out that the ability to observe changes in health over time or monitor the achievement of established goals requires a timespan of several weeks between DIALOG\u0026thinsp;+\u0026thinsp;sessions, and emphasised the significance of employing DIALOG\u0026thinsp;+\u0026thinsp;over an extended period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eExperiences of the digital tool\u003c/h2\u003e \u003cp\u003eParticipants provided feedback on their experiences of the digital tool. Their statements described their perceptions of and interactions with the user interface in the digital tool, including its design, ease of use, and overall usability. The statements suggest that the participants found the digital tool to be user-friendly and easy to understand. They appreciated the visual presentation of results and felt that it provided valuable support, even for individuals who struggle with the use of technology. Some participants viewed DIALOG\u0026thinsp;+\u0026thinsp;as an effective and accessible self-analysis tool that offered a more comfortable experience than traditional paper-based methods. Some downsides were reported. One participant encountered difficulties navigating the digital interface during the self-rating task, particularly when changing questions or topics and choosing areas for further support, while another participant needed support from the clinician due to limited computer skills. One participant suggested that the design could be more user-friendly and intuitive, with larger icons.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think it was a great idea (with the DIALOG\u0026thinsp;+\u0026thinsp;program on a computer) actually, because it's not like staring over a piece of paper and not finding the answer. (p1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eI think this seems to be easy to work with. Now I get support from my therapist all the time, because I am so unsure about computers and technology. It seems to be good; I get a good impression of it. Pretty easy to understand for someone who has difficulty understanding computers, so it was easy to understand at the time. (p9)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStatements regarding the use of DIALOG\u0026thinsp;+\u0026thinsp;through video meetings were generally positive. Screen-sharing enhanced clarity, enabling participants to follow and engage with the content.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think it worked very well, using DIALOG\u0026thinsp;+\u0026thinsp;during video meetings. It was perhaps even easier to do it that way than usual. It makes things more concrete. I'm not a very tech-savvy person, so what you see on a screen feels kind of not real, even though I know that the person I'm talking to through the screen feels a bit strange and distant. DIALOG\u0026thinsp;+\u0026thinsp;makes it more concrete when you meet through a screen. (p2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study suggest that the use of DIALOG\u0026thinsp;+\u0026thinsp;during clinical encounters had a positive impact on participants\u0026rsquo; experiences of patient-clinician meetings in Swedish psychosis care. Participants reported feeling empowered through joint decision-making and had a better understanding of their health and improved engagement in proactive health management. DIALOG\u0026thinsp;+\u0026thinsp;was perceived as a valuable tool in facilitating structured yet flexible discussions, where patients and clinicians could identify areas for improvement related to the patient\u0026rsquo;s health and other areas of life while setting achievable goals.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eClinical encounters with and without DIALOG+\u003c/h2\u003e \u003cp\u003eWhile routine encounters without DIALOG\u0026thinsp;+\u0026thinsp;often lacked structure and sometimes overlooked important topics, the use of DIALOG\u0026thinsp;+\u0026thinsp;provided a structure that enabled focused discussions and the exploration of a variety of health domains based on the patient\u0026rsquo;s needs. In encounters where DIALOG\u0026thinsp;+\u0026thinsp;was not used, some participants reported that the clinician dominated the conversation and primarily discussed medications and symptoms. Moreover, the use of DIALOG\u0026thinsp;+\u0026thinsp;offered valuable memory support tools through various features, such as written transcripts, visualisation of results, and consistent follow-up, which helped participants retain, organise, and recall important information. Such cognitive compensatory interventions have been associated with improvements in functioning for patients with psychotic disorders (Allot et al., 2020). Even though all participants were satisfied with the structure within DIALOG+, some participants were not able to generate solutions during the sessions due to time constraints. Additionally, some participants suggested combining DIALOG\u0026thinsp;+\u0026thinsp;sessions with less structured routine encounters to optimise the healthcare experience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSupport for co-production\u003c/h2\u003e \u003cp\u003eThe