Telehealth for psychological interventions has existed for decades, with historically limited uptake, primarily due to strict regulations [1] and limited reimbursement [2]. COVID-19 facilitated the swift global adoption of telehealth [3], and payors have acknowledged the need to ease regulatory burdens and sustain telehealth reimbursement postpandemic [4-8]. To date, telehealth has primarily been studied as an alternative to in-person care [9-12] and as a means of supporting access to care for historically marginalized groups [13,14]. However, little research has examined how to leverage the platform to support evidence-based practices (EBPs) and patient-centered care.

Telehealth provides a unique opportunity to apply behavioral economics (BE) principles to structure therapy encounters in ways that nudge clinicians toward delivering high-quality services. BE approaches address psychological biases that influence individual decision-making [15]. These frameworks recognize that human decision-making often occurs under suboptimal conditions, leading individuals to deviate from “rational” choices in numerous ways. Classic examples of such “bounded rationality” (ie, the recognition that humans make decisions with limited cognitive resources and thus rely on heuristics [16]) include individuals failing to opt in to retirement investments that would serve their best interests (due to status quo or loss aversion bias [17]) or making suboptimal decisions in cognitively demanding situations (eg, as a result of decision fatigue or availability heuristics [15]). In health care, clinicians may be aware of the right course of action (eg, “I should deliver x treatment for y condition”), yet often choose other, less empirically supported interventions for various reasons related to environmental cues (eg, availability biases), individual cognitive styles (eg, aggregate heuristics), and other biases [18]. Research has shown that structuring environments and nudging clinicians toward recommended practices can improve quality of care [19-21]. Common BE applications include strategies that guide decision-making by providing information (eg, social reference points or peer comparisons, making key information visible), implementing structural changes (eg, changing choice defaults, altering options presented to influence the attractiveness of some choices over others), and offering cognitive assistance (eg, reminders) [18,22,23].

While BE holds strong potential to inform cost-effective, pragmatic implementation strategies that support clinicians in delivering EBPs, its role in changing mental health clinicians’ behavior has received little attention. The nature of traditional behavioral health sessions—occurring behind closed doors and prioritizing privacy—makes it difficult to implement supports during encounters. The continuation of telehealth access postpandemic provides a context ripe for improving treatment delivery. Telehealth has traditionally been regarded as a medium for delivering treatment, with content and processes comparable to in-office visits [24]; however, it also offers an infrastructure well-suited to BE strategies that can optimize clinician use of EBPs, track and reward fidelity to EBPs, and make EBP use easier and more motivating.

In this study, Behavioral Nudges to Enhance Fidelity in Telehealth Sessions (BENEFITS), we will develop and pilot test an implementation strategy that leverages the technological infrastructure of telehealth encounters to nudge and incentivize clinicians to increase fidelity to the structural components of cognitive behavioral therapy (CBT). We focus on CBT because it is an EBP for many mental health conditions, and increasing clinician fidelity to CBT can enhance care quality and improve patient outcomes [25-27]. Prior research suggests that when community clinicians use CBT at all, it is often delivered with poor fidelity [28-30].

We focus on structural components of CBT for 2 reasons. First, they represent a core and distinct CBT competency [31,32] and form the backbone of CBT practice; they are delivered regardless of diagnosis. A typical CBT session begins with a brief check-in on treatment progress, a collaborative agenda, and a review of prior homework. The core of the session emphasizes intervention techniques and skills, and it concludes with planning a between-session homework practice. While the specific clinical content—such as which interventions are selected and what homework is assigned—is tailored to the patient’s presentation, use of these structural components remains consistent across sessions. Structural components also support shared decision-making and facilitate the selection and tailoring of interventions to patient preferences and symptoms, thereby enhancing patient-centered care [33]. Clinical trials further suggest that these components are independently associated with improved clinical outcomes [34-37]. Our work has shown that community clinicians demonstrate consistently low fidelity to structural components [32,38], even when their intentions to deliver them are high [39].

