Video credit: HSJ

How can digitising pathways improve care for people with chronic conditions?

Ben Wilson, Product Specialist Lead at Orion Health, talks about how digitising pathways can improve care for people with chronic conditions, areas that have successfully introduced them and what leaders need to do to implement them

Chronic conditions like diabetes, heart disease and respiratory illnesses are among the biggest challenges facing modern healthcare systems. Patients often move between specialists, general practitioners, and community care teams, yet critical health information doesn’t always follow. The result? Repeated tests, delays in treatment, unnecessary hospital admissions, and frustrated patients forced to retell their story time and again.

Orion Health’s Digital Care Pathways offer a more innovative, connected solution.

The challenge: Disjointed care

Traditionally, patients with chronic conditions encounter fragmented care across siloed systems. Each touchpoint captures data independently, whether with a hospital, GP, or specialist. This disconnected model leads to repeated investigations, poor continuity of care, and preventable hospitalisations.

The solution: Digital care pathways

Digital Care Pathways revolutionise care delivery. Patients are electronically enrolled onto a shared, condition-specific pathway. From GPs to community nurses, clinicians across the healthcare setting can access and contribute to a shared, structured care plan.

This enables:

  • Standardised data capture across care settings
  • Timely task prompts for clinicians to ensure proactive care
  • Real-time collaboration across the care team
  • Patient confidence in a consistent treatment journey

Real-world results: Diabetes care in Northern Ireland

Northern Ireland has successfully rolled out digital care pathways for all patients with diabetes, including adults and children. Multidisciplinary teams can access lab results, assessments, and referral data through shared electronic records. This model promotes continuity and informed decision-making across the patient journey.

Scotland, too, has implemented similar digital pathways with measurable improvements in coordinated chronic disease management.

The benefits go beyond the bedside

  1. Streamlined Reporting & Audits
    • Automated data capture simplifies national audits and statutory reporting, saving administrative effort and improving data quality.
  2. Empowered Patients
    • Treatment plans, results, and appointment details can be accessible to patients, improving engagement and shared decision-making.
  3. Population Health Insights
    • Standardised data unlocks rich analytics. Health systems can stratify risk, measure outcomes, and refine interventions based on real-world evidence.

What should health leaders do next?

To realise the benefits of digital care pathways, healthcare leaders should:

  • Learn from peers like Northern Ireland and Scotland to accelerate progress
  • Engage clinicians and stakeholders early to design relevant workflows
  • Assess supplier interoperability to future-proof technology investments