eHealth Centre of Excellence

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. 




EMR decision support tools Automated Solutions eServices


Virtual Care Tablets/eForms




Automated Solutions

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.




Cody bot

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

Standardized data also enables more seamless sharing of patient information across the OHT, which our Sharon bot can help to facilitate!




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.​ 



EMR support

Our decision support tools for primary care EMRs have been designed to support preventative care for a number of chronic health conditions. 





Our team collaborates with system partners to design and deploy EMR-integrated tools for Chronic Disease Prevention and Management (CDPM) that provide clinical decision support based on current best practices.


These tools are tailored to high-needs patient populations and rely on these conditions being appropriately coded in the EMR – which our bots (see above) can facilitate! 


These EMR decision support tools can be customized according to the regional needs of your OHT.


CDPM EMR tools



eConsult    eReferral    Virtual care   

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.


  • Virtual care can support more accessible care for patients, and leaves more time in a provider's schedule for patients who require urgent in-person care. 


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


Click here to go back to main OHT page






Click here to get started!