Second, structural components are well-suited to BE strategies, which are best applied to change discrete, observable, and measurable behaviors. Leading theories of clinician behavior change [40-42], along with our prior studies [38,39], suggest 2 major reasons why clinicians trained in CBT fail to use CBT structural components—each with distinct implications for designing implementation strategies using BE approaches. First, some clinicians may have strong motivation (or intentions) to use structural components; however, aspects of their organizational setting or their patients’ presentation in treatment may make it difficult to act on those intentions. For example, a patient may present with much to share, and the clinician may forget to set the agenda or be reluctant to pause the client long enough to do so. For these clinicians, effective implementation strategies should either make it easier to act on their intentions or bypass intentions altogether by making the use of structural components the default (eg, automatically sending progress monitoring measures to clinicians rather than requiring them to do so). Second, other clinicians may have weaker intentions to use CBT components due to factors that influence intention strength, such as holding negative attitudes about a specific component (eg, believing homework is unhelpful or irrelevant), experiencing limited normative pressure to use CBT components (eg, perceiving that one’s supervisor disapproves of structured sessions), or having low self-efficacy (eg, lacking confidence in planning a homework assignment). For these clinicians, effective implementation strategies should strengthen intentions by improving attitudes, leveraging norms, or increasing self-efficacy to promote behavior change. BE offers strategies to address the mechanisms of action identified in both pathways and thereby improve clinician CBT delivery.

The field of surgery provides a useful example of the potential benefits of BE strategies for improving patient care. Surgeries are complex, requiring providers to execute highly specified procedural techniques while also knowing how and when to deviate in response to diverse problems or complications [43]. There is extensive evidence demonstrating the effectiveness of structuring surgical environments to minimize risk, optimize outcomes, and nudge surgeons to engage in safety and quality checks (eg, surgical checklists) [19,20]. Such behavioral infrastructure facilitates the delivery of high-quality care by reducing the cognitive load of remembering routine protocols [21], allowing surgeons to focus their efforts on applying clinical skill and judgment to optimally help patients. CBT structural components, when implemented correctly, provide the scaffold that supports clinicians in delivering CBT intervention techniques, which can be complex and often require adaptation [44,45] and tailoring [46] in response to patient needs that may change within and between sessions [47]. Unlike surgery, the private, in-person therapy environment has historically offered limited opportunities for BE strategies to support clinicians in delivering these structural components; therapy is typically conducted without a support team, as found in an operating room. Leveraging telehealth encounters to embed checklists and other nonintrusive nudges may reduce clinicians’ cognitive load, allowing them to focus more fully on selecting and delivering interventions and skills that yield comparable benefits for their patients.

In BENEFITS, we will develop and evaluate Tele-BE, a novel telehealth infrastructure designed to nudge and incentivize clinicians to use core structural CBT components. Tele-BE is intended solely to support fidelity to the structural elements of CBT that should be present in sessions, regardless of where a patient is in active treatment (with expected exceptions such as first sessions, termination sessions, or crisis sessions). Tele-BE will remain agnostic to intervention content (ie, clinicians will be encouraged to use a CBT skill in session, but not any specific skill). Importantly, in other contexts, BE strategies have raised ethical concerns regarding coercion to engage in behaviors one might not otherwise choose [48,49]. Therefore, studying BE strategies to support mental health EBP delivery should incorporate careful consideration of participants’ and end users’ ethical concerns. We will address any concerns raised by clinicians or patients to ensure that clinicians do not feel undue pressure to deliver therapeutic care they consider inappropriate. Our specific aims are listed in Textbox 1.

All research activities will take place in the City of Philadelphia, building on a strong history of CBT implementation efforts in the region through the Beck Community Initiative (BCI). The BCI is a partnership with Philadelphia’s Department of Behavioral Health and Intellectual Disability Services to implement high-quality CBT in the public mental health system. BCI provides training in CBT theory and strategies through intensive workshops, followed by 6 months of weekly case consultation. During the consultation phase, therapists submit recorded therapy sessions, and their CBT competence is rated in at least 4 sessions using the Cognitive Therapy Rating Scale (CTRS). Mean competence scores at the end of training (41.2) have been just above the criterion threshold for certification, highlighting substantial opportunities to further improve therapist skills even after training [50]. Importantly, BCI-trained therapists demonstrated substantial variability in their intentions to use CBT structural components following training [39]. Research also shows that training effects diminish over time without additional support, such as behavioral nudges [51]. Philadelphia’s Medicaid behavioral health payor continues to support telehealth reimbursement, providing an ideal context in which to test the effects of BE strategies on CBT fidelity. All participants will complete a consent process with research team members before engaging in any study activities.

Table 1 presents the target mechanisms and illustrates how Tele-BE is anticipated to map onto each, guided by leading behavioral theory to (1) strengthen clinician intentions to use CBT structural components when motivation is low, and (2) support clinicians in acting on their intentions when motivation is high. Multimedia Appendix 1 presents the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 checklist for this study.