participants seemed to value the visualization of their health status and the structured way of evaluating their treatment. Choosing topics for further discussion appeared to help patients make preference-based decisions, sometimes leading to a care plan aligned with their goals. The subsequent DIALOG\u0026thinsp;+\u0026thinsp;sessions included discussions on how the patient could actively contribute to their care with the support of healthcare professionals. The supportive features of DIALOG\u0026thinsp;+\u0026thinsp;seem to align with Elwyn's iterative co-production cycle, which consists of the steps 'co-assess', 'co-decide', 'co-design', and 'co-deliver' to ensure that the patient is involved in the entire care process (Elwyn et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This is also consistent with the findings of Omer et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), who demonstrated that DIALOG\u0026thinsp;+\u0026thinsp;enhances an individual\u0026rsquo;s sense of competence across various life domains.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eContinuous Feedback and solution-focused approach\u003c/h2\u003e \u003cp\u003eThe use of continuous patient-reported ratings of well-being and experiences of care is a key feature of DIALOG+. This continuous feedback loop seems to enhance the therapeutic process in multiple ways and enables longitudinal tracking of the patient's progress over time. Patients suggested that the ratings can serve as indicators of whether intended actions have actually resulted in improvements. If not, patients and clinicians can collaborate to explore solutions. Furthermore, the patients\u0026rsquo; ratings can help identify signs of deterioration, which otherwise can be difficult to predict (Lambert, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This type of continuous measurement aligns with continuous feedback methods known as Routine Outcome Monitoring (ROM) and Progress Monitoring (PM), which have also shown positive effects on treatment lengths while reducing care costs (Goodman et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The problem-solving methodology in DIALOG\u0026thinsp;+\u0026thinsp;is designed to work to address identified problems in a structured way. Through the problem-solving process, patients and clinicians collaborate to explore potential solutions and agree on options and suitable actions. The result of this study suggests that this type of collaborative approach seems to foster a sense of ownership and empowerment among patients, as they play an active role in decision-making in their own treatment. Furthermore, patients suggested that the problem-solving approach seems to promote structure, helping patients and clinicians maintain their focus during the clinical encounter. Previous studies have demonstrated that problem-solving interventions can significantly enhance patient outcomes, especially in mental health settings. These interventions have been shown to reduce the risk of deterioration and increase recovery rates compared to standard routine encounters (Lambert, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Overall, the results of this study support the claim that the continuous feedback and solution-focused approaches integrated into D\u0026thinsp;+\u0026thinsp;facilitate the achievement of co-produced care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePractical Implications\u003c/h2\u003e \u003cp\u003eDIALOG\u0026thinsp;+\u0026thinsp;could serve as a method to facilitate co-production in healthcare, establishing a foundation for placing the patient in the role of a decision-maker. Furthermore, DIALOG\u0026thinsp;+\u0026thinsp;enables longitudinal tracking of the patient's progress over time, providing a comprehensive view of the patient's journey and allowing for the evaluation of treatment effectiveness on an individual level. Through the use of continuous feedback and a problem-solving approach, DIALOG\u0026thinsp;+\u0026thinsp;also has the potential to facilitate tailored care plans based on the patient's needs. Beyond using DIALOG\u0026thinsp;+\u0026thinsp;on an individual level, aggregated patient rating data can enable the identification of strategies and areas for improvement at various levels within the healthcare system, contributing to quality improvement initiatives that ultimately enhance overall care and outcomes for individuals with severe mental illness (Gremyr et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Dialog\u0026thinsp;+\u0026thinsp;also appears to be suitable for use during video meetings, which aligns with previous research on videoconferencing interventions for patients with schizophrenia-spectrum disorders (Santesteban-Echarri et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eFuture research\u003c/h2\u003e \u003cp\u003eIn an ongoing study conducted in psychosis outpatient care settings in Sweden, clinicians' experiences with DIALOG\u0026thinsp;+\u0026thinsp;are being investigated. Understanding clinicians' perspectives, attitudes, and experiences when using DIALOG\u0026thinsp;+\u0026thinsp;is crucial for implementation and