Therapy Fidelity is a mobile interface that displays 132 sequential steps of cognitive behavioral therapy (CBT) for treating posttraumatic stress disorder (PTSD) to improve the fidelity of following the treatment protocol.

The Challenge

Leaders in the field of psychotherapy have been encouraging psychotherapists to adopt evidence-based treatments such as CBT for 20 years but it has been largely unsuccessful. Therapists have been unwilling and unable to rigorously follow CBT protocols with fidelity. Therapists cannot memorize all 132 steps, and patients have very limited access to the steps. As a result, treatment of patients suffers.

Child psychiatrist Michael Scheeringa, MD identified a solution for this problem—a mobile interface that displays a CBT treatment protocol and that can be viewed by therapists and patients simultaneously. Through the guidance of Dr. Scheeringa and in partnership with Tulane University, Agaric developed the Therapy Fidelity web app.

Our Approach

Designed For Use During a Therapy Session

When a patient attends their therapy session, it is far more likely that they arrive with a mobile phone than with a laptop. The need for a seamless mobile experience was one major reason we decided to build Therapy Fidelity as a single page application using React.js. Single page applications are great for reducing the number of network calls made to the host server since they do not need to request markup templates every time an end-user clicks to a different part of the site.

Consequently, most of the network calls made by the app are made to read or write data to one of several third party APIs. We worked to mitigate these, too, by using the React Query library, a powerful and configurable tool for fetching, caching, and updating data in React. The result is an app that clearly indicates when data is loading, allows the user to continue navigating the app while update requests are being processed, indicates the results of those requests once they resolve, and prevents redundant fetching of data that has already been cached—in other words, a fast, smooth, and intuitive end-user experience, even on a limited-bandwidth device. One additional benefit of the data caching—many third party APIs will bill per API call after a limited number of requests; without caching that data in the browser, these API services could get expensive fast.

Simple, Consistent, and Flexible Design Elements with Tailwind UI/CSS

Throughout the building process, we looked to Tailwind UI for example components. By doing so, we made sure that the app has a consistent look and feel and is responsive so that it looks good on devices of all screen sizes. As this app mostly functions as a utility dashboard, the pre-designed components sufficed for the apps aesthetic needs, meaning that Tailwind UI saved us a lot of time on design work. Often we had to make minor adjustments to the markup so that it would suit our specific needs, and very seldom did we need to add any custom classes to our CSS stylesheet, which incidentally results in removing the often expensive overhead of building and maintaining our CSS architecture. Again, this is great for an app with simple aesthetic needs but which also needs re-usable and flexible responsive components.

HIPAA Certified Storage with TrueVault

In order to facilitate a quickest time-to-market, we opted to utilize an existing HIPAA certified provider for the storage, retrieval, and access controls/monitoring of protected data. TrueVault provides a JavaScript library for communicating with their RESTful backend. Their backend includes provisions for dealing with all aspects of the data, such as authentication, authorization, logging, and so-on. We were able to use their Vault-based data model to separate patient records into individual silo's per-therapist, and use their group-based security to set nearly all relevant permissions for the app's use. TrueVault certainly comes with its limitations and challenges, but it sure would have taken quite a bit more time and resources to build and certify a custom storage system.

Automated Quality Assurance using Typescript and React Testing Library

Additionally, we needed to ensure that each client's data is stored and retrieved accurately. TypeScript, which provides a type system for JavaScript, helped to ensure that as our application passed data around, it was of the expected type. Using a typed language also reduces the possibility for software errors generally. Beyond using good tools to write the application, checks must be in place to ensure that as it evolves, things do not break. Here, we leveraged React Testing framework and other tools to walk through the functionality of the application and ensure that everything continued to function correctly, and even stored the correct data; By mocking (simulating) the TrueVault service we could inspect what the application would be storing there directly.

The Delicate Balance of Computing Large Sets of Sensitive Data

While the majority of permissions available to a logged in client were sufficient, there were cases where privileged tasks needed to be performed. Therapy Fidelity's People Like Me system is a great example. People Like Me involves a multi-step form which upon completion shows how many people with similar conditions were able to significantly improve their condition following the successful completion of a 3 month adherence to therapy protocol:

First, a patient selects for comparison the results of a single survey they have completed, consisting of numerical indicators  for several psychological conditions (anxiety, depression, PTSD, etc.)

Second, they configure which parameters they would like to match on. For example, a patient could choose to only see how many people who had shared a similar pre-therapy anxiety score were able to improve their condition following therapy.

Finally, they view the results.

Now it must be acknowledged that this system is parsing through and accessing patient data in real time. Of course, it would be a breach of patient privacy law for the patient to have such access to all of this other patient data, so we made sure that all data was scrubbed before reaching storage to reduce any personally identifiable information, and that computations occurred securely on a server before serving back results to the client.

Rather than utilize something like a full VPS server that performed these functions for us, we were able to leverage functions-as-a-service to provide the specific privileged function access, specifically AWS Lambda functions. This helped us keep the surface area of the application as low as possible for security purposes, while providing server-side style functionality. The language we chose for these was Go, for its performance, excellent built-in framework, and because we were able to build for our needs with very minimal additional libraries, which again helps mitigate security concerns.

While these functions-as-a-service were used several times throughout the site, it will be hard to forget Dr. Scheeringa's excitement about the realization of the People Like Me tool.

What's Next?

Therapy Fidelity was an excellent development experience—both for the thrill of developing a single page app and for carrying on Agaric's history of building tools for medical and scientific communities. As always, we are looking forward to our next opportunity to engage in these communities and build something wonderful.

