JMIR Publications

ABSTRACT

Background:

In Spain, the heart failure prevalence is twice the European average, attributed to inadequate patient management amongst other causes. Therefore, a standardized care model known as the “Care Model for HF patients” (Modelos Asistenciales de Atención al Paciente con Insuficiencia Cardíaca) was developed to emphasize the importance of sequential visits from discharge until the patient transitions to chronic care to prevent rehospitalizations. The standardized care pathway has been implemented in some areas of the Andalusia Health Service. However, there is uncertainty about whether their electronic health records, named Diraya, can effectively support the standardized care model's implementation. Failure to integrate effectively could lead to data inaccuracies and non-compliance with the standardized care pathway.

Objective:

This study aimed to explore how to improve Diraya, to help healthcare professionals comply with the transition standardized care model for heart failure patients, during the transition from hospital towards chronic care.

Methods:

Sixteen semi-structured interviews with nurses and physicians from the hospital and primary care were analyzed through thematic analysis. Recommendations for improvements were based on these findings, supplemented by literature, and corroborated by additional semi-structured interviews.

Results:

In total, 65 codes, 23 sub-themes, and 8 themes were identified. The main themes were optimizing medical data management for enhanced clinical workflow, agreement on standardization and enhancement of the discharge report, enhancing clinical decision support through updated guidelines and automated tools, optimizing interoperability as a solution for better management of the heart failure patient, and encouraging communication based on digital tools and personal connection. Among all the themes fifteen improvements were suggested.

Conclusions:

The Diraya system fails to support the transition standardized care model effectively, burdening healthcare professionals with excessive, often ethically questionable administrative tasks. To enhance transition standardized care model implementation, significant updates are necessary for Diraya's clinical information, computer systems, and Andalusia Health Service organization.