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

Abstract

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.

Background

The past decade has seen a rapid acceleration of digitalization in health and the development of telemedicine (TM) solutions. The global COVID-19 pandemic (2020–2021) had an unexpected positive impact [1–4], driving innovation in crisis management through advances in contact tracing, e-health, online learning, and remote work [2, 5]. An optimized digital infrastructure allows health authorities to implement TM solutions as essential complementary health care services, helping alleviate the overall pressure on health care organizations and increasing accessibility [5–7].

TM solutions are well suited for treating and caring for patients with chronic wounds, mainly because of the possibility of photodocumentation. This enables continuous monitoring of wound progression while ensuring clear communication and efficient data exchange across multisectoral and interdisciplinary care pathways. Additionally, TM solutions have the potential to reduce service provision inequalities and enhance care delivery. By extending expertise beyond medical centres, TM solutions serve as an efficient tool for patient evaluation, diagnosis, and treatment [5, 8, 9].

Among patients with chronic wounds, managing diabetes-related foot ulcers (DFUs) is particularly challenging due to the underlying illness and treatment culture, which significantly impacts quality of life and increases overall morbidity and mortality [10–13]. Moreover, patients with DFUs frequently require hospitalization and a specialized multidisciplinary approach to manage and prevent their complex condition. In addition, cross-sectoral management of treatment and care for patients with DFUs faces several challenges, including coordination [14] and communication among health care professionals [10, 14, 15], technological barriers [15], and organizational issues such as time constraints. Geographic variations in care pathways [14] and the need for patient-centred [14–16] care further complicate effective management.

Further, a scoping review shows that patients perceive TM as promoting holistic, person-centred care, empowering them and reducing perceived burden on family, community, and the healthcare system [15]. Thus, Costa et al. [17] reinforce the importance of a holistic approach for patients with DFUs. In contrast, a Norwegian randomized trial found no significant differences in quality of life (QoL) between DFU groups with and without TM in their care pathway [18]. Given that TM represents a complex intervention in a complex, cross-sectoral setting, we therefore applied realist evaluation as a framework to examine underlying mechanisms and contextual factors influencing outcomes.

Aim

This study aimed to explore the cross-sectoral use of TM technology (Pleje.net©) in DFU treatment and care by health care professionals (HCPs) through a realist evaluation (RE) process, identifying what works for whom and under what circumstances.

Design and method

We employed an RE methodology in conjunction with ethnographic participant observation to investigate the role of the TM solution Pleje.net© in the management of patients with DFU. Our ethnographic approach was inspired by Hammersley and Atkinson [19], and we utilized their framework for data generation.

Context, mechanism, and outcome configurations

Our analysis followed the context, mechanism, and outcome configuration (COMC) framework and cumulative empirical patterns formulated through thematization. This approach highlighted key insights, as outlined by Pawson and Tilley and elaborated by de Souza et al. [20–23]. These scholars emphasize that a robust explanation requires a deep exploration of the relationships among context, mechanisms, and outcomes. To address the complexity of health care practice, we applied the RE methodology, a theory-driven approach first developed by sociologists Ray Pawson and Nick Tilley [23]. RE is grounded in critical realism, a philosophical perspective developed by Roy Bhaskar [24, 25]. Critical realism assumes that the world functions as an open system where practices are shaped by multiple social interactions within dynamic environments [24, 25]. Consequently, RE seeks to explain how causation functions within social practice. The key concepts of RE - context, mechanism, and outcome - are interconnected and form the CMOC framework [20, 22, 23].

Context refers to the conditions under which an intervention takes place, including individual participants, local regulations, norms, institutional traditions, and broader sociocultural factors [20]. Mechanisms are the underlying processes that drive observed effects. They have three key features: they capture individuals’ interactions and responses within a given context, help explain the observed outcomes, and influence the context despite being hidden. Mechanisms are not physical components, interventions, or variables that can be directly observed or statistically analysed. Outcomes are the intended and unintended effects resulting from an intervention, which emerge from the activation of different mechanisms within a given context [20, 23]. Thus, creating CMOCs.

involves an interpretative, analytical process that examines outcomes and seeks to understand why they occur [20, 21, 23, 26, 27].