Aim 1 will be conducted in 2 phases. In phase 1, we will interview 3 CBT-trained clinicians and 3 clinical supervisors who have previously received CBT training and either provide telehealth services or supervise a clinician who does. Clinicians and supervisors will not be recruited in dyads. Sample sizes are intentionally small at this stage, as the primary goal of aim 1 is to examine prototype usability to enable rapid refinement and development of the first fully functioning platform. We will present each anticipated Tele-BE feature and target mechanism (Table 1), along with initial prototypes (Figure 1), and solicit feedback on how to refine the prototype to maximize usability and engagement with target mechanisms (eg, clinician intentions, intention-behavior gap); minimize unintended negative effects on patient experience (eg, perceptions that clinicians are distracted); and ensure that Tele-BE integrates with clinical, supervision, and administrative workflows. We do not anticipate changing the structural components targeted, but we may make small adjustments to how each is described based on feedback. We will also ask whether there are additional session features that would be useful for Tele-BE to target or capture. Interviews will probe perceived motivators and barriers to adopting the Tele-BE system, including ethical concerns. For example, therapists may value the potential for improved session structure and care quality but express concern about patient perceptions of recording or about the platform infringing on their autonomy to make clinical decisions. Such feedback is critical for design and implementation planning (eg, clarifying that the interface is clinician-facing only and that clinicians can override prompts). Participants will also complete a brief demographics questionnaire to ensure that feedback is gathered from a diverse group across study phases. Recommendations from each participant will be summarized and reviewed by the larger research team to identify refinements before moving to the next phase. Results will be shared with the technology development team, which will build an initial Tele-BE working prototype incorporating this feedback. We will then reconvene the same participants for a second interview, during which they will trial the interactive prototype and suggest further refinements. All feedback will be collated and synthesized, with input echoed by multiple participants given greater weight in decisions about changes. Participants will receive US $100 in compensation for their activities, and their feedback will be integrated into the next Tele-BE iteration. Draft interview guides for aim 1, phase 1 activities are provided in Multimedia Appendix 2.

In phase 2, we will conduct usability testing with 3 newly recruited CBT-trained community clinicians, using the same eligibility criteria as in phase 1. Participants will interact 1-on-1 with a basic version of Tele-BE, with the primary objective of identifying major bugs and usability issues in preparation for aim 2. Consistent with phase 1, the small sample size is intentional, as the focus of this phase is to assess usability among clinicians, the tool’s primary end users. Each clinician will meet individually with the study team and use the current version of Tele-BE for approximately 45 minutes. During this session, participants will conduct a mock therapy session with a graduate student clinician experienced in providing community-based CBT, followed by an immediate debrief to obtain feedback on both the clinician’s end user experience and the “patient’s” perspective. Participants’ interactions with Tele-BE will be recorded using Health Insurance Portability and Accountability Act (HIPAA)–compliant videoconferencing software. Following the session, participants will complete a brief interview assessing the user experience, including learnability, acceptability, usefulness, overall satisfaction with aesthetics, perceived efficiency, and potential for integration with both clinical and supervision workflows. Semistructured interviews will probe each user interface element of the Tele-BE prototype. At the end of the session, participants will also complete brief quantitative measures to assess perceptions of Tele-BE, including the Acceptability of Intervention Measure (AIM) [52], a validated 4-item scale assessing the perceived acceptability of an innovation; the Feasibility of Intervention Measure (FIM) [52], a 4-item scale evaluating perceived feasibility; and the System Usability Scale (SUS), a well-established 10-item measure with strong psychometrics and sensitivity to change [53,54]. Participants will also complete a brief demographics questionnaire and receive US $75 for their participation. Collected data will identify areas for improvement in acceptability, feasibility, and usability, and refinements will be incorporated before aim 2.

We will recruit 5-10 clinician-patient dyads who are already providing or receiving telehealth therapy services to engage with Tele-BE in an open field trial. The final sample size will be determined based on when saturation is reached (see below). The primary aim of this trial is to identify software bugs and evaluate usability and acceptability issues that emerge over extended use of Tele-BE, while refining our BE strategies. Secondary goals are preliminarily assessing the extent to which Tele-BE engages target implementation mechanisms and supports clinicians in delivering CBT structural components to guide further refinements. Clinicians and patients will be recruited in pairs, with participating clinicians using Tele-BE with a consenting patient of their choice for up to 4 consecutive therapy sessions or over 5 weeks of treatment, whichever occurs first. After obtaining consent, each clinician-client dyad will receive a personalized, secure link to use during their regularly scheduled telehealth sessions for up to 5 weeks. Only the clinician will require instructions on using Tele-BE. Client participants will not view the Tele-BE interface, so their telehealth sessions will appear similar to standard care.

