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Benefits of care orchestration in Primary Care

Recognizing the need for more integrated and patient-centered care, the concept of care orchestration emerged and encompasses several strategies to drive improvements in healthcare quality, patient experience, and health outcomes. In this blog post, we deep dive into the advantages it provides for solving major challenges that shape primary care.

Matilde Ferreira

Matilde Ferreira

June 2, 2023 · 8 min read

Fragmented care delivery, with limited coordination among providers and healthcare settings, is leading to medical errors1, preventable hospitalizations2, higher affluence to emergency departments across the globe, revenue losses due to surgery cancellations, and so on. However, recognizing the need for more integrated and patient-centered care, the concept and strategies of care orchestration emerged and refer to the coordination and synchronization of healthcare activities across multiple providers, settings, and time frames to optimize patient outcomes.  
Over time, technological advancements, such as electronic health records (EHRs) and interoperability functionalities, have been playing a crucial role in enabling seamless information sharing and communication among care teams, but care orchestration is not a well stablished reality yet. On the other hand, primary care physicians are increasingly tasked with coordinating services delivered not just by other specialists and hospitals but also by home care professionals and social service agencies, experiencing several gaps when it comes to keep track on patients’ progress.3 
Can care orchestration be the light at the end of the tunnel for these professionals? 

Back to basics: major challenges of being a family physician 

  • Time constraints: primary care physicians often have a large number of patients to see, and the limited time available for each appointment can be a major challenge. This can make it difficult to address all the patient's concerns adequately and can lead to rushed consultations. In addition to stressful work environments,4 some studies relate time constraints with low adherence to guidelines and affect patient safety.5
  • Increasing patient load: the demand for primary care services is growing, while the number of primary care physicians is not keeping pace. Whereas the overall number of doctors per capita has increased in nearly all countries, between 2008 and 2018, the share of general practitioners (GPs) has come down in most countries.6 This results in high rates of patients without a family physician and larger patient loads for individual physicians, leading to less time available for each patient and potential burnout. 
  • Complexity of cases: primary care physicians are often the first point of contact for patients with a wide range of health issues. In the current scenario, in which one out of three adults suffer from multiple chronic conditions,7 general practitioners need to have a broad knowledge base and be skilled in managing various conditions, from acute illnesses to chronic diseases.  
  • Administrative burden: physicians in primary care face increasing administrative tasks, including documentation, coding, and insurance requirements. Time spent on paperwork can detract from patient care and contribute to physician burnout. In fact, nearly a third of physicians said they spend 20 hours or more a week on paperwork and administrative tasks8 and point it as the main cause of burnout.​9
  • Prevention and patient education: primary care plays a crucial role in preventive care and patient education. Encouraging healthy lifestyle choices, addressing risk factors, and promoting disease prevention require effective communication and time investment, which can be challenging within the aforementioned constraints of a primary care visit. 
Ensuring seamless transitions of care between different healthcare settings, coordinating with specialists, and maintaining effective communication on top of such struggling daily work is quite challenging. And that’s why care orchestration must kick in.  

Intelligent, automated, and evidence-based care journeys: increasing autonomy and capacity in primary care 

UpHill is a clinical pathway software that integrates with existing information systems to automate tasks and bridging gaps in care. With UpHill orchestrating care, providers have a comprehensive view of their patient's status throughout their journeys as individuals and as a population, including past history and expected next steps. 
For primary care this means autonomy, capacity, visibility/traceability, prioritization and proximity.  

Decision support system increasing primary care autonomy. 

A decision support system plays a vital role in increasing primary care autonomy for diagnosis and treatment while simultaneously upskilling generalist physicians and delivering self-sufficient primary care. By leveraging evidence based clinical pathways, these systems provide comprehensive and real-time clinical decision support in making accurate diagnoses, choosing appropriate treatment options, and, when empowered with communication tools, monitoring patient progress. Ultimately, decision support systems revolutionize primary care, enabling physicians to deliver efficient, accurate, and patient-centered care independently. 
Must have:  
  • Evidence-based clinical pathways adjusted to local reality. 
  • Step by step pathway interaction. 
  • Patient data storage on top of the decision support system. 