Realist evaluation

Following best practices in RE, we structured this study around four key steps in the research process (Fig. 1) [20, 23].

Fig. 1.

The realist evaluation research process, inspired by Pawson and Tilley [23]

RE: Development of the programme theory (Steps 1 and 2)

The RE research process begins by identifying C, M, and O within the existing theoretical scope of the study. The programme theory serves to guide research by pinpointing and explaining regularities [20, 23, 26]. In accordance with Pawson and Tilley’s RE framework, this initial phase is referred to as a “baseline study” [20, 22, 23, 28]. This step is crucial in shaping the initial programme theory, ensuring that the evaluation is firmly rooted in existing knowledge and practices [23].

Our study builds on previous work. First, we conducted a literature review exploring how patients with DFU experience TM solutions [15]. Second, we examined the interplay between patients and HCPs in a cross-sectoral setting related to the management of patients with DFU [10].

By analysing these interactions and incorporating insights from the international literature, we establish a foundational understanding of how the TM solution Pleje.net© functions within a cross-sectoral Danish health care context. Following the literature on RE [20, 21, 23, 26, 29], we frame our research question as “What works for whom, under what circumstances?”

What works? The TM technology Pleje.net© enhances the quality of care and treatment.

For whom? Patients with DFU.

Under what circumstances? When effective collaboration occurs between HCPs across sectors, including hospitals, home care, and general practice, it is facilitated by Pleje.net for communication and care coordination.

The programme theory:

The TM communication technology Pleje.net© improves treatment and care for patients with diabetic foot ulcers when their care is managed through cross-sectoral collaboration.

RE: Data generation (Step 3)

Patients were recruited from a Danish wound centre of excellence in DFU treatment and care. HCPs, trained in our inclusion and exclusion criteria, facilitated patient recruitment. Potential participants were contacted either in person or by phone to discuss study participation. Patients who met our inclusion criteria were provided with a written study overview before providing informed consent. Table 1 presents the inclusion and exclusion criteria.

Table 1.

Patient inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
• Adult > 18 years. • With diabetes and diabetic-related foot ulcer(s). • Enrolled in the TM solution Plele.Net® as a part of the treatment and care communication, embedded in an outpatient clinic for treatment and care of DFUs. • Treatment and care for primary health care (nursing and/or general physician).	• Unable to understand and read Danish or English. • Having any cognitive impairment that challenges their competencies to give informed consent.

Following the recommendations of Hammersley and Atkinson [19], we conducted a state-of-the-art literature review [15] and formulated a structured observation guide. This guide helps observers document clinical interactions while encouraging a reflexive approach.

We observed patient–HCP interactions both in patients’ homes and in outpatient wound care clinics where Pleje.net© was used. Following Hammersley and Atkinson’s approach, participant observation was documented through detailed field notes that included not only observed interactions but also informal interviews and narratives gathered during the observations. These combined data allowed us to study cross-sectoral collaboration in DFU care.

The first author and three nurses collected data following 20 h of training in ethnographic data-generating techniques. In this study, we conducted passive observations of actions and communications made by various individuals present in the context. Thus, the nurses recorded detailed field notes, transcribed them within 24 h, and discussed the findings with the first author. All narratives were anonymized, and field notes were afterwards promptly destroyed. We conducted 68 h of observations in 2023–2024, evenly distributed between the wound center and primary healthcare settings.

RE: Analysis (Step 4.1)

The analysis of an RE involves two main steps. First, a three-phase process is used to identify the individual CMOC components (step 4.1). Second, an inductive synthesis of CMOCs is conducted to develop cumulative themes (step 4.2), which relies on empirical uniformities [21, 23].

Although we present the analytical process as linear, it was iterative, involving a “back-and-forth” movement between the theory and identifying context, mechanism, and outcome in the three-phased analysis.

The construction of CMOCs relies on complete configurations, as multiple mechanisms can trigger diverse outcomes in various contexts. Additionally, CMOCs were continuously compared and refined to identify interactions and connections. Comparisons determine how different mechanisms operate in various contexts and whether they produce the same or different outcomes. This process was initially conducted by the first and last authors, followed by the third author.

