JMIR Publications

ABSTRACT

Optimal patient care relies on close coordination between primary care practitioners and specialists across inpatient and outpatient settings. In many health care systems, primary and specialized care sectors often remain organizationally and technologically fragmented. As a result, patients and medical professionals across all specialties face overly complex care pathways that are difficult to navigate, frequently causing discontinuities of care. Although digital health technologies have the potential to reduce structural barriers and enhance coordination, many current applications are only partially integrated into existing digital infrastructure, poorly aligned with clinical workflows, or insufficiently adapted to varying levels of digital literacy. Rather than mitigating current fragmentations, these shortcomings risk creating new barriers and discontinuities in care pathways. Based on our work in the field of digital solutions in cross-sectoral care pathways, we outline the following key requirements for integrated digital solutions: (1) digital tools must support standardization while accommodating the flexibility of clinical practice; (2) they must be developed in modular components through close collaboration of all stakeholders involved in the care process to ensure low-threshold usability for patients and medical professionals; (3) digital tools must comply with prevailing IT-standards to ensure interoperability; and (4) digital tools must be scientifically evaluated in clinical and real-world settings. We illustrate these requirements using the example of a modular digital care platform designed to support all stakeholders involved in the inherently cross-sectoral care pathway for hereditary breast and ovarian cancer syndrome (HBOCS). Our experience shows that the success of digital health solutions in integrated care relies not only on technological performance, but also on interdisciplinary expertise, supportive infrastructure and policy, as well as openness to innovation in care delivery.