Sri Lanka’s primary care clinics will test a single digital care pathway that integrates treatment for diabetes, high blood pressure, heart disease, kidney disease, and common mental health conditions. People with multiple long-term conditions often receive fragmented care because separate clinical guidelines do not account for how treatments interact. This project builds a co-designed digital pathway—embedded in the OpenMRS clinical information system—that standardises referrals, automates audit feedback to clinicians, and gives patients a digital interface. A cluster randomised trial across 50 primary care units will test whether the pathway improves care quality and efficiency compared with usual practice. If the pathway works, it could replace disjointed paper-based care with a single, coordinated system that helps clinicians follow integrated guidelines without extra paperwork. For patients, that means fewer duplicate appointments and treatment plans that account for all their conditions at once. The project also trains a local stakeholder group to sustain and spread the pathway nationally, so the impact could extend well beyond the trial sites.
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Background: Long-term health conditions pose a notable burden on lower-and-middle-income countries, contributing to disability and reduced life expectancy. Sri Lanka has a high prevalence of type-2-diabetes, hypertension, cardiovascular disease, chronic kidney disease, and mental health conditions. In people with multiple long-term conditions (MLTC), their management becomes increasingly complex, often resulting in fragmented care and inconsistent adherence to clinical guidelines. Moreover, existing guidelines do not consider the interplay between assessment and treatment recommendations across MLTCs. Objective: This research project aims to leverage the implementation of clinical information systems, such as OpenMRS, in primary care services in Sri Lanka to develop and evaluate a stakeholder co-produced digitally integrated care pathway (DICP). The DICP intends to standardise care, and enhance clinical management, efficiency, and the patient experience for people living with MLTCs. Methods: The project encompasses six interconnected work-packages (WPs) that will culminate in the development and evaluation of a novel DICP for patients with type 2 diabetes, hypertension, and associated cardiovascular disease, chronic kidney disease, and common mental health conditions (depression and anxiety). In WP1, a stakeholder consultation group (SCG) will be established, comprising patients, clinicians, clinical informaticians, and policy makers from Sri Lanka. They will co-produce the DICP, ensure trial implementation and that end points reflect stakeholder priorities. They will also lead on dissemination and maintenance of the DICP nationally. WP2 is a mixed methods rapid evaluation of existing primary care pathways, and stakeholder led prioritisation of recommendations for improvement. Stakeholder focus groups will inform the integration and enhancement of DICPs within existing care pathways, leveraging the newly introduced clinical information systems. In parallel, the SCG will also assist in selecting relevant clinical guidelines for primary care, and guideline recommendations will be prioritised for DICP implementation through a nominal group technique workshop. WP3 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). Integrated digital guidelines Digital referral Automated audits and feedback to clinicians Digital patient facing interface The implementation and effectiveness of the DICP will be evaluated through a cluster randomised controlled trial (WP4) in 50 primary care medical units. A contemporaneous process evaluation and economic evaluation (WP5 and WP6) will explain the findings of the RCT and evaluate the likelihood of adoption and maintenance within the community. Peer-to-peer learning, mentorship and formal academic training will be combined to build capacity for health systems research, implementation science and MLTC care in Sri Lanka. Deliverables: The formation and training of a multidisciplinary group of local stakeholders to champion the research and implementation of DICPs for MLTC management. The development of a contextually appropriate co-produced DICP for the management of diabetes, hypertension, and associated cardiovascular disease, chronic kidney disease and mental health conditions in primary care. Evaluation of the implementation, effectiveness, and cost-effectiveness of the DICP, including an assessment of its impact on locally relevant processes of care.
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