During the identification and development of the CMOC, we used the NVivo 14 [30] “visual mapping” functionality to display the identified CMOCs across the entire dataset and to illustrate how the CMOCs were interconnected [21, 23, 27].

Table 2 illustrates the development of a CMOC that summarizes the empirical uniformity characterizing the CMO configuration.

Table 2.

Phase one in the realist analysis includes identifying O, C, and M as summed up in the empirical uniformity headline of the CMOC

Questions to the data	Analytical content from data
O utcome What can be seen in the data?	O: A personalized approach, continuous education, close collaboration, and feedback mechanism help prevent the sudden development of wounds or the occurrence of additional wounds.
	⇩
C ontext In what concrete or abstract context does the outcome occur?	C: The Wound Center experts provide daily support to primary sector HCPs regarding the treatment and care of clients with diabetic foot ulcers.
	⇩
M echanisms What is the underlying mechanism triggering this outcome in the specific context	M: The experts respond personally to questions on Pleje.net® within 24. M: There is continuous and open communication between experts and nurses, fostering close collaboration and quick responses to any issues. M: Experts use their personal knowledge of individual nurses and their training backgrounds to tailor their responses and advice. M: Experts ensure that nurses are up-to-date with the latest methods and techniques through annual courses and training in wound treatment and care.
	⇩
CMO Configuration What empirical uniformity characterizes the CMO config.?	CMOC63: Experts share their knowledge in planned activities focusing on a collaborative approach.

RE: Analysis (Step 4.2)

We employed an inductive accumulation process based on 84 CMOCs and their corresponding empirical uniformities. This approach enabled us to identify three thematic cumulations, which are presented as hypotheses, elaborated upon in the Results section. Table 3 demonstrates this process, highlighting the interpretation of CMOCs and empirical patterns for the third accumulation.

Table 3.

The inductive CMO configuration process and empirical uniformities for the third accumulation. The table illustrates the progression from initial CMOCs on the left to thematic cumulations on the right, and should be read from left to right

CMOCs presented with the empirical uniformity headline	Cumulated subtheme on interpreted CMOC and the empirical uniformity headlines	Thematic accumulation as an empirical uniformity headline
CMOC2 HCPs together facilitate treatment and care of patients with DFUs	Relationships make a powerful context for changing TM practice	Building bridges: The power of relationships in sustaining TM use
CMOC6 Interpersonal connections among HCPs enhance the use of TM technology
CMOC7 The context of “knowing each other” adopted and aligned the use of TM
CMOC19 When documentation/communication was appreciated, valued, read, and utilized by colleagues, this increased motivation to utilize the technology
CMOC22 Trust increased motivation to challenge the organizational discourse
CMOC27 Respect and recognition acted as a mechanism for responsibility and accountability, encouraging consistent use of TM	Professional and personal values as triggers for respectful collaboration using TM
CMOC34 The feeling of confidence in contacting each other for advice
CMOC45 Personal motivation to perform the best treatment and care
CMOC46 Person centeredness for patients is a shared goal
CMOC59 We depend on each other in the treatment and care
CMOC63 Experts share their knowledge in a planned activity focusing on a collaborative approach	I know what you know and vice versa when we rely on the TM technology
CMOC69 Courses acted as triggers for professional dedication and high standards of treatment and care
CMOC70 Being together gives insight into what is essential in different contexts
CMOC81 Ongoing education forms bonds during sessions

Ethical considerations

The institutional authorities of the Central Denmark Region, to which the authors are affiliated, formally reviewed this study (project number: 1-16-02-47-22) and concluded that Research Ethics Board approval was not needed. Following Danish ethical guidelines on qualitative data generation, no ethical approval is needed, as no data refer to identifiable persons or institutions. This complies with the Danish Code of Research Integrity and the Declaration of Helsinki [31], ensuring ethical standards for human volunteers [32].

All the informants provided informed written consent and were allowed to withdraw from the study at any time. The observations were anonymized to prevent the disclosure of identifiable information about clients, HCPs, or collaborating organizations. Immediately after each observation, the field notes were securely stored in a briefcase.