For any clinicians who happen to be reading this and are interested in using the Therapy Fidelity app for their own practice, Scheeringa Mind offers it as a service and provides a 30-day free trial. There are also plenty of video tutorials on how to use the app, which might help to preview just what you might be getting into.

As Scheeringa Mind Company grows and Therapy Fidelity sees more use, we will be sure to publish any updates or major achievements. We are anticipating great strides in research on CBT protocol and look forward to seeing the results.

Find It Cambridge is an online resource that empowers families, youth, and those who support them to easily find activities, services, and resources in Cambridge, Massachusetts. It serves as a one-stop-shop website for those who live and work in Cambridge.

Agaric led development and functionality-focused consulting on this project from its inception in 2016.  In 2020, we upgraded the site and made the program locator and event finder platform that powers it available to all communities.

The Challenge

Building an event calendar and program directory central to people’s lives is challenging. City governments are notorious for silos and redundancy. The City of Cambridge was determined to do differently.

This started with thorough user research led by the city. Over 250 interviews and 1,250 surveys were completed by Cambridge residents and representatives from the city, schools, and community-based organizations. Taking the time to survey and interview everyday residents ensured we could confidently build a truly helpful site.

From that research we learned that the site needed:

• Powerful, but intuitive search for Cambridge residents
• Friendly authoring experience for service providers
• Phone number with a human on the other end

The Approach

To make the research findings a reality we combined forces with Terravoz, a digital research and development agency, and Todd Linkner, a designer and front-end developer who defined Find It Cambridge’s brand identity and developed an accompanying style guide.

A Search for Locals

There are hundreds of events, programs and organizations in Cambridge. To find exactly what one is looking for a sophisticated filtering system is a must. We chose Apache Solr, leader of the pack when it comes to advanced filtering.

One particularly interesting facet came out of Cambridge’s unique geography. Despite spanning a relatively small area, Cambridge’s neighborhood boundaries are infamously creative. Even longtime residents don’t necessarily know where one neighborhood ends and another starts. So, while filtering by neighborhood is helpful, we decided a visual aid was in order.

Todd Linkner created a custom SVG image file representing Cambridge’s neighborhoods. We then took that SVG file and wrote a custom module that associates each neighborhood map section to a Drupal vocabulary term. The result is a clickable map filter aiding site visitors in quickly finding programs and activities in their area.

Supporting Service Providers

For a knowledge hub like Find It Cambridge to thrive, it needed buy in from service providers. Getting their input during the research phase set that relationship off on the right foot. The resounding feedback was that the site needed to be easy for them to use.

This proved to be a challenge because while ease of use was critical, it was also essential that events and programs have rich metadata. The more data we ask of users, the more complex interfaces become.

To address this we leveraged Drupal’s customizable dashboard and the Field Groups module.

Customized Dashboard

By default, the first page a user sees when logging into a Drupal site is an underwhelming user profile page.

We customized a dashboard with the key actions providers take on the site: creating new content, updating past content and answering questions about the site.

While there is a Drupal Dashboard module, we opted to build this ourselves for maximum flexibility and control. Doing so allowed us to break information out into several working tabs. A custom administrative page for internal documentation pages and other Find It Cambridge information turns control over the “Have Questions?” section of the dashboard over to site administrators, rather than being hardcoded.

Delete Without Worries

With dozens of service providers managing content on the site mistakes are bound to happen. The worst scenario is accidentally deleting a node. In Drupal when a node is deleted it is gone forever. To protect against these we used the Killfile module to “soft delete” nodes, allowing for their recovery if needed.

Helping Managers Help Providers

Another key piece to getting relevant, timely information added to the site is helping the Find It Cambridge team remind and support service providers to use the site and update their information. To that end we put together a statistics page listing organizations in alphabetical order, along with the number of programs and events they have. This allows the team to quickly spot duplicate entries and other incorrect data.

We also implemented a notification system. Any time a service provider adds or updates content the Find It team receives an email. This helps managers stay on top of the ever changing content of the site.

Results

Since Find It Cambridge launched, 333 organizations have created accounts and contributed to the directory. Residents now have a single site they can refer to stay connected with events and access programs. The effort has also fostered increased collaboration across city departments and services.

Connecting community is an ongoing process and we continue to improve the site to better connect residents.

In 2020, we completely overhauled the site and built the program locator and event finder that powers FindItCambridge as software and as a platform available to all cities, towns, and regions to adopt.

What'd we get wrong?  What resources are we missing?  Send us a note or tell us in the comments below!

Upcoming trainings

Find It websites help residents find all that their communities have to offer.

Cities and towns everywhere offer children and adults myriad programs, events, and places for enriching experiences. These activities and services come from various levels and agencies of government—operating schools, libraries, parks, and more—as well as from not-for-profit organizations, civic groups, private educational institutions, and others. However, any given person—say a single parent with three kids—has no time-efficient way of knowing about all of these opportunities.

Cambridge, Massachusetts, took on this problem. No software or website can solve this by itself, but an easily searchable directory with built-in reminders and tools to help keep it up to date makes finding all available opportunities achievable. Developed based on hundreds of hours of research and interviews led by the Cambridge Kids' Council, Find It Cambridge makes it easier for parents and other care-giving adults to find the amazing array of activities, services, and resources that are available for children, youth, and families in Cambridge.

This year, Agaric gave the site a major upgrade and made Find It capabilities freely available for other cities and towns.

If this is of interest to you for your city or region, especially if you work in an afterschool network or are otherwise in the thick of bringing opportunities to children, please get in touch by e-mail, at 1 508 283 3557, or through our contact form!

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