sustained use. This research also examines the perceived usefulness of DIALOG+, its integration into existing workflows, and challenges or barriers encountered. Furthermore, observational studies could offer valuable insights into the interaction between patients and clinicians during DIALOG\u0026thinsp;+\u0026thinsp;sessions. Observing these interactions in real time can provide valuable insights into how Dialog\u0026thinsp;+\u0026thinsp;is used, the communication dynamics between patients and clinicians, the impact of the tool on clinical encounters, and its contribution to co-production. There is also a potential to utilise various Patient-Reported Outcome Measures (PROMs) to enhance healthcare systems so that they become learning health systems, fostering greater patient involvement through self-reported measures. This integration allows for the seamless utilisation of aggregated data to drive quality improvement initiatives, thereby optimising patient outcomes and system efficiency (Green et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Further research could investigate the potential of DIALOG\u0026thinsp;+\u0026thinsp;as a tool to facilitate the transition to a learning health system.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e This study was conducted in the early stage of implementation, resulting in a limited pool of patients eligible for participation. In order to efficiently collect data under these circumstances, a convenience sampling method was used (Taherdoost, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Participants were selected based on their availability and willingness to participate. Therefore, the patients included in this study may not necessarily be representative of the entire population. On the other hand, the included patients were mainly patients with psychotic disorder and the mix of age and gender, and the richness of data in interviews and analysis, still provides valuable insights into how patients with psychotic disorders experience the use of DIALOG+.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e The findings suggest that DIALOG\u0026thinsp;+\u0026thinsp;could serve as a tool to establish an iterative co-produced care process during routine encounters, empowering patients through shared decision-making that places them at the centre of the conversation. Furthermore, DIALOG\u0026thinsp;+\u0026thinsp;seems to enhance patients' understanding of their health and facilitate the journey toward improvement. The continuous feedback loop, driven by patient ratings, contributes to addressing unspoken concerns and providing a comprehensive view of well-being. Moreover, the built-in solution-focused approach appears to aid patients in maintaining focus during conversations, which increases the understanding of patient concerns while aiding in the establishment of achievable goals. This highlights the potential of DIALOG\u0026thinsp;+\u0026thinsp;as a tool that can be used to tailor care plans according to patient-specific needs. Additionally, DIALOG\u0026thinsp;+\u0026thinsp;seems to provide built-in memory support features, which is particularly important for patients with cognitive impairments. Despite the concerns some participants raised about the structured meeting format and time constraints, DIALOG\u0026thinsp;+\u0026thinsp;seems promising as a means to improve patient-clinician interactions and treatment outcomes in Swedish psychosis outpatient care.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eEthical approval was obtained from the Swedish Ethical Review Board prior to data collection (Dnr 2020\u0026ndash;03653). Informed consent was obtained from all participants, and participants were informed of the voluntary nature of their participation and their right to withdraw at any time without consequences. The confidentiality of the participants was maintained throughout the study by assigning pseudonyms and ensuring secure data storage.\u003c/p\u003e\u003c/div\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors ML, AG, and ACA designed the study, and ML developed the interview guide with contributions from AG and ACA. ML conducted patient interviews and conducted the qualitative analysis along with KA, and discussed the results with the other authors. ML was mainly responsible for drafting the manuscript with contributions from all authors. All authors, ML, KA, AG and ACA, critically reviewed the analysis and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe want to extend our sincere gratitude to the patients who generously participated in the interviews for this study. Your contributions have been invaluable to our research. We also thank Sahlgrenska University Hospital and the Department of Psychotic Disorders for providing the support and resources necessary to conduct this study. Your collaboration and dedication to advancing medical research are greatly appreciated.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAllott, K., Van-Der-El, K., Bryce, S., Parrish, E. M., McGurk, S. R., Hetrick, S., ... \u0026amp; Velligan, D. (2020). Compensatory interventions for cognitive impairments in psychosis: a systematic review and meta-analysis. \u003cem\u003eSchizophrenia bulletin\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(4), 869-883.