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

Figure 2

The cloud-based health portal. The workflow functionalities can be obtained: (1) Notification of a new patient can be sent from the hospital to the team coordinator. (2) Normally, the team coordinator will need to meet the patient while at hospital or at home to define the needs and wishes for the patient. (3) Team members and their access can be defined by the team coordinator. (4) In a virtual team meeting, risk factors can be identified. (5) All information collected and defined health care plans with actions are shared between all interdisciplinary team members, and also with the patient and/or close relatives. (6) The patient can access all information and can be notified of action points. (7) Automated data transfer needs to be established from the patient’s vital sign devices, including questionnaires and patient-reported outcome reports. (8) Automatic access from the local doctor’s EHR system to the cloud portal with notifications. (9) Automatic access from the municipality’s EHR system to the cloud portal with notifications. (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 cloud portal. (12) Handover of care plan to municipal home care services for regular visits at home.