A decade of an online clinical guidance platform for hospital clinicians: they use it, they like it and it makes a difference

Hospital HealthPathways (HHP) is an online clinical guidance platform for hospital clinicians in Waitaha Canterbury, and it turned 10 years old in November 2025. In those 10 years it has become inextricably woven into the fabric of the Waitaha Canterbury health system.

What is it?

It followed the successful precedent of Community HealthPathways (or simply HealthPathways, as it was known then; CHP), which went live in 2008 as a clinical guidance platform for general practice (primary care) teams. CHP was an outcome of a project largely based around facilitated meetings among general practice representatives and particular groups of specialists to gain a common understanding of each other’s perspectives regarding access to specialist hospital services for particular patient types—what was going well and what wasn’t. Ultimately, the meetings arrived at an agreed list of “what we can do tomorrow” actions to improve what wasn’t going so well. A clear and recurrent stated need was to make the agreements visible to relevant clinicians. HealthPathways was created and soon grew well beyond defining the interface between community and hospital care to include a local, authoritative collation of guidance for the management of many hundreds of conditions. It became the foundation for evidence-informed, locally agreed “how we do it around here” advice. Evidence mounted for its value, including its use for implementing and embedding new models of care for numerous conditions from colorectal cancer to mental health.^1–15

Based on these results, and results from other health systems that adopted HealthPathways, and taking into account the cost associated with the provision of the platform, technical writing and the time of local clinicians as pathway writers (clinical editors), modelling of a CHP programme for a population of 5 million people over a 5-year time frame estimated NZ$9.76 (New Zealand dollars) of potential cost savings for every $1 invested.¹⁶

Other health systems signed up to develop their own sites, using the Waitaha Canterbury content initially, and localising it for their own context. Now there are HealthPathways sites in over 50 health regions, covering all of Aotearoa New Zealand, most of Australia, increasing numbers in the United Kingdom and, more recently, Canada. Each of these regions explicitly shares content to promote both standardisation of care (particularly among regional groups, such as New Zealand, Wales and the states of Australia) and to share the workload. This collaborative “network” is called the HealthPathways Community, and is enabled by the structural and technical hub provided by Streamliners, a social enterprise that is owned 20% by the New Zealand government and 80% by the Joined Up Systems Trust (https://justnz.org)—a charitable trust with their stated  purpose “to encourage and support the integration of health and social care services”.¹⁷

Meanwhile, in the Waitaha Canterbury hospitals, particularly Christchurch City Hospital—which provides secondary care for the city and tertiary/quaternary services for much larger catchments—clinicians were using a locally produced clinical guidance book known colloquially as the Blue Book. This book had evolved over generations and was a well-loved and much-used local resource. However, the Blue Book was getting big, with more content being added over time. It relied on mostly voluntary input from specialists, usually in their own time. The content was becoming more difficult to maintain and, ultimately, some who had shouldered the significant burden of this work retired from the role. Willing replacements were not easily found.

The year was 2014 and work began to replace the Blue Book with a hospital version of HealthPathways, using Streamliners and the same layout, style and methodology for pathway production. This site became “Hospital HealthPathways” (HHP), necessitating the re-branding of the sites for general practitioners as “Community HealthPathways” (CHP). It went live for the end user audience in November 2015.

HHP is written for hospital clinicians—particularly (but not only) junior doctors and other doctors working outside their specialist area of expertise, and with information, and links to information, for nursing and allied health staff.

Canterbury HHP has about 900 live pages, more than 400 of which are clinical pathways. The site also has many resource pages and placeholder pages, linking the end user to pathways in CHP or other useful documents on the intranet or internet. Request pages, advising how to make referrals, get advice and how to access other services for the patient, are a crucial component, both for end users and for the health system to define access criteria and relevant processes.

A foundation objective is that it provides “single-source, common format” guidance—the “single-source” site for clinical information for hospital clinicians, with a common format that makes it familiar and easy to follow.

It contains evidence-informed clinical guidance and local process guidance: how to get things done and how we do it around here. The concept of “evidence-informed” is that it is the translation of evidence (which is often not definitive or might give options) into locally agreed guidance for what the clinician should do in their context. The process guidance is particularly important. It tells the end user how to get things done—who they need to talk to and how they contact them, the steps needed to get a computed tomography scan, for example, or add a patient to the theatre list and so on. The local consensus on clinical management and the process guidance for the local context is achieved by local “clinical editors” working with local specialists (subject matter experts), and is a popular feature not provided by many clinical guidance platforms. In addition, because it is “localised” with the input of local clinical leaders, it has authority when there might be debate about management options.