We will use rapid-cycle methods to test and refine both the platform and the BE features developed in aim 1, with the goal of optimizing messages and visual displays. Adjustments will be made after each dyad completes aim 2 activities, continuing until feedback saturation is reached and a version suitable for formal testing in aims 3 and 4 is achieved. To streamline this process, we will use “fake back ends” to test BE strategies whenever possible, avoiding time-consuming web programming for features that may require revision. For example, study staff may message clinicians directly to simulate portal-generated messages based on feedback. The exact content of messages may evolve over time in response to participant input. Using a fake back end allows small changes across enrolled dyads to be tested more efficiently.

As noted, the Tele-BE platform is designed to be agnostic to specific CBT interventions and only nudges the use of interventions within the standard CBT session structure. A key focus of this design phase is ensuring that clinicians understand how to “override” any recommendation to use a particular structural component, maintaining full autonomy over clinical decisions. Aside from supporting Tele-BE use during already scheduled CBT sessions, research staff will provide no guidance on session conduct. Recruiting from the BCI-trained pool of therapists ensures that the CBT structure aligns with routine care. The only restriction is that clinicians will not be asked to use Tele-BE during first patient encounters or termination sessions, as these sessions may not follow the standard structure that Tele-BE is designed to support.

After each dyad’s trial period, staff will interview clinicians and patients separately about their experiences. Clinician interviews will assess system usability using the same structured interview employed in aim 1, covering learnability, acceptability, usefulness, satisfaction with aesthetics, efficiency, and workflow integration. Semistructured questions will also explore clinicians’ perceptions of how Tele-BE influenced their use of CBT structural elements, whether it produced any desirable or undesirable effects on the session or therapeutic relationship, and whether they felt comfortable overriding platform recommendations. The final portion of the interview will solicit suggestions for improving Tele-BE. Brief patient interviews will focus on the patient experience, assessing whether Tele-BE is perceived to have any desirable or undesirable effects on the therapeutic relationship or patient-centered care processes (see Multimedia Appendix 3). Clinicians will receive US $75 and patients US $25 for participating in these activities. We will use rapid qualitative analysis procedures to synthesize feedback and identify changes needed for the next testing cycle. All feedback will be reviewed with the full research team to resolve any conflicting information.

All study activities will be overseen by the City of Philadelphia (protocol number 2024-58) and the University of Pennsylvania (protocol number 855355) Institutional Review Boards (IRBs). All participants will complete informed consent before participation. Identifiable data will be stored and analyzed using HIPAA-compliant, password-protected electronic systems. Participants will receive compensation for study activities as outlined above; these rates are consistent with prior work and designed to provide appropriate incentives while minimizing the risk of coercion. To address ethical considerations related to BE strategies—specifically the potential for nudges to influence participants to engage in behaviors they might not otherwise choose—we will collect data on any concerns raised by clinicians or patients. This will ensure that clinicians do not feel coerced to deliver care they deem inappropriate, and the feedback will inform future iterations of Tele-BE to prevent undue pressure in clinical decision-making.

Any modifications to the strategy or outreach materials will be submitted to the IRBs according to each institution’s procedures. Any deviations from the protocol or adverse events will be documented and reported. All participants will receive a copy of their consent documentation before engaging in any study activities.

We will convene a 3-member Data and Safety Monitoring Board (DSMB) composed of independent experts with no professional or financial conflicts of interest related to the study or investigators. The DSMB will be responsible for reviewing study data for quality and integrity, ensuring adherence to the protocol, monitoring participant safety, evaluating study conduct and progress, and making recommendations regarding study continuation, modifications, or suspension/termination. The DSMB will meet before patient enrollment (ie, before aim 2) and annually thereafter for the duration of the study.

