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Aim To understand what contextual influences, mechanisms and outcomes affect the implementation and use of localised, online care pathways (HealthPathways) in primary and secondary care. Design and procedure Mixed-measures design. Quantitative data included number of page views and conditions viewed. Qualitative data from semistructured interviews and focus groups were gathered over a 6-month period, and analysed using NVivo software. Setting The first HealthPathways UK site, South Tyneside, England. Participants General practitioners, nurses, practice managers, hospital consultants and system leaders (managers, commissioners) (n=76). Results Use of the pathways significantly increased over time. Themes were developed showing how online care pathways were used—leadership, pre-existing networks and relationships; development of systems and processes for care pathways, the use of online care pathways to support decision-making and referral, and perceived availability of resources. Inter-related themes were arranged into configurations consisting of contextual influences, mechanisms and outcomes. Recommendations were made for future implementations, such as improved data collection processes to understand how and why there was variance in the use of pathways. Conclusions This study was early in the implementation process; however, emerging themes will facilitate the future implementation and use of online care pathways. Recommendations are made for further research to include other health and social care users and patients to inform future developments.