At Canvas, our mission is to give care teams superpowers with software. We've built an open, extensible platform that advances a future where patients have improved access to high-quality, proactive chronic care management.

Canvas isn't just another EMR—it's a clinical operating system designed specifically for the complexities of modern healthcare delivery, including the longitudinal, team-based care that chronic conditions demand.

Canvas: Modern EMR Platform for Healthcare Innovation

Canvas delivers all the core functionality you need to run your practice, but with a fundamental difference: everything is built on a unified architecture that makes chronic care management seamless rather than an afterthought.

Core Platform Capabilities

Comprehensive Clinical Documentation Canvas provides flexible, structured charting that supports multidisciplinary care teams and longitudinal patient relationships. Our signature Narrative Charting experience feels natural to clinicians while capturing structured data that powers population health insights and automation. Hyperscribe, Canvas's clinical copilot, further enhances documentation by working in real-time with full patient context to capture structured information, suggest care actions, and automate routine documentation tasks—all while maintaining clinical accuracy and provider control.

Integrated Order Management

  • Lab orders: Bidirectional Health Gorilla integration for seamless ordering and results
  • Imaging requests: Direct fax capability to facilities
  • Automatic results: Flow directly into patient charts with structured data capture
  • Chronic care monitoring: Support for trending HbA1c, lipid panels, kidney function tests

Advanced Prescription Management

  • Send prescriptions with integrated safety checks
  • Manage refills and controlled substances
  • Access real-time medication history data
  • Support complex chronic care medication regimens

Flexible Scheduling and Visit Types

  • Build custom visit types for chronic care encounters
  • Apply preparation templates for specific conditions
  • Enable patient self-scheduling for routine follow-ups
  • Pre-visit intake assessments and questionnaires

Complete Practice Management

  • Insurance verification and eligibility checking
  • Claims management and payment collection
  • All within the same unified system
  • No separate billing software needed

Team-Based Care Coordination

  • Assign tasks across roles using shared inboxes
  • Role-based views for different team members
  • Critical for managing ongoing chronic care interventions
  • Track care coordination across multiple providers

Patient Portal and Engagement

  • Patient self-scheduling
  • Complete forms and assessments before appointments
  • Access lab results and communicate with care teams
  • Reduces administrative burden while supporting engagement

Deep Unified Architecture

Canvas's unique Deep Unified Architecture means clinical documentation, care coordination, billing, and patient management share the same data foundation. Canvas structures clinical data using widely accepted medical coding systems like ICD-10, LOINC or CPT but its real differentiator is how the architecture links these domains into a coherent, fully navigable model.

When a provider documents a patient's HbA1c result, that data immediately becomes available for:

  • Care coordination dashboards for tracking patient progress
  • Clinical decision support and care reminders
  • Care planning and follow-up scheduling
  • Real-time HCC coding and risk adjustment
  • Quality measure tracking and value-based care support

This eliminates the data silos that plague traditional EMR systems and enables sophisticated, real-time chronic care applications that would require expensive custom integrations in legacy EMRs.

Seamless Interoperability

Canvas connects with the broader healthcare ecosystem through multiple channels:

Prescription Networks Real-time connectivity with Surescripts ensures reliable prescription processing, medication history access, and formulary checking—essential for the complex medication management required in chronic care.

Health Information Exchanges (HIEs) Direct integration with regional HIEs ensures comprehensive patient data access, critical for understanding the full picture of patients with multiple chronic conditions managed across different providers.

Laboratory Partners Bidirectional integration with Health Gorilla and other lab networks enables seamless ordering and result processing. Chronic care biomarkers like HbA1c, lipid panels, and kidney function tests flow directly into trending and monitoring workflows.

Streamlined Chronic Care Workflows in Canvas

Chronic care management requires a fundamentally different approach than episodic care. Canvas is designed from the ground up to support the longitudinal, team-based, data-driven approach that delivers better outcomes for patients with conditions like diabetes and hypertension.