Results

On the basis of the RE analysis, we identified three cumulations on the use of the TM-solution Pleje.net© in managing patients with DFUs by HCPs in a cross-sectoral setting. Each cumulative headline is marked with C, M, and O to illustrate its connection to the RE methodology.

• Time matters (O): navigating allocated and limited time (M) in person-centred care and treatment (C).

• Tech hurdles (O): adapting/aligning perceptions (M) and mastering digital tools (C).

• Building bridges (M): the power of relationships (O) in sustaining TM use (C).

Time matters: navigating allocated and limited time in person-centred care and treatment

We identified how HCPs often faced the challenge of balancing allocated time for each patient with the pressing demands of their schedules. The interpretation became an underlying mechanism for “if and how” the HCP gained or documented information in TM technology.

A representative example derived from our data.

The patient arrives at a nursing clinic in a municipality to get the DFU wound dressing changed. The HCP looks at the clock above the door and says, “Oh, it’s getting late—we need to get started.” The patient responds, “Yes, but I am here on time, aren’t I?” The HCP says, “Yes, but changing your dressings is a big task, and only 20 minutes have been allocated.” The nurse continues: “What did they say at the Wound Center? I need to know—for I don’t have time to read about it [In the TM journal] (SC19.09SF2)

Furthermore, our results indicate that the experience of time constraints hampered the use of TM. We interpreted this reluctance as being rooted in familiarity with conventional practices, which, in turn, served as a mechanism for reducing workplace stress and saving time by avoiding the use of TM.

However, we also observed how the connection between time and self-perceived work experiences and methods hampered the use of TM.

The HCPs skipped using TM because of their busy schedules and confidence in traditional methods. An HCP expressed, “I do not have time to look into this now—maybe later,” and “I have made this bandage change a million times” (SV21.09SL)

In contrast, this CMOC also revealed that the interplay between time and self-perceived work experiences prompted a deliberate and cautious approach to TM use, even in identical patient cases, thereby limiting its implementation.

As the patient and the HCP meet at the door, the HPC says, “Hey XXX, how are you doing?” The patient replies, “I’m good—I was wondering if it was us who were going on a date.” They both laugh and smile at each other. The HCP then says, “Okay, let us take a look at your feet. Have you noticed anything new since our last ‘date’?” They laugh again. While the patient takes off his shoes and socks, the HCP opens the PC and logs into the TM solution. She says, “Alright, now we have something to compare with,” as she looks at the pictures. The HCP documented in the TM while the patient left the room, waving goodbye. (SK2509SL)

Thus, we identified that effective time management and creative solutions, such as having the patient remove their shoes and socks while the HCP handles the TM solution, were appropriate for ensuring continuity in individual care, even within the constraints of a busy health care environment. This approach allowed HCPs to multitask efficiently, and the patient received the necessary attention. However, we also found that structural-level discourse on time management shaped HCPs’ actions, prompting the use of TM.

In the Danish primary health care system, every task is assigned a predefined time slot from a standardized catalogue designed to streamline practice and ensure efficiency. The system is used as an administrative and organizational management tool to manage time in everyday practice.

The predefined time slots often conflicted with the reality of patient care. They frequently left little room to accommodate patients’ needs and for HCPs to provide treatment and care on the basis of professional decision-making, as illustrated in this example:

A newly educated HCP reported, “I only use TM when I have been allocated time in my schedule by the coordinator; otherwise, I am not doing it.” (SR0609LB)

As a result, HCPs need to navigate these constraints strategically, demonstrating the ability to emphasizes the importance of individual knowledge and initiative in balancing time management with the delivery of continuous, high-quality treatment and care for patients with DFUs. This awareness empowered HCPs with the professional responsibility of assessing and delivering appropriate care and treatment, ensuring a person-centred approach. Consequently, scheduling dedicated time slots for TM use served as a mechanism for validation and support from administrative HCPs, contributing to higher usage rates of Pleje.net©.

Overall, our findings underscore the need for a more flexible approach to time management in health care settings, particularly when continuity is crucial. Effective time management and organizational strategies are crucial for maximizing the benefits of TM solutions such as Pleje.net©, allowing HCPs to enhance their treatment and care of patients with DFUs in a cross-sectoral setting.