The rapid expansion of telehealth [3] presents novel opportunities to address the therapy environment’s infrastructure through technology, an approach previously limited by the closed-door, solitary nature of traditional therapy. This pilot randomized hybrid effectiveness-implementation trial aims to develop and evaluate the initial acceptability and feasibility of a novel telehealth tool designed to improve clinician fidelity to CBT structural components. While telehealth has long been promoted as a means of increasing patient access to CBT by expanding the pool of available providers, its potential to enhance clinicians’ delivery of EBPs has not yet been fully leveraged. To our knowledge, this study represents the first effort to leverage telehealth platform infrastructure to enhance clinician delivery of EBPs, rather than treating telehealth primarily as a medium that replicates traditional face-to-face therapy. It is also among the first to apply and evaluate BE strategies for a psychosocial EBP. Our focus on the cross-cutting, transdiagnostic structural elements of CBT—rather than diagnosis-specific protocols or intervention techniques (eg, exposure therapy)—is a further point of distinction. BE strategies are particularly well-suited for changing discrete provider behaviors that are observable and measurable [15,78], and CBT structural components (eg, agenda setting) share these characteristics. This approach enables us to directly target clinician behaviors through Tele-BE in a manner that aligns with BE-informed implementation strategies. It also lays the groundwork for future research that could layer intervention-specific implementation strategies on top of those targeting structural components.

Initially, we considered linking our trial phases to sessions attended rather than calendar weeks; however, most outpatient sessions occur weekly, and no-show rates are lower with telehealth [79]. These no-show rates will inform the design of future trials. We also considered including a broader set of EBPs with structural components (eg, dialectical behavior therapy), but focused on CBT due to its implementation within our partner public health system and to maintain specificity in our patient population. Other EBPs will be examined in future work. While we considered including supervisors in aims 2-4, we prioritized initial testing with direct end users—therapists and patients. Supervisor representation is incorporated in aim 1 design, and clinicians report on supervisory practices during the trial; follow-up trials will more formally include supervisors. We also considered limiting inclusion criteria to specific patient diagnoses for our clinical trial; however, given our focus on transdiagnostic CBT, we determined this approach would be more appropriate for subsequent trials. Additionally, we considered formally measuring organizational constructs (eg, culture and climate) in this pilot; however, our primary focus is on addressing target mechanisms of action through the BE strategies. Ultimately, we anticipate that Tele-BE will be implemented as part of broader organizational quality improvement efforts, making these organizational constructs critical to evaluate in larger, confirmatory trials.

Several limitations of this study should be noted. First, although the study team aims to make Tele-BE as generalizable as possible, this pilot will not fully evaluate how it will perform across community agencies, which vary widely in resources and emphasis on telehealth service delivery [80,81]. For example, in Philadelphia, community mental health agencies differed in their capacity to transition quickly to remote care at the start of the pandemic, largely due to the costs of obtaining a HIPAA-compliant video service. To mitigate this limitation, our platform is designed to be embedded in a HIPAA-compliant web page rather than requiring a dedicated app installation, meaning clinicians will only need access to an internet browser to use it. In addition, we restrict eligibility to English-speaking patients, as our primary focus is on establishing the feasibility, acceptability, and preliminary effectiveness of Tele-BE. This restriction limits the generalizability of our findings. Finally, the 12-week duration of our pilot trial does not allow us to examine the potential for Tele-BE to support sustained fidelity over time. To address this, we will include specific questions in our aim 3 qualitative interviews with both clinicians and patients about their perceptions of using or receiving Tele-BE over a longer period, which will inform future studies on the sustainability of its effects.

In addition to next steps that include a fully powered evaluation of Tele-BE, future studies will extend its use to other EBPs that employ structural components and examine the durability of BE strategies (ie, whether effects persist over time), the generalizability of effects (eg, whether increases in fidelity transfer to in-person sessions conducted by the same clinicians and whether Tele-BE ultimately improves patient outcomes), and strategies for scaling up Tele-BE if it proves effective. This work will also lay the groundwork for future research to determine whether targeting structural components, rather than CBT broadly, is a more efficient way to improve fidelity across CBT protocols and, eventually, other EBPs that include structural components, such as dialectical behavior therapy. Such work also has the potential to advance the CBT and implementation science fields by enabling disaggregation of treatment effects associated with structural components from intervention technique fidelity. We will also explore additional strategies to leverage the telehealth infrastructure to make it easier and more motivating for clinicians to deliver evidence-based care, such as embedding links to CBT worksheets or tip sheets/session guides for common CBT skills delivered during sessions. Of note, Tele-BE is intended to address some, but not all, of the barriers clinicians face in delivering CBT. The nudge approach proposed here represents a low-cost, low-barrier method with substantial potential to increase clinician fidelity to a level that could meaningfully improve clinical outcomes.

This study will provide insight into the potential of leveraging the telehealth infrastructure to improve CBT fidelity by integrating BE strategies into the telehealth interface. If the study produces promising results, it will pave the way for large-scale testing of Tele-BE to enhance clinician CBT fidelity and patient outcomes across mental health settings that provide telehealth services.