Abstract
BACKGROUND: In Spain, the prevalence of heart failure is twice the European average, partly due to inadequate patient management. To address this issue, a standardized care model, the Care Model for Patients with Heart Failure (Modelos Asistenciales de Atención al Paciente con Insuficiencia Cardíaca), was developed. This model emphasizes the importance of sequential visits from hospital discharge until the patient transitions to chronic care to prevent rehospitalization. The standardized care pathway has been implemented in certain areas of the Andalusia Health Service. However, there is uncertainty about whether the region's electronic health record system, Diraya, can effectively support this model. If not properly integrated, it could lead to data inaccuracies and noncompliance with the standardized care pathway. OBJECTIVE: This study aimed to explore how to improve Diraya to better support health care professionals in adhering to the transition standardized care model for patients with heart failure as they move from hospital care to chronic care. METHODS: In total, 16 semistructured interviews were conducted with nurses and physicians from both hospital and primary care settings. Thematic analysis was used to analyze the data and recommendations for improvements that were developed based on the findings. These recommendations were further supported by existing literature and validated through additional interviews. RESULTS: In total, 65 codes, 23 subthemes, and 8 themes were identified. The main themes included 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 patients with heart failure, and encouraging communication based on digital tools and personal connection. In total, 15 improvements were proposed, such as standardizing technology across Andalusia Health Service facilities and offering targeted training programs. These measures aim to enhance interoperability, streamline communication between different health care settings, and reduce the administrative burden for health care professionals. CONCLUSIONS: Diraya currently does not adequately support the transition standardized care model, placing a significant administrative burden on health care professionals, often with ethically concerning implications. To ensure effective implementation of the standardized care model, major updates are necessary for Diraya's clinical information management, system functionality, and organizational structure within the Andalusia Health Service.