HHP uses the same methodology as CHP and works closely with CHP when developing material. The close collaboration both reduces workload (and cost) and enhances health system integration; the patient journey is “joined up” by this collaboration, and all clinicians share a common view of that journey. A foundation belief in this relationship is that the combination of HHP and CHP is worth more than the sum of its parts. In addition, partner guidance sites for allied health clinicians (Allied HealthPathways) and for patients (HealthInfo) have enhanced the opportunities for collaboration and integration.

The combination promotes integration of care—community to hospital referral, hospital to community discharge planning, and within the hospital it promotes standardisation of care—agreed ways of doing things among relevant in-hospital specialties.

Hospital crowding and delays in care are increasingly under the spotlight of time-based performance targets, such as the “Shorter Stays in the Emergency Department” target in New Zealand and the “National Emergency Access Target” in Australia. In Waitaha Canterbury, HHP is seen to promote efficient patient flow by establishing agreed process decisions, such as criteria for direct admission to acute assessment wards, agreed scopes of investigation for different departments (e.g., emergency department [ED] vs general surgery), agreed patient disposition decisions (e.g., gynaecology vs general surgery, or orthopaedics vs general medicine) and clearer guidance about the transfer of care back to the community. It is explicitly seen as a tool in the toolkit for addressing overcrowding and patient flow.

They use it

In 2019, a survey of doctors and medical students at Christchurch hospitals showed that almost all recipients (98%) use HHP at least once a week, with 72% saying they used it every or most working days, and particularly on acute days and after-hours (in: survey commissioned by the author, 26 July 2019). In August 2025, another survey of junior doctors had 95% strongly agree and 4% agree (99% total agreement) with the statement that they use HHP frequently to treat and manage patients (in personal communication: resident medical officers, 8 August 2025).

Figure 1 shows the total page views on the HHP site per month since the site went live in November 2015, demonstrating the inexorable rise with a current rate of more than 75,000 page views per month.

View Figure 1.

They like it

The 2019 survey mentioned above had 101 respondents from a denominator of approximately 550 junior doctors. (in: survey commissioned by the author, 26 July 2019). It was commissioned by the Waitaha Canterbury health pathways team and was distributed by the Canterbury District Health Board via its mailing list. In addition to using HHP regularly, 96% of respondents agreed or strongly agreed that it made their job easier, 92% agreed or strongly agreed that it improved the care they provided to their patients, 96% agreed or strongly agreed that it is easy to use in clinical practice, 97% agreed or strongly agreed that it is clear and easy to understand and 97% agreed or strongly agreed that it contains high-quality information.

Free-text responses were numerous and very positive: for example, “It's an incredibly useful resource that's been invaluable in day-to-day practice, especially as a junior doctor, and especially out of regular working hours when seeking the advice of senior colleagues is potentially less easily accessible.”

The August 2025 survey had different origins. Cost-saving objectives saw a Health New Zealand – Te Whatu Ora “reset”, which was perceived to threaten the ongoing viability of HHP. With this threat apparent a survey was constructed and distributed by members of the local junior doctor population, with no involvement, nor even awareness, from the HealthPathways leadership team. Within 24 hours the survey received 112 responses and was submitted. As detailed above, the responses indicated that HHP was used extensively (in personal communication: resident medical officers, 8 August 2025). In addition, 96% strongly agreed and 4% agreed (total 100% agreement) that the content and quality of HHP is of high value, 92% strongly agreed and 7% agreed (total 99% agreement) that HHP information increased efficiency as a doctor and 59% strongly disagreed and 38% disagreed (total 97% disagreement) that there are suitable alternatives to HHP for Christchurch Hospital. Again, the free-text responses were numerous and positive but also demonstrated a depth of feeling associated with the threat of loss of HHP. For example: “It is practically impossible to overstate the value of this resource to my daily work. It takes an exceptional set of circumstances to move me to fill in an online survey, but this is a hill I’m willing to die on.”

It makes a difference

HHP has not been subjected to a large amount of research and when it has been it is difficult, in a complex and continually evolving system, to attribute outcomes to specific interventions such as HHP. The junior doctors’ strong perceptions of the value of HHP, demonstrated in the two surveys discussed above, are very important. In addition, the evidence attesting to the value of CHP presented earlier can be extrapolated to indicate a likely similar value for HHP. The following discussion will include some other research that has been done, both where there is good evidence for attribution and where HHP was a component of a bigger health system change process.

