DIGIPATHS: Digitally Integrated Care Pathways for Multiple-Long-Term-Conditions Management in Primary Care, Sri Lanka
This research group aims to enhance care for multiple long-term conditions in Sri Lanka by using digitally integrated care pathways (DICPs) comprising electronic health records, clinical decision support tool, automatic feedback and patient-facing application. Each component of the DICP will be co-developed and evaluated for clinical, implementation and cost effectiveness.
Long-term health conditions are increasingly common in low-and-middle-income countries, leading to disability and early death. In Sri Lanka, many people suffer from diabetes, high blood pressure, heart disease, kidney disease, and mental health conditions. Managing multiple conditions is challenging and leads to poor health outcomes.
Our research project aims to improve care for people with multiple long-term conditions in Sri Lanka using electronic health records (OpenMRS), OpenClinical and DExtER, to create a digitally integrated care pathway (DICP). The DICP will standardise care and enhance the patient experience through digital technologies.
The project consists of six work-packages (WPs). We will first establish a stakeholder consultation group of patients, doctors, and policymakers to collaborate with throughout the project (WP1). We then aim to understand current healthcare pathways for multiple long-term conditions and prioritise guideline recommendations that are locally feasible (WP2). The DICP will be developed to optimise the care pathway and incorporate guideline recommendations; there will be four key components: digital guidelines, a digital referral system, automated feedback for clinicians, and a patient-facing interface (WP3).
We will test the effectiveness of the DICP in 50 primary care centres using a cluster randomised controlled trial (WP4), evaluate the implementation factors for nationwide scale up (WP5), and evaluate the cost effectiveness to inform policy and practice (WP6). The project will train local experts on how to implement and maintain the DICP for sustainable impact.
Work package 1 (07/2024 - 12/2024)
A stakeholder consultation group (SCG) will be established, comprising patients, clinicians, clinical informaticians, and policy makers from Sri Lanka. They will co-produce the Digitally Integrated Care Pathway (DICP), ensure trial implementation and end points reflect stakeholder priorities. They will also lead on dissemination and maintenance of the DICP nationally.
Work package 2 (12/2024 - 03/2025)
The first part of this work will be a mixed methods rapid evaluation of existing primary care pathway comprising pathway mapping, structured observations and focus group discussions to inform the integration and enhancement of DICPs within existing care pathways, leveraging the newly introduced clinical information systems. The second part of this work will comprise stakeholder led prioritisation workshops to select locally relevant and feasible clinical guidelines for managing multiple long-term conditions in primary care settings in Sri Lanka.
Work package 3 (07/2025 - 04/2027)
We will develop the DICP using an iterative co-design, co-production process in partnership with Sri Lankan developers and the SCG. We envisage the DICP to have four key components embedded within a clinical information system (OpenMRS): i. Integrated digital guidelines, ii. Digital referral, iii. Automated audits and feedback to clinicians, iv. Digital patient facing interface.
Work package 4 (12/2027-10/2029)
The DICP will be evaluated through a cluster randomised controlled trial in 50 primary care units. The effectiveness of the DICP will be compared to usual practice for improving clinician adherence to clinical guidelines and initiation of referral when criteria are met for patients with multiple long-term conditions. The effectiveness of adherence/uptake of clinical guidelines for multiple long-term conditions relative to usual care, in improving treatment targets will be secondary outcomes.
Work package 5 (12/2027-09/2029)
During the cluster RCT a parallel mixed methods process evaluation will be conducted. Semi-structured interviews, focus group discussions, structured observations and data from the DICP will be used to identify the context, individual and process determinants of likely adoption and maintenance of the DICP in Sri Lanka.
Work package 6 (04/2028-03/2029)
We will also conduct a cost-utility analysis (cost per quality-adjusted life year (QALY)) by attaching utility values to outcomes.