Tech hurdles: adapting/aligning perceptions and mastering digital tools

Variability in priorities and technological familiarity among patients and HCPs shaped their use of TM. For patients, the primary concern was ease of use and the immediate benefits of the technology in managing their health.

The HCP informs and shows the patient the app, saying, “Here you can see the pictures and send in new ones if you want. However, you will also need to use the computer.” The patient responded, “It seems a bit difficult to use both the app and the computer.” (SV19.09SF3)

In our CMOCs, we found that the complexity of using different kinds of technologies was a mechanism experienced as a technological hurdle. Patients’ opportunities to be active in their treatment and care were restricted, and full patient involvement was not achieved.

Furthermore, patients felt overwhelmed by using TM, quoting a lack of user-friendliness and intuitive design, which triggered frustration. This frustration extended beyond the technology itself to their broader experience of living with DFUs, including fears of losing a part of themselves—a toe, a foot, or even a leg—and the resulting loss of control over their overall life situation.

The patient said, “I don’t understand why this app has such small text and why it’s so difficult to click the right place. I’ve had diabetes for over 20 years, my sight is poor, I have less sensitivity in my fingers, and I’m 72 years old. Please tell me why it’s not made for people like us. We can send spaceships to Mars, but what about helping those of us who face these everyday problems? What if my inability to use it means that I miss something important and lose my foot? Then, we’d have to move from our house. I’m so angry.” (SV26.10CC).

Thus, resistance to and fear of TM led HCPs to view TM primarily as a tool for their own use rather than as a means of involving patients. They perceived the technology as a way to ensure continuity of care, but only if it could be seamlessly integrated into their work schedules without disrupting their workflow.

The HCP says, “I often use TM. I try to review and examine the pictures, but on days when I am busy or the technology is challenging, I just follow the same procedure as the last time the patient was here. I always take pictures as recommended, but we only have our own smartphones, so I must remember to upload them [via the computer] at the end of the day. Sometimes I forget to do it, and then I just delete them.” (SV19.09SF4)

Thus, organizational management, integration into daily workflows, and the user-friendliness of the technology significantly influenced how and when HCPs used the TM solution. Similarly, HCPs with limited proficiency in the technology struggled to integrate it effectively into their practice, potentially compromising the quality of care. Those who lacked confidence in using TM either avoided it or used it inefficiently, leading to incomplete documentation and missed opportunities for patient engagement. This resulted in a fragmented care experience and reduced patient satisfaction.

Patient: “I think the wounds look better today”. HCP: “I don’t know; I haven’t seen them for a while”. Patient: “I think Kirsten [another HCP] took a picture on Monday.” HCP: “I don’t use the system. I haven’t taken the course, and I don’t have a smartphone, so I can’t do it”. Patient: “Ok, but it would have been nice to know. I’m visiting my daughter for four days in the south of Shetland. Can you ask for these pictures to be sent to the HCPs there?” HCP: “No, as I said, I don’t use this system.” (HJ16.11LB)

We further identified structural conditions that triggered suboptimal use and handling of the TM solution. Firstly, in some contexts, only a few designated HCPs were trained to handle TM, made the rest of the HCP group feel unfamiliar with the TM and its functionalities and less engaged in personal care and were unable to perform their jobs satisfactorily.

The HCP: “In our part of the municipality, it is only two who have got a password and course in using the TM. So, I must report to them, if they are at work, to get the information and the pictures uploaded. But someone has made this decision, so I just followed the procedure of shifting the dressing.” (SV21.09SL2)

Second, the lack of integration with existing electronic patient journal (EPJ) systems hinders the optimal use of the TM solution. HCPs experience a double workload, as they must document information in both the EPJ and TM systems. This lack of integration forces HCPs to choose between adhering to the overarching management discourse or upholding professional values of continuity in collaboration with the Center of Excellence for Wound Treatment and Care.

Conversely, HCPs view TM as an integrated and essential part of their daily work concerning updating and monitoring progress and treatment and care of the patient’s DFU. This approach underscores the role of TM as a vital tool for improving cross-organizational communication among HCPs and ensuring continuous monitoring of patients’ DFUs.

TM adoption is challenged not only by a lack of engagement or challenges in using complex technology but also by structural and organizational decisions that affect its integration.

