title: Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP).
abstract: BACKGROUND
  Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated.
  
  
  OBJECTIVE
  To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR).
  
  
  METHODS
  We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups.
  
  
  RESULTS
  We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program.
  
  
  CONCLUSIONS
  This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.
authors.affiliation: Department of Geriatric Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands. s.robben@ger.umcn.nl.
authors.forename: Sarah Hm
authors.initials: SH
authors.lastname: Robben
authors.forename: Mirjam
authors.initials: M
authors.lastname: Huisjes
authors.forename: Theo
authors.initials: T
authors.lastname: van Achterberg
authors.forename: Sytse U
authors.initials: SU
authors.lastname: Zuidema
authors.forename: Marcel Gm
authors.initials: MG
authors.lastname: Olde Rikkert
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Schers
authors.forename: Maud M
authors.initials: MM
authors.lastname: Heinen
authors.forename: René Jf
authors.initials: RJ
authors.lastname: Melis
keywords: Self-care; cooperative behavior; electronic health records; frail elderly; interdisciplinary communication