\u003c/li\u003e\n\u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2022). \u003cem\u003eThematic analysis: A practical guide\u003c/em\u003e. Sage\u003c/li\u003e\n\u003cli\u003eCrump, C., Winkleby, M. A., Sundquist, K., \u0026amp; Sundquist, J. (2013). 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Effective patient\u0026ndash;clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design. \u003cem\u003eProgramme Grants for Applied Research\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(6).\u003c/li\u003e\n\u003cli\u003eSaarni, S. I., Vierti\u0026ouml;, S., Per\u0026auml;l\u0026auml;, J., Koskinen, S., L\u0026ouml;nnqvist, J., \u0026amp; Suvisaari, J. (2010). Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders. \u003cem\u003eThe British Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e197\u003c/em\u003e(5), 386-394.\u003c/li\u003e\n\u003cli\u003eSantesteban-Echarri, O., Piskulic, D., Nyman, R. K., \u0026amp; Addington, J. (2020). 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Organizing care for patients with chronic illness. \u003cem\u003eThe Milbank Quarterly\u003c/em\u003e, 511-544.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"DIALOG+, Severe mental illness, Psychotic Disorders, Digital intervention, Co-production, Patient Reported Outcome Measures, Routine outcome monitoring, Continuous Feedback, Problem-solving","lastPublishedDoi":"10.21203/rs.3.rs-4579887/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4579887/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInvolving patients in their care and including them in continuous follow-up is a challenge. This challenge is often compounded by a lack of self-reported outcome measures. Incorporating such measures could aid healthcare professionals in collaboratively designing care plans and adjusting treatments as therapy progresses. Previous research highlights the positive impact of continuous feedback based on treatment outcomes and problem-solving methodology in routine psychiatric care. DIALOG\u0026thinsp;+\u0026thinsp;is a digitally supported conversational tool designed to enhance the therapeutic effectiveness of patient-clinician meetings by incorporating continuous self-reported outcomes and a solution-focused approach. The objective of this study was to investigate the disparities in patients' experiences when using DIALOG\u0026thinsp;+\u0026thinsp;compared to standard treatment and to examine the implications for clinical use within a Swedish setting.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study was designed to describe patients\u0026rsquo; experiences using DIALOG\u0026thinsp;+\u0026thinsp;in psychosis outpatient care in Sweden. A convenience sample of patients who used DIALOG\u0026thinsp;+\u0026thinsp;three times or more was included in the study. Individual semi-structured interviews were conducted with ten patients. The interviews were analysed using reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis identified two themes: 'The supportive features of DIALOG+' and 'Providing a constructive structure'. These themes consist of six sub-categories: Expanded the understanding of my health; Moving toward improvement; Provided memory support; Empowering participation; Distinguishing DIALOG\u0026thinsp;+\u0026thinsp;as a constructive complement, and Experiences of the digital tool.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe structure of DIALOG+, including continuous feedback and the solution-focused approach, seems to enhance person-centred care for patients with psychotic disorders, fostering shared decision-making and aiding memory support. It also facilitates a collaborative understanding of the patients\u0026rsquo; health concerns and personal goals, which shows that DIALOG\u0026thinsp;+\u0026thinsp;could be useful as a tool to develop care plans that are more tailored to the patients\u0026rsquo; needs. Despite some concerns about structured dialogues, DIALOG\u0026thinsp;+\u0026thinsp;holds promise for improving patient-clinician interactions and treatment outcomes in psychosis care in Sweden. Additional research is planned, which will include an exploration of clinicians' experiences with DIALOG\u0026thinsp;+\u0026thinsp;as well as observational and effectiveness studies.\u003c/p\u003e","manuscriptTitle":"Patients’ Experience of Patient-Reported Outcomes, Continuous Feedback, and a Solution-Focused Approach (Using DIALOG+) in Psychosis Care in Sweden","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-08 17:15:17","doi":"10.21203/rs.3.rs-4579887/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0f34999-4889-43c0-9a80-a59c6052162b","owner":[],"postedDate":"July 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-06T04:38:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-08 17:15:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4579887","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4579887","identity":"rs-4579887","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}