Building bridges: the power of relationships in sustaining TM use

Strong interpersonal connections seem to be the most central factor facilitating TM use, ultimately improving patient outcomes and improving HCPs’ job satisfaction.

As illustrated previously, the context in which HCPs operate is critical to the adoption, alignment, and effective use of TM. However, when “knowing each other” is introduced as a trigger, we observed a strong and visibly heightened sense of obligation to use TM. The HCPs felt that the documentation and communication were appreciated, valued, and utilized by trusted colleagues and enhanced their motivation to embrace the challenge of using the technology and engaging in organizational discourse. We identified that this mutual respect and recognition acted as a mechanism for enhancing responsibility and accountability, encouraging the consistent use of TM.

When they enter the clinic, the HCP and a patient are sitting and drinking a cup of coffee. The HCP: “We have a bit of extra time today. Join us” The patient: “Yes—I am having a nice time because two days ago, Lene [an HCP at the Wound Center] said that wound healing was progressing”. The HCP says with a smile: “When Lene says something, we do believe it, but I am looking into the TM now, seeing if we are going to do anything different.” (KK19.09SF1)

The relationships between HCPs also increased TM use, as they were confident in reaching out for advice and remaining alert to changes in DFU status.

A patient who underwent right leg amputation and had several wounds on the left foot came to a municipal clinic for treatment and care. The HCP observed severe progression in infection symptoms. The patient mentioned attending a wedding and not changing the wound dressing for several days. The HCP immediately phones the Center of Excellence in Wound Care and Treatment. During the conversation, first names are used, and the clinic HCP refers to a discussion they had during a course four months prior. The call concludes with concrete advice and an appointment for the patient at the Center that same afternoon. The clinic HCP says, “It is so nice to talk with them. I feel safe and encouraged to go the extra mile in documenting as long as I have them by my side.” (SV19.10SF)

Consequently, the context of trust and collaboration triggers a mechanism of enhanced communication and thorough documentation. Their knowledge of their colleagues’ expertise and competencies provides confidence in patient treatment and care, embodying the principle that “four eyes are better than two.”

We also identified a CMOC illustrating how ongoing training sessions and competence development courses focusing on evidence-based practices for treatment and care for patients with DFUs serve as a mechanism for professional development while also providing a context for building and strengthening relationships. Furthermore, the educators in these training sessions serve as role models, delivering course activities that are perceived as meaningful and well executed. We observed how this sense of professionalism and meaningfulness acted as a motivating mechanism for HCPs to deliver higher standards of treatment and care, reinforcing the importance of effective TM use.

However, these role models and their relationship-building also served as catalysts for patient care grounded in comprehensive, well-coordinated collaborative efforts rather than individual practices. Conversely, the relations developed through the course activities also served as an underlying mechanism for the HCP educators and role models in their practice at the Center of Excellence, as illustrated in this data:

In the Center of Excellence, the HCP looked into the TM, saying, “It is so clear to see who has attended the course and who has not. I can see how former participants use the structure we teach, highlighting the most important information regarding the patient and the wounds. These participants also more often contact us during or right after a consultation to seek advice or give an alert.” (SV05.10LB)

Thus, HCPs at the Center of Excellence identified those HCPs who had attended the courses through their detailed and consistent documentation. Their deeper understanding of treatment and care triggered a sense of responsibility for collaborative engagement, which has the potential to significantly enhance the quality of patient care.

Discussion

In this study, we aimed to explore the use of the TM technology Pleje.net^® in the management of patients with DFUs by HCPs in a cross-sectoral setting.

