Table 8.

Perceived disadvantages of the TCApp by eating disorder specialists.

Domain and Key themes		ED specialists who agree with example statements (N=8), n	Examples of ED specialists´ statements
Mobile health characteristics
	Problems with the design: Platform	8	“A different new screen was opened for each of my patients...It was difficult for me to follow several patients at the same time.”
	Technical problems	1	“In some cases, the application stopped working; this meant a lot of extra work without getting good results. Surely it depended on a user‘s smartphone model (Chinese), or it occurred due to the fact that they had downloaded another application that was interfering with the use of the TCApp.”
	Lack of satisfaction with content available I: Inappropriate motivational components	2	“I would modify all content (she refers to the option offered to patients by the app to receive prizes and rewards according to their performance). Many patients with AN profile are stressed when receiving prizes; they want to be first in the list, corresponding to their high levels of perfectionism and competitiveness. It can be counterproductive for these patients”; “My patients decided not to share the awards received through social networks for confidentiality issues. They wanted to keep everything inside the application and not get out of this environment.”
	Lack of satisfaction with content available II: Lack of personalization	8	“The app should be personalised according to patients’ clinical characteristics...for example, severe patients who presented a lack of consistency in their treatment in general, showed the same with the app”; “You cannot use the same instructions concerning the frequency of use of the app (once a day) for all patients. You should assess before whether this frequency is beneficial for them or not, according to the treatment stage, specific diagnosis, and other clinical characteristics of your patients”;“We should try to accommodate the therapeutic objectives offered by the app to the patient’s profile.”
	Lack of satisfaction with content available III: Monotonous activity	1	“Patients’ online activity was monotonous...for example, emotions experienced during the day were static...a specific emotion felt at a specific moment during the day cannot represent the emotional status of the patient for the entire day...Some further specifications may be added, for example, next to each emotion, an objective for the following week or a further explanation of the context around emotions and their function could be provided, in order to make emotion records more motivating for them.”
	Lack of satisfaction with content available IV: App was not interactive	3	“The app was not dynamic and interactive enough and its functionalities depended on the initiative demonstrated by the patient. Therefore, at times, when patients were feeling worse, they had no initiative to interact actively with the app and thus, they did not use it at all”; “The use of the app depended exclusively on each patient. For the most resistant and difficult patients, we had to follow-up a lot and remind them during sessions that they had to use the app regularly.”
External factors: Human environment
	Lack of appropriate collaboration among colleagues	1	“Lack of coordination among different health professionals participating in the study. Sometimes it was not clear who was doing what.”
External factors: Organizational environment
	Study design: Strict instructions	1	“Some of my patients felt frustrated and under pressure with the fact that they had to use the app at least once a day.”
	Economic resources available	2	“In private institutions (ie, Dexeus), sometimes patients are willing to replace face-to-face sessions with their therapist with the chat option offered by the app There are economic reasons behind this...I think that in private hospitals, the app should be used differently; you cannot force a patient to have extra visits if you consider it important, as you would do in a public hospital”; “The implementation of the app in private practice is easier...You can charge each visit 2 euros more, for example, and offer patients complementary treatment with the app...In public hospitals this option does not exist at the moment, as there is a lack of budget and of direct interest in mHealth.”
	Lack of time and workload	6	“Due to workload or need to attend emergencies and other priorities, sometimes patient monitoring through the app was postponed”; “Unfortunately, sometimes the symptom monitoring was not regular and constant (by us), as initially agreed when we were given the study protocol.”