How to Enhance Digital Support for Cross-Organisational Health Care Teams? A User-Based Explorative Study

Figure 1

The information flow cycles in the interdisciplinary team across organisations: (1) e-messages of a new patient from the hospital to team coordinator. (2) Visit to the patient while in hospital. (3) Discuss the actual patient problems in an interdisciplinary team meeting. (4) Team meeting and analysis of risk factors. (5) Define a digital personalised plan with actions. (6) The digital personalised plan with actions is documented in both the hospital’s EHR and the municipality’s EHR systems. (7) The patient is discharged from the hospital with home care follow-up. (8) Information e-message sent to the local doctor (GP). (9) Information e-message sent to the municipality home care service. (10) An interdisciplinary health and care team support is established to follow up planned actions (mean 30 days). (11) On-going activity and reports documented in the hospital’s EHR and in the municipality’s EHR systems. (12) Handover of care plan to municipal home care services for regular visits at home.