Chronic Condition Tracking Canvas maintains organized patient records for chronic conditions with clear visibility into:

  • Diabetes patients: Track HbA1c trends, medication adherence, eye exam due dates
  • Hypertension patients: Monitor BP patterns, medication effectiveness, lifestyle factors
  • Heart failure patients: Follow weight trends, medication compliance, functional status
  • COPD patients: Track lung function, exacerbation frequency, inhaler technique
  • Cancer patients: Monitor treatment timelines, side effects, survivorship milestones

Care Coordination Support Canvas helps providers identify patients who need follow-up through automated alerts for:

  • Patients with diabetes due for routine HbA1c or eye exams
  • Hypertensive patients needing blood pressure checks after medication changes
  • Heart failure patients requiring weight monitoring and medication adjustments
  • Patients requiring preventive care screenings (mammograms, colonoscopies)
  • Medication management and refill coordination across multiple chronic conditions

These needs surface naturally in provider workflows rather than requiring separate system queries.

Care Team Coordination for Chronic Conditions

Canvas supports multi-disciplinary chronic care teams with role-based workflows designed specifically for managing conditions like diabetes and hypertension. Care coordinators can assign tasks across the team: health coaches follow up on blood pressure monitoring and lifestyle modifications, clinical pharmacists review complex medication regimens for diabetic patients, diabetes educators provide ongoing self-management support, and primary providers focus on clinical decision-making and treatment adjustments.

Longitudinal Health Monitoring and Assessment

Canvas tracks the clinical indicators most critical to chronic care management over time. Blood pressure readings and patterns help identify hypertension control trends, while HbA1c levels and glucose data support diabetes management. Mental health screening with validated assessments like PHQ-9 and GAD-7 addresses the depression and anxiety commonly seen in chronic disease patients. Weight management, medication effectiveness, and symptom progression are all tracked longitudinally to support comprehensive chronic care.

Individualized Care Planning and Goal Setting

Canvas enables creation of chronic care plans tailored to each patient's conditions and circumstances. Diabetes care plans can include specific HbA1c targets, blood pressure goals for hypertensive patients, and timeline-based milestones for medication adjustments. Care plans integrate directly with task management to ensure follow-through on interventions like specialist referrals, lab monitoring, and patient education sessions.

Complex Medication Management

Canvas maintains comprehensive medication histories essential for chronic care patients who often take multiple medications. The system tracks active prescriptions, over-the-counter supplements, medication adherence patterns, and adverse reactions. This comprehensive medication data supports the complex regimen management required for conditions like diabetes and hypertension while enabling clinical pharmacists to optimize therapy and identify potential interactions.

Canvas includes basic quality measure tracking and reporting capabilities that support chronic care management and value-based care arrangements.

Easy Customization for Chronic Care Workflows

Canvas makes it simple to tailor your EMR to support specific chronic care needs without requiring technical expertise. These built-in customization tools help practices deliver more consistent, efficient care.

Note Templates and Visit Types for Chronic Care

Disease-Specific Templates and Visit Configuration Create custom note templates and visit types tailored to chronic conditions. Templates can be pre-populated with condition-specific assessment sections, structured fields for key vitals and lab values, and built-in care plan sections with common interventions. Visit types can automatically bring recent results directly to the point of care, include automated reminders for condition-appropriate monitoring, and trigger patient preparation workflows.

Key Capabilities:

  • Custom note templates: Standardized documentation for diabetes, hypertension, heart failure, COPD, and other chronic conditions
  • Tailored visit types: Condition-specific workflows that surface relevant data and reminders
  • Patient preparation: Automated pre-visit tasks like questionnaires, lab orders, and medication reviews
  • Recent results integration: Bring trending data and monitoring results directly into clinical workflows
  • Care team coordination: Ensure consistent protocols across all team members

Condition-Specific Questionnaires:

  • Diabetes: Self-care assessment, hypoglycemia frequency, foot care habits
  • Heart disease: Functional status (NYHA class), chest pain frequency, activity tolerance
  • Mental health: PHQ-9 for depression, GAD-7 for anxiety screening
  • COPD: Symptom assessment, exacerbation triggers, inhaler adherence

Automated Scoring and Clinical Actions:

  • Assessment results trigger automatic alerts for concerning scores
  • Generate care recommendations based on validated thresholds
  • Create tasks for care team members when intervention is needed
  • Track improvement or deterioration over time with visual trends

Developer Tools: Accelerating Chronic Care Management

Canvas's developer tools transform how you deliver chronic care by enabling deep customization and automation that works natively within clinical workflows. From standards-based data exchange to intelligent workflow automation, these tools help you build chronic care solutions that anticipate needs and streamline complex care coordination.

