Building bridges in diabetic foot ulcer care: a realist evaluation of the cross-sectoral use of telemedicine solutions

BACKGROUND: Over the past decade, the digitalization of health and telemedicine solutions has accelerated. Optimized digital infrastructure enables telemedicine as a complementary health care service, reducing organizational pressures and increasing accessibility. Tele medicine (TM) is well suited for chronic wound care, particularly diabetes-related foot ulcers, owing to its photo documentation and data exchange capabilities. This study aimed to explore health care professionals' (HCPs') cross-sectoral use of TM technology for the treatment and care of patients with diabetic foot ulcers (DFUs). METHOD: The study used a realistic evaluation design. From 2023 to 2024, we conducted 68 h of participant observation of healthcare professionals in hospital and primary care during DFU treatment within a Danish cross-sectoral setting. The Standards for Reporting Qualitative Research (SRQR) were applied. RESULTS: We generated three key themes: (1) Time matters: navigating allocated and limited time in person-centred care and treatment. (2) Tech hurdles: adapting/aligning perceptions and mastering digital tools. (3) Building bridges: the power of relationships in sustaining telemedicine use. CONCLUSION: Our study led to a refined program theory allowing us to propose an answer to the problem of "what works, for whom, and under what circumstances": HCPs' cross-sectoral collaboration using the TM communication solution Pleje.net© enhances the treatment and care of patients with DFUs. This improvement is achieved in a cross-sectoral setting when care management addresses organizational challenges, such as managing time constraints, overcoming technological hurdles, and fostering strong relationships among HCPs. When robust relationships are present, the TM solution facilitates timely and coordinated care across different sectors, ultimately improving patient outcomes in a multidisciplinary setting. Findings are limited to a Danish cross-sectoral healthcare context and may not be directly transferable to other health systems.