Supporting Proactive Care for Senior and Complex Patient Populations

Digital health tools can assist primary care clinicians to effectively deliver proactive care to their senior and high-risk (mutiple conditions) patient populations, ensuring patients stay as healthy as possible.

Automated solutions can support primary care clinicians by enabling them to more efficiently and proactively use the patient data in their EMRs to identify patients who may benefit from a targeted preventative care approach.

Our Cody bot supports clinicians with a solution to quickly code patient populations in their EMR, without adding an additional administrative task.

After deploying Cody:

Patients can now be searched accurately in the EMR and can be targeted for routine testing and screening
- Criteria is based on prescribed guidelines for managing patients that might have been previously missed
Patients that are on a particular medication but do not have the diagnosis listed in the problem list are also flagged

What this means for your OHT:

Improved data quality, leads to actionable proactive care interventions for targeted populations (high-risk for COVID-19, seniors, patients with multiple conditions, and palliative)

Data that has been appropriately coded improves patient metrics, driving quality improvement and population health management – a key component of OHT maturity

Our bots support optimal use of our EMR decision support tools (see below), as standardized and structured data means that clinicians can more effectively use the patient information in their EMRs to deliver proactive care.

The Evidence2Practice Ontario program is designing a suite of EMR decision support tools that enable clinicians to quickly and easily surface evidence-based quality standards about a number of conditions at the point of care.

Did you know that heart failure is one of the five leading causes of hospitalization and 30-day readmissions and the most common cause of hospitalization for people over age 65? Appropriate care can improve a patient’s quality of life and help with symptom management.

The Evidence2Pratice Ontario (E2P) program is now offering an EMR-integrated heart failure tool, available for TELUS PS Suite with versions for OSCAR Pro and Accuro QHR coming in 2023.

E2P heart failure toolbar

Features of the tool include:

Increased support for investigations into heart failure diagnosis

Evidence-based guidance to assist clinicians with identifying, tracking, and supporting at-risk patients

Increased support for medication plan management

Easy access to information for clinicians to reference, with picklists to facilitate appropriate medication selection, built-in notification flags to have medication changed if the patient’s condition is worsening, and more

A modular approach that supports adaptive workflows

Users can fill out certain parts of the tool to gather information during the patient visit instead of opening an entire form to fill out a specific part

Other digital health solutions, such as eServices, Virtual Care, and Tablets/eForms, can also support care management for patients who may become high users of the healthcare system.

Ontario eServices Program:

eConsult provides primary care providers access to expert advice from up to 94 different speciality groups across the province – submit a question and receive a reponse in as little as one day!

If an in-person appointment is needed, eReferral can facilitate more seamless transitions across the care spectrum.

Tablets/eForms increase the number of communication channels for patients who may require regular touch-points with their primary care clinician.