FHIR API: Standards-Based Integration

Canvas's comprehensive FHIR R4 API provides standards-based data exchange for chronic care management. Unlike many EMR systems that only offer read-only FHIR access, Canvas supports extensive write capabilities across major healthcare data types, enabling true bidirectional integration with external chronic care systems and remote monitoring platforms.

Canvas SDK: Native Workflow Automation

The Canvas SDK is a Python-based toolkit that runs plugins directly within Canvas infrastructure, providing real-time access to clinical data and the ability to modify workflows instantly based on patient conditions and care events. Advanced automation capabilities like Hyperscribe and composable intelligent agents enhance these workflows by enabling sophisticated decision-making and coordination while maintaining human oversight and control.

Intelligent Automation and Composable Workflows

Hyperscribe: Your Clinical Copilot Canvas's clinical copilot, Hyperscribe, transforms chronic care documentation by working as a real clinical assistant during patient encounters. Unlike basic ambient scribes, Hyperscribe captures structured information with full context of the patient's medical record, applies clinical guidelines in real-time, and can initiate actions like ordering labs or scheduling follow-ups based on the conversation. Built using the Canvas SDK, Hyperscribe demonstrates the platform's ability to integrate advanced automation capabilities directly into clinical workflows.

Composable Multi-Model Automation Canvas enables different intelligent services to communicate and work together in real-time. For chronic care management, this means Hyperscribe's documentation can feed directly into clinical decision support protocols, which can trigger care coordination tasks, which in turn can generate patient outreach campaigns. Because all these components operate within Canvas, there's no cumbersome data transfer or external integration—just intelligent, coordinated automation that enhances chronic care delivery.

Human-in-the-Loop Control Canvas's event-driven architecture ensures clinicians maintain control over automated actions. Providers can configure where automation makes autonomous decisions (like generating routine follow-up reminders) and where human approval is required (like medication adjustments or specialist referrals). This approach enables safe, responsible automation that enhances rather than replaces clinical judgment in complex chronic care scenarios.

Examples of the SDK in Chronic Care Management

Monitoring and Escalation Pathways

Build intelligent monitoring systems that automatically detect critical changes and trigger responses in real-time:

  • Immediate clinical alerts: Critical lab results like elevated HbA1c automatically generate urgent tasks for care managers
  • Mental health screening escalation: Concerning PHQ-9 scores trigger immediate intervention protocols
  • Specialist referral automation: Declining lung function tests trigger pulmonology referrals for COPD patients
  • Real-time processing: Unlike legacy systems with overnight batch processing, responses happen immediately
  • Multi-condition monitoring: Track diabetes, heart failure, kidney disease, and other chronic conditions simultaneously

Structured Patient Outreach and Engagement

Automate proactive patient engagement based on care patterns and missing data:

  • Home monitoring compliance: Send portal messages when patients miss blood pressure readings or daily weights
  • Appointment reminders: Automated notifications for specialist follow-ups and routine care visits
  • Care gap alerts: Notify patients about overdue screenings or lab work
  • Personalized messaging: Tailored communications based on patient's specific conditions
  • Cross-condition coordination: Track engagement across multiple chronic diseases

Automated Clinical Workflows and Documentation

Streamline clinical decision-making with intelligent workflow automation:

  • Progressive screening protocols: PHQ-2 positive results automatically trigger PHQ-9 assessments
  • Documentation automation: Clinical commands inserted based on assessment results
  • Care protocol triggers: COPD assessment scores automatically generate rehabilitation referrals
  • Supervisory workflows: Chart review tasks generated for complex patients
  • Cognitive load reduction: Reduce manual documentation while ensuring comprehensive care