Structured referrals and visibility over patient progress enhancing collaboration. 

 Having clear referral criteria, on top of a predefined care journey, ensures that patients are referred to the right specialists or healthcare facilities, minimizing unnecessary referrals and improving the efficiency of the healthcare system. Additionally, interoperability capabilities enhance the accuracy of referrals by considering a wide range of patient-specific factors, such as medical history, symptoms, and test results, which may not always be readily apparent to the referring physician. Finally, it works bilaterally ensuring primary physicians real time visibility over patient progress.  
Must have:  
  • Predefined care journeys guiding and standardizing care provision. 
  • Clear referral criteria. 
  • A single source of truth for the patients’ needs and history. 

Task automation increasing primary care capacity. 

By automating routine and repetitive tasks, primary care providers can streamline their workflow and focus on delivering essential patient care. Administrative tasks, such as appointment scheduling, patient follow-up, data entry, and documentation, can be automated, freeing up valuable time for physicians to concentrate on direct patient interactions. This increased efficiency allows primary care providers to see more patients within the same time frame, effectively expanding their capacity to deliver care. Moreover, automation can facilitate the management of chronic conditions by automating reminders for medication adherence, scheduling follow-up appointments, and monitoring patient progress.   
Must have
  • Predefined care journeys identifying which actions can be automated. 
  • Interoperability capabilities linking different systems, to reduce repetition. 
  • Real time visibility and significancy on automated actions. 

Real time monitoring enabling prioritization.  

As stated in previous articles, prioritization is the escape root when demand is great, and resources are limited. By leveraging advanced technology and real-time data, primary care providers can monitor patients' health status, track key indicators, and identify individuals who require immediate attention or urgent interventions. This proactive approach allows for timely intervention and prevents potential complications, by alerting primary care providers to critical changes in a patient's condition and enabling them to prioritize and allocate resources accordingly.  
Must have:
  • Automatic follow-ups using an omnichannel approach. 
  • Automatic patient stratification through validated scores. 
  • Automatic alert generation and care journey adjustment based on patients’ answers. 
To listen more about on how UpHill is helping primary care units to face an always growing demand while conciliating remote monitoring, care prioritization and close patient-doctor relationship, have a look on this webinar.


  1. Monegain, B. (2010, October 22). Joint Commission confronts deadly miscommunications. Healthcare IT News.
  2. Kern, L., & Seirup, J. (2018, September). Fragmented ambulatory care and subsequent healthcare utilization among Medicare beneficiaries. AJMC. 
  3. Doty, M., Tikkanen, R., Shah, A., & Schneider, E. (2019, December 10). Primary care physicians’ role in coordinating medical and health ... Health Affairs.
  4. von dem Knesebeck, O., Koens, S., Marx, G. et al. Perceptions of time constraints among primary care physicians in Germany. BMC Fam Pract 20, 142 (2019).
  5. Tsiga E, Panagopoulou E, Sevdalis N, et al The influence of time pressure on adherence to guidelines in primary care: an experimental study. BMJ Open 2013;3:e002700. doi: 10.1136/bmjopen-2013-002700
  6. OECD/European Union (2020), Health at a Glance: Europe 2020: State of Health in the EU Cycle, OECD Publishing, Paris,
  7. Hajat, C., & Stein, E. (2018). The global burden of multiple chronic conditions: A narrative review. Preventive medicine reports, 12, 284–293.
  8. Henry, T. A. (2018, November 13). Do you spend more time on administrative tasks than your peers?. American Medical Association. 
  9. What is physician burnout?. American Medical Association. (2023, February 16). 
Matilde Ferreira

Matilde Ferreira

Content Strategy & Communication Manager

Graduated in Communication Sciences, early on fell in love with storytelling. Started off as a journalist and then pivoted to the public relations world, she was always driven to craft relevant stories and bring them to the stage.

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