Our first accumulation, “Time matters,” underscores the need for a more flexible approach to time management in health care settings, particularly when continuity is crucial, as in the management of patients with DFUs. By recognizing the limitations of rigid time allocations and allowing for more adaptive practices, health care systems can better support HCPs’ use of TM for this patient group. This aligns with a scoping review by Søndergaard et al. (2022), who concluded that TM may promote holistic and person-centred care and treatment [15]. Other studies also illustrate how more adaptive practices not only improve patient outcomes but also enhance the overall efficiency and effectiveness of health care delivery [6, 33]. Having control over logistics, time management, and decisions seems crucial for HCPs to act efficiently in health care systems. The review by Bernstrøm et al. (2019) illustrates how flexible work schedules reduce work-related stress among HCPs and improve their work‒life balance. The study further revealed how giving HCPs responsibility and decision-making authority improved patient care [6]. Another systematic review by Ghiwaa et al. highlights the crucial role of organizational culture and values in either facilitating or hindering TM adoption. This process depends on reinforcement from top management and organizational policies that support adaptability, change, and innovation through TM [5]. Thus, addressing time management, organizational challenges, culture, and values is essential to maximize the benefits of TMs such as Pleje.net©.

However also, other organizational factors, such as infrastructure, human resource management, financial resources, and leadership styles, are also shown to play a significant role in the successful implementation of TM solutions [34]. For example, hospitals with robust infrastructure and effective management practices and supportive leadership are better equipped to integrate TM technologies into their care pathways. In addition, individual factors [13, 35], including the digital literacy and readiness of health care professionals [15, 35], also impact the adoption and utilization of TM solutions [13, 15, 17, 35, 36]. Health care systems that invest in training and capacity building for their staff are more likely to see successful implementation and sustained use of TM technologies [36]. Thus, by effectively navigating organizational factors, individual factors, different cultures within the pathway, and allocated and limited time, HCPs can improve the treatment and care of patients with DFU in a cross-sectoral setting via the TM solution [4, 5, 37].

Our second accumulation, “Tech hurdles,” identifies the complexity of using different technologies as a challenge for HCPs and patients. As a result, patients face obstacles in actively participating in their treatment and care. The results highlight the critical role of user-friendly technology in TM adoption, aligning with previous studies showing that the ease of use of TM significantly influences patient and HCP engagement and satisfaction [4, 38].

However, research has shown mixed results regarding the effectiveness and acceptance of telemedicine (TM) among health care professionals (HCPs), primarily due to technological barriers and varying levels of digital literacy [15]. Studies indicate that cross-sectoral management of treatment and care for patients with DFU faces several challenges beyond technical literacy. Factors such as coordination [13] and communication among health care professionals [10, 14, 15], technological barriers, and organizational issues such as time constraints are as critical as the technology itself. Additionally, the perception of technology as complex can hinder effective patient participation, ultimately impacting health outcomes [39]. Notably, the randomized trial by Iversen et al. (2020) revealed no significant differences in quality of life (QoL) when comparing DFU groups with and without the TM solution as part of their care pathway [18]. However, a 2025 study on readmission for heart failure patients revealed that a TM solution decreases the need for hospitalization compared with the control group not having TM [7]. Therefore, designing intuitive and accessible TM solutions designed for specific situations integrated into culture and organizations is essential for enabling HCPs and patients to utilize the technology fully and enhancing patient involvement, leading to better health management.

Our third accumulation, “Building bridges,” illustrates how the integration of TM and specific wound care training served as a catalyst for TM adoption, even though the training focused on treatment and care for patients with DFUs rather than the technology itself. Building bridges through strong professional relationships is crucial to the sustainable implementation of TM and the attainment of high standards in patient care and organizational support [10, 15, 40].

In support of our results, studies have demonstrated that adequate training and organizational policies that promote technology use are key factors in overcoming barriers to TM adoption. These studies illustrate how health care organizations can increase HCPs’ confidence and competence in using TM by providing targeted training and fostering a supportive environment [41, 42]. Furthermore, studies have shown that investing in comprehensive training programs and ongoing support for HCPs can address these challenges, ensuring that TM is effectively integrated into clinical practice [5, 41, 42]. Our results may align with another perspective highlighted by Rodriguez et al. (2020), who explain that TM enhances communication and coordination among health care providers, enabling more timely and effective interventions. They further emphasize that TM bridges gaps in health care access and delivery [43].

Applying realist evaluation was essential for this study, as it enabled us to uncover the underlying mechanisms that influence outcomes in a complex, cross-sectoral setting. By focusing on context–mechanism–outcome configurations, RE provided a deeper understanding of how and why telemedicine works or fails under specific circumstances, rather than merely describing observed patterns. These insights, together with our findings, underscore the importance of organizational support and targeted training to strengthen health care professionals’ confidence and competence in using TM. Cross-sectoral education and supportive organizational structures are therefore crucial for effective collaboration and sustainable implementation of TM solutions, ultimately improving patient care.