Dynamic Chart Customization Based on Patient Conditions

Personalize the clinical interface based on each patient's primary conditions:

  • Condition-specific displays: Hypertension patients see blood pressure trends prominently
  • Relevant data prioritization: Diabetes patients have glucose monitoring and HbA1c trends featured
  • Workflow optimization: Heart failure patients see weight trends and functional status first
  • Clinical thinking patterns: Interface matches how providers approach each condition
  • Adaptive layouts: Charts automatically adjust based on patient's chronic disease profile

Custom Clinical Decision Support Protocols

Develop sophisticated clinical protocols with comprehensive tracking and intervention logic:

  • Multi-condition monitoring: Track diabetes targets, COPD exacerbations, and heart failure metrics simultaneously
  • Custom HTML dashboards: Build tailored monitoring interfaces for specific conditions
  • Real-time data analysis: Identify poorly controlled patients and missing follow-ups instantly
  • Integrated decision support: Recommendations appear seamlessly in clinical workflows
  • Deep Unified Architecture benefits: Access interconnected clinical data without manual system queries

Getting Started with Canvas Development The Canvas development environment includes comprehensive documentation at docs.canvasmedical.com, an open-source GitHub repository with examples at github.com/canvas-medical/canvas-plugins, and integration with SMART on FHIR applications from the SMART Health IT App Gallery for extending functionality with third-party clinical tools.

Case Study: Complete Chronic Care Management Workflow

This case study follows a patient with multiple chronic conditions through their initial visit and follow-up care, demonstrating how Canvas's integrated platform accelerates care delivery and optimizes chronic care management.

New Patient Visit: Initial Assessment and Care Planning

Patient Background A 58-year-old patient presents for establishment of care with Type 2 diabetes, hypertension, and depression. They work full-time and have struggled with medication adherence across all conditions. Their hypertension has been poorly controlled despite multiple medication trials, with recent readings consistently above 150/95 along with their most recent A1c >9%. They report feeling overwhelmed managing multiple conditions and have inconsistent home monitoring habits for their diabetes and hypertension.

The Initial Visit Experience

Enhanced Documentation and Intelligent Interface The provider opens the patient chart and Canvas immediately adapts the interface. As soon as the diabetes diagnosis is documented, the patient summary automatically reorganizes to prioritize diabetes-relevant data at the top. During the visit, Hyperscribe captures the patient conversation in real-time, structuring clinical information as the provider speaks and automatically populating the chronic care visit template with diabetes complications screening, blood pressure trending, and depression assessment sections.

Intelligent Clinical Workflows The provider completes the PHQ-2 depression screening as part of the chronic care template. The patient scores positive on both questions, so Canvas automatically inserts the full PHQ-9 assessment into the documentation flow. Hyperscribe assists by suggesting relevant follow-up questions based on the patient's responses and the full medical record context. The PHQ-9 scores 12, indicating moderate depression, and Canvas automatically generates appropriate follow-up tasks and patient resources.

Advanced Clinical Decision Support Canvas recognizes the combination of diabetes and depression as high-risk for poor outcomes. A protocol card appears recommending an integrated diabetes-depression care approach, with Hyperscribe contributing real-time insights about medication options that address both conditions while avoiding medications that might worsen depression symptoms. The system creates a care plan template that combines diabetes self-management with mental health support.

Seamless Care Coordination with Intelligent Assistance During the visit, the provider orders labs through the electronically enabled integration, schedules diabetes education using a custom visit type, and creates tasks for the care coordinator to arrange an overdue eye exam. Established clinical decision support rules assist by suggesting additional relevant orders based on clinical guidelines and the patient's condition combination. Canvas automatically assigns the patient to the high-risk chronic care panel and distributes 6 specific tasks across care team members based on the patient's condition complexity.