A postgraduate masters student studied HHP and, in particular, compliance with the Community Acquired Pneumonia (CAP) pathway,¹⁸ and found that approximately two-thirds of patients presenting with CAP had an associated hit on the HHP CAP pathway within 4 hours of their presentation to hospital (implying clinicians were using the HHP pathway to manage patients with CAP) and presentation of the same clinical guidance for the management of CAP on HHP, compared to a previous clinical guidance format (the Blue Book), improved compliance with the guidelines and reduced variation in practice. Specifically, inappropriate use of amoxicillin and clavulanic acid, when amoxicillin was all that was required, showed a 9% absolute reduction of inappropriate use (from 75% to 66%).

A follow-up masters project¹⁹ included concurrent interviews of clinicians managing patients with CAP to examine their reasons for compliance or non-compliance with the pathway. Unsurprisingly, about half of those who did not comply exactly with the pathway deviated for good reasons—the presentation was more consistent with another pathway (e.g., sepsis in adults or acute chronic obstructive pulmonary disease [COPD]) or there were pre-existing microbiology results to guide antibiotic choice. This “appropriate non-compliance” emphasised the role of HHP guidance in partnership with the clinician who applies the guidance according to their clinical wisdom.

A small but significant study showed clear attribution of HHP to the reduction of unnecessary tests. Addition of explicit advice (called a “practice point”) regarding amylase blood tests on the pancreatitis pathway advised the end user that repeat amylase testing is usually not required as the utility of the test is for diagnosis and not for monitoring. This intervention improved compliance with amylase testing by an absolute increase of 13%, from 65 % to 78%.²⁰ (Note: amylase is no longer the recommended test for diagnosis of pancreatitis as lipase is preferred).

Although HHP was only a part of a new model of care for transient ischaemic attack (TIA; a new way of managing TIA with facilitated outpatient investigation and management), a revised TIA pathway on HHP was one of the vehicles for implementing and imbedding the change. The outcome was a 34% absolute reduction in hospital admissions with TIA (from 69% to 35%), with no increase in representations with ischaemic stroke (in personal communication: summary of research findings communicated by Dr Laura Joyce, 18 November 2025).

Similarly, a new model of care for atrial fibrillation (AF) was introduced with HHP assisting as an implementation and imbedding vehicle. The new “Rate-and-Wait” process introduced rate control, anticoagulation and discharge from the ED for review in an AF clinic the next day for delayed cardioversion if still in AF. Cardioversions in the ED dropped from 32 out of 182 AF presentations before the new process to six out of 178 after the new process. Total cardioversions (ED, cardiology or the AF clinic) dropped from 65 out of 182 presentations to 32 from 178 presentations after the new process. Total admissions as a hospital inpatient dropped from 79 out of 182 to 54 out of 178 with no increase in adverse events (ischaemic or bleeding events, re-presentations to hospital or death).²¹

Chest pain is a common presentation to EDs and the requirement to “rule out” acute coronary syndrome (ACS) traditionally requires a prolonged ED stay or admission to hospital to do two or more blood tests at least 6 hours apart. Consequently, a series of projects have been undertaken to iteratively introduce accelerated diagnostic pathways (ADP), which include clinical risk stratification and (ultimately) a single blood test, allowing prompt discharge of many patients with ACS adequately excluded. Again HHP, while not being the actual change in practice, assisted with both the implementation of change and imbedding the improved processes over many years. For more than 10 years of this research theme, while presentations to EDs have increased, ED length of stay and inpatient admission rates for these patients have decreased markedly, and the unnecessary admission numbers of patients to inpatient cardiology services, who ultimately prove not to have ACS, have reduced from nearly 1,400 per annum to about 400.²²

Summary

HHP in Waitaha Canterbury is 10 years old. In its short life it has become “part of the furniture” with clinicians, particularly junior doctors, using it routinely. The evidence for benefit presented, although not definitive, is very positive. They use it, they like it and it makes a difference.

Beyond that, the passion evidenced in the recent survey of junior doctors who were faced with losing HHP is testament to the value we know it adds. Indeed, it is intuitive that a well-constructed, well-presented, easily accessible, authoritative, localised guidance suite, partnered with its community siblings, improves quality, efficiency, standardisation, integration and the wellbeing of both clinicians and patients.

If our future is governed with good sense and vision, the next 10 years should continue to realise the value of HHP in Waitaha Canterbury and ultimately throughout the motu.