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Modules

Intake Services Admin Delivery Insights Research Waitlist

Features

Government Services Clinical Coding AI Handover Wellness & Monitoring Care Pathways Deterioration Engine Notifications Bulk Integration Forms & Documents Security

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How it works
Platform

Chronic condition pathways. Prevention built in.

Configurable care pathways for cardiovascular disease, diabetes, chronic kidney disease and COPD. Prevention screening at every touchpoint. Medication reconciliation at every transition. Automated escalation when thresholds are breached.

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Capabilities

Structured pathways. Proactive care.

Condition pathways

Pre-built templates for CVD, diabetes, CKD, COPD, heart failure and hypertension with condition-specific monitoring cadences: BP daily, glucose daily, eGFR 3-monthly, SpO2 daily, spirometry annual. Configurable per organisation.

Prevention screening

Screening assessments embedded at pathway entry and scheduled intervals. AUSDRISK, cardiovascular risk, diabetic foot, renal function — catch risk factors early.

Medication reconciliation

Automatic reconciliation triggered at every care transition — admission, discharge, handover, specialist review. Every line requires an explicit decision.

Escalation triggers

Surveillance widgets on each pathway feed the deterioration engine — nine detection rules evaluate window-based patterns and route alerts by role and urgency.

Goal-intervention-outcome

Structured tracking per condition: goals set, interventions delivered, outcomes measured with source attribution. Clear clinical audit trail.

Automated handover

AI-generated clinical handover documentation at every pathway transition point. Structured, coded, audit-ready.

Interface

Pathway coordination — at a glance.

A unified view of chronic condition progress, goals, escalations and next actions for each person.

HealthOS — Care Pathways PATIENT Margaret T. Age 81 | Female | UR 4820173 CVD Type 2 DM CKD 3 ACTIVE PATHWAYS CVD Prevention Diabetes Management CKD Monitoring KEY MEDICATIONS Metformin 500mg BD Perindopril 5mg OD Atorvastatin 40mg OD Empagliflozin 10mg OD LAST RECONCILIATION 14 May 2026 (GP review) CVD PREVENTION PATHWAY ✓ Enrolment ✓ Baseline Screen ✓ Week 4 Week 12 Week 24 Current Goals BP < 140/90 mmHg 70% HbA1c < 53 mmol/mol 85% eGFR stable (>45 mL/min) 60% Goals shared across CVD + Diabetes + CKD pathways ESCALATION Active Systolic trend >140 mmHg (7-day avg) GP review triggered Triggered: 16 May 2026 09:14 AEST | Rule: CVD-BP-ESC-01 Next Actions Medication reconciliation due (post-GP review) AUSDRISK screening scheduled (Week 12) Recent Interventions Date Pathway Intervention Clinician Outcome 14 May Diabetes HbA1c review — reduced from 58 to 51 mmol/mol Dr S. Park On target 10 May CVD BP titration — Perindopril increased 4mg to 5mg Dr S. Park Pending FHIR R4 / AU Core | CarePlan | Goal | Condition | MedicationStatement Indicative wireframe — HealthOS Care Pathways (chronic condition coordination)

Multimorbidity by design

Older Australians rarely have one chronic condition. HealthOS pathways are designed for multimorbidity — a person can be on multiple concurrent pathways with shared goals and coordinated medication reviews across conditions.

  • Multiple concurrent pathways per person (e.g. CVD + diabetes + CKD simultaneously)
  • Cross-pathway intelligence: one BP reading satisfies monitoring widgets on both CVD and CKD pathways — no duplicate measurements required
  • Clinical worklist shows due, overdue and completed monitoring widgets across all active pathways, sorted by urgency
  • Cross-pathway medication reconciliation prevents duplicate or contraindicated prescribing
  • Polypharmacy awareness built into reconciliation workflows
  • FHIR CarePlan Bundle export per pathway instance — CarePlan + Goals (LOINC-coded) + Observations (UCUM units) with SNOMED CT-AU condition coding for independent evaluation

Prevention and early detection

Every pathway embeds prevention screening as a first-class design principle — not an afterthought. Risk factors are identified early, interventions triggered proactively, before conditions escalate.

  • AUSDRISK diabetes risk assessment at pathway entry
  • Cardiovascular risk screening (absolute risk calculator)
  • CVD: BP daily, weight weekly (HF signal), LDL annual, quarterly medication/clinical review
  • Diabetes: glucose daily (CGM-preferred), HbA1c quarterly (lab), BP daily, weight weekly, quarterly review
  • CKD: eGFR 3-monthly, ACR 6-monthly (lab), BP daily, weight daily (fluid balance), quarterly nephrology
  • COPD: SpO2 daily, respiratory rate daily, spirometry annual, quarterly respiratory review
  • Threshold bands from RACGP Red Book, KDIGO 2024, GOLD 2024 and ADS guidelines

Evidence-based threshold bands

Clinical threshold bands are sourced from Australian clinical guidelines and configurable per organisation. The longitudinal rules engine replays thresholds against incoming monitoring data — from paired devices, manual entry, or ingested clinical systems.

  • Systolic BP: at-risk >140 mmHg, critical >180 mmHg (CVD, HTN, CKD, HF)
  • Blood glucose: at-risk <4 or >11.1 mmol/L (diabetes)
  • eGFR: at-risk <60, critical <30 (CKD)
  • SpO2: at-risk <92%, critical <88% (COPD, HF)
  • HbA1c: at-risk >53 mmol/mol, critical >75 mmol/mol (diabetes)
  • All thresholds configurable per pathway, per person, per clinician preference

Connected across the platform

Care Delivery

Fifteen clinical modules. One care record.

Deterioration Engine

Nine detection rules. Window-based analysis. Role-based alerting.

Wellness & Monitoring

Cellular-connected devices. Between-visit early detection.

See chronic condition pathways in action.

A 45-minute walkthrough with real pathway data from a reference deployment.

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