Between Visits: Automated Care Management

Intelligent Monitoring in Action Over the next three months, Canvas continuously monitors the patient's care:

  • Home blood pressure readings uploaded via the patient portal trigger alerts when readings exceed 140/90 for two consecutive weeks
  • Medication adherence data from pharmacy integrations shows missed doses, prompting automated pharmacy outreach
  • Patient portal inactivity for 3 weeks triggers a personalized engagement protocol
  • Lab results automatically flow back with trend analysis, and an HbA1c result automatically triggers care manager alerts when elevated

Proactive Patient Engagement Canvas sends 4 personalized portal messages about medication timing based on the patient's specific challenges. The reminder system helps the patient complete their overdue diabetic eye exam, and an automated survey identifies transportation barriers, triggering a social work referral. Nutrition education resources are automatically delivered based on the patient's dietary logging patterns.

Follow-Up Visit (3 months later): Ongoing Management and Optimization

Enhanced Visit Preparation and Documentation The patient returns for their scheduled follow-up. Canvas automatically displays lab results with trend analysis, home monitoring data, and patient-reported outcomes. Templates define key sections of the follow-up visit template based on provider need, highlighting important changes and trends.

Automated Insights Drive Clinical Decisions A protocol card highlights that the patient's medication adherence improved from 60% to 85% thanks to automated reminders. Clinical decision support recommends specific medication adjustments based on current trends, and the system notes that the patient responds well to text message reminders rather than phone calls. Diabetes group education class is recommended based on the patient's learning preferences and schedule.

Streamlined Documentation Clinical commands automatically populate based on lab values and home monitoring trends. Care plan updates generate automatically based on goal achievement, and next visit planning is automated based on current control status. The quality measures dashboard updates in real-time, showing progress on diabetes care bundles.

Measurable Impact After Three Months

Clinical Improvements

  • Faster issue identification: Blood pressure concerns identified 2 weeks earlier than traditional monitoring
  • Better medication adherence: Automated reminders increased compliance by 25%
  • Accelerated care coordination: Eye exam completed 6 weeks sooner due to automated scheduling
  • Enhanced depression management: Early intervention prevented worsening symptoms

Provider Efficiency Gains

  • Reduced documentation time: Automated clinical decision support cut documentation time by 40%
  • More focused visits: Provider spends time on clinical decision-making rather than data gathering
  • Proactive care delivery: Issues addressed before becoming urgent problems
  • Streamlined workflows: Consistent, comprehensive care through automated protocols

Patient Experience Benefits

  • Increased engagement: Portal usage increased 300% due to personalized, automated outreach
  • Better understanding: Automated education delivery improved diabetes self-management knowledge
  • Reduced burden: Simplified medication management through smart reminders and coordination
  • Improved outcomes: Better glucose control and blood pressure management through continuous monitoring

Why This Works: Effortless Chronic Care Management

For Providers: Intelligence That Feels Natural Canvas doesn't just store data—it actively works to make providers more effective. The PHQ-2 to PHQ-9 progression happens automatically within the clinical workflow. Blood pressure trends surface exactly when needed. Care gaps appear as actionable tasks without manual tracking. Providers focus on clinical decision-making while Canvas handles the coordination, documentation, and follow-up logistics that usually consume valuable time.

For Patients: Personalized Care That Anticipates Needs Patients experience care that feels coordinated and proactive rather than reactive. Home monitoring data automatically triggers appropriate responses. Educational resources arrive at the right moments. Appointment reminders and medication support happen seamlessly through their preferred communication methods. What traditionally requires multiple phone calls, missed connections, and care gaps becomes a smooth, supportive experience.

For Care Teams: Unified Coordination Care coordinators, pharmacists, diabetes educators, and specialists all work from the same intelligent platform. Tasks flow automatically to the right team members at the right times. Everyone sees the same patient progress, upcoming needs, and care plan adjustments. The result is coordinated care that actually feels coordinated to both providers and patients.

The Platform Difference Canvas transforms chronic care from a collection of separate tasks and systems into one intelligent platform that learns and adapts. What starts as individual features—templates, monitoring, automation—becomes a comprehensive chronic care solution that gets smarter with every patient interaction, delivering measurably better outcomes while making everyone's job easier.

Start Your Chronic Care Management Trial

Experience this comprehensive approach yourself with Canvas's chronic care management trial, featuring realistic AI-generated patients and pre-configured workflows designed for immediate clinical impact.

Start Your Chronic Care Management Trial