Strengths and limitations

This study’s scope may be limited, as it was conducted exclusively with patients from two specialized centres of excellence for wound treatment and care in Denmark. However, these centres serve patients from 15 municipalities, enhancing our findings’ transferability. Additionally, understanding the extent of cross-sectoral collaboration can be complex. We found that RE, which incorporates contextual perspectives, effectively addresses this complexity. To ensure the transparency and rigor of our RE methodology, we meticulously detailed our analytical process and explained how the methodological foundation guided the study. Data collection was conducted by the first authors, along with trained data collectors, which enriched the data quality.

Furthermore, RE recognizes the value of first-hand experiences that participants share, whether through direct communication with the observer or interactions with others. Therefore, our data examples are presented as both observations and communications. The research group thoroughly discussed all of the study’s parts, in line with the RE methodology.

Conclusion

Our study highlights how time management, user friendly technology, organizational culture, and values, together with strong relationships between HCPs in a cross-sectoral setting, enhance the use of Pleje.net^®. This, in turn, improves the continuity and quality of care for patients with DFUs, fostering trust and engagement throughout their care pathways. These factors collectively contribute to person-centred care.

This led to the refinement of the programme theory, serving as the conclusion of our study:

The use of the TM solution Pleje.net© by HCPs in cross-sectoral collaboration enhances the treatment and care of patients with DFU. This improvement is achieved in a cross-sectoral setting when care management addresses organizational challenges, including time constraints, technological hurdles, and the need to foster strong relationships among HCPs.

When these robust relationships are present, the TM solution facilitates timely and coordinated care across different sectors, ultimately improving patient outcomes in a multidisciplinary setting.

Implication

Following this study, we suggest these implications for practice and suggestions for further research.

• Prioritize time management to ensure that HCPs can use Pleje.net^© without compromising other responsibilities.

• Invest in user friendly technology to minimize adoption barriers and ensure efficient use of Pleje.net^©.

• Foster a collaborative culture that values innovation and continuous improvement to support TM solutions such as Pleje.net©.

• Encourage trust-based relationships among HCPs across sectors to facilitate seamless communication and coordination of care.

To further explore our findings, we recommend extending this evaluation to other geographic areas or contexts. This will help assess the transferability of our results, ensuring that the observed benefits are not limited to a specific context. Additionally, we suggest elaborating on our baseline study to establish a more thorough foundation for conducting comparative research on the use versus nonuse of TM in cross-sectoral pathways for patients with DFU. Finally, we propose exploring the mechanisms within HCP relationships in cross-sectoral settings that facilitate effective collaboration and bridge-building.

Author contributions

Made substantial contributions to the conception and design, acquisition, analysis, and interpretation of the data: SFSO and AH. Involved in drafting the manuscript or revising it critically for important intellectual content: SFSO, AH, and MD. Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content: SFSO, AH, and MD. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: SFSO, AH, and MD.

Funding

This research is independently supported by the Clinical Academic Group Task Force on Cross-Sectoral and Interdisciplinary Programs, Viborg Regional Hospital, Denmark.

Data availability

Data for this review can be acquired by request to the first author.

Declarations

Ethics approval and consent to participate

In Denmark, this study does not require ethical approval, as no data can be traced back to individuals or institutions. The institutional authorities of the Central Denmark Region, to which the authors are affiliated, formally reviewed this study (project number: 1-16-02-47-22) and concluded that Research Ethics Board approval was not needed. Following Danish ethical guidelines on qualitative data generation, no ethical approval is needed, as no data refer to identifiable persons or institutions. This complies with the Danish Code of Research Integrity and the Declaration of Helsinki [31], ensuring ethical standards for human volunteers [32]. All the informants provided informed written consent and were allowed to withdraw from the study at any time. The observations were anonymized to prevent the disclosure of identifiable information about clients, HCPs, or collaborating organizations. Immediately after each observation, the field notes were securely stored in a briefcase.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.