How Professionals Share an E-Care Plan for the Elderly in Primary Care: Evaluating the Use of an E-Communication Tool by Different Combinations of Professionals

Abstract

Background: Home-dwelling elderly patients with multimorbidity are at risk of fragmentation of care because of the many different professionals involved and a potentially unclear level of communication. Multidisciplinary communication seems to occur incidentally. Mutual feedback is needed for a professional team to provide consistent care and adequate support to the patient system. eHealth technology can improve outcomes.

Objective: The aim of this study was to evaluate the use of a tool, Congredi, for electronic communication by professionals for the care of home-dwelling elderly patients.

Methods: The research group was recruited through general practices and home care organizations. Congredi, a tool designed for multidisciplinary communication, was made available for professionals in primary care. It consists of a care plan and a communication channel (secure emailing). Professionals opened Congredi records for elderly patients who had 2 or more professionals involved. The records were the unit of analysis. Data were gathered from the Congredi system over a period of 42 weeks.

Results: An inclusion rate of 21.4% (203/950) was achieved; nearly half of the participants were nurses. During the study, professionals were active in 448 patient records; female professionals were prevalent. In the patient records, 3 types of actions (care activities, emailing, and process activities) were registered. Most activities occurred in the multidisciplinary records (mean 12.2), which had twice the number of activities of monodisciplinary records (6.35), and solo records had a mean of 3.43 activities. Most activities were care activities (mean 9.14), emailing had a mean of 0.89 activities, and process activities had a mean of 0.29.

Conclusions: An e-communication tool (Congredi) was usable for improving multidisciplinary communication among professionals. It even seemed to yield results for 40% of the professionals who used the e-care plan on their own. The content of the tool provided an active communication practice, with significant increases observed in the actions that must be shared for the effective coordination of care.

Keywords: Internet; eHealth; elderly; email; general practitioners; medical informatics; nurses; primary care.

Figure 1

The eHealth Enhanced Chronic Care Model. ACO: accountable care organizations; RHIO: regional health information organization; EHR: electronic health record; PHR: electronic patient health record or patient portal.

Figure 2

Congredi problem inventory: problems listed in text and in the social, functional, mental, physical, and communication (SFMPC) domains.

Figure 3

Congredi care plan: problems, aims and actions shown in social, functional, mental, physical, and communication (SFMPC) action blocks.

Figure 4

Congredi email module: secure email for professionals about their patients.