⭐ Built in Studio
One record for the whole patient
1
Chart
Every active condition, its measures, and its medications on one chart, so a drug for one is visible against the other two.
2
Manage
Calls, refills, and specialist notes logged to the patient as they happen, between visits that are months apart.
3
Bill
Minutes counted against CCM codes 99490 and 99439, with the documentation already attached to the claim.
Go deeper on chronic care management
How a chronic care program runs on Canvas, and how the EMR options for CCM compare.
EMR GuideChronic Care Management, Explained
What it takes to care for someone carrying three conditions at once, where the work between visits actually goes, and what changes when all of it lives in one record.
Read the guide
Compare EMRsHow to Choose the Best Chronic Care Management EMR
Most CCM software is a second platform beside the EMR you already run. Here is what that costs you, how the ambulatory EMRs compare, and the questions worth asking before you sign.
Read the guideConditions chronic care programs manage
Type 2 diabetes
A1c, medications, and CGM data trend together in one place, so the care team can see where a patient sits against goal without opening three tabs.
Hypertension and heart disease
Home blood pressure readings arrive as structured data, and the CPT-II coding runs off the reading rather than off a manual chart review.
COPD and chronic respiratory disease
Symptom scores, exacerbation history, and inhaler adherence track together across months of management.
Chronic kidney disease
Staging, labs, and medication adjustments follow the patient, so a change in kidney function is visible when it happens rather than at the next annual.
Arthritis and osteoporosis
Screening, treatment, and follow-up run on the same longitudinal record as everything else the patient is managing.
Multiple comorbidities
Most CCM patients carry several of these at once, and the chart is built to hold all of them rather than treating one as primary and the rest as history.
Build the workflow your practice needs in Studio
Describe the tracking, outreach, or coordination workflow you need in plain language, and Studio writes it, tests it, and deploys it to your own instance.
The panel, not one chart at a time
Weight, BMI, and blood pressure across the whole panel, filtered by age, sex, and date range, with a distribution and a monthly trend.
Admissions you can actually query
Inpatient stays captured as structured data: dates, reason, ICU stay, disposition, and whether it was a readmission inside thirty days, with the history on the chart summary.
Every score on one page
Each scored instrument with its latest value, the change since last time, and how long it has been. Any trend drops into a note in one click.
Care management time, logged as it happens
A timer on the chart records each session with its activity and minutes, a banner carries the running monthly total, and a monthly sweep files the claim.
FAQ
Who is this EMR built for?
Practices running chronic care management as a program, including primary care groups, value-based organizations, and virtual-first practices managing patients with several chronic conditions at once. It fits a single practice enrolling a few hundred patients and a multi-site group running the program across every panel.
How does care team time get tracked?
Time accrues against the patient as the work happens, across calls, messages, and coordination. The monthly total stays visible while there is still time to act on it, rather than being reconstructed from notes at billing time.
Does the EMR handle the CCM billing codes?
Time thresholds map to the CCM codes and the claim goes out with its supporting documentation attached. CMS requirements change year to year, so confirm the current rules against the year you are billing.
What about patients enrolled in more than one care management program?
Program eligibility, consent, and enrollment live on the patient record, so a patient in more than one program shows up that way instead of being counted twice.
Can I build a workflow that does not exist yet?
This is the main reason practices with an unusual care model choose Canvas. Describe the workflow you need in Studio and it gets built, tested, and deployed to your instance, or build directly on the Canvas SDK if your team would rather work in code.
Care Management Platform: How to Choose the Right One
Discover what a care management platform is, its key features, & how to choose one. See how Canvas enables FHIR API integration, automation, and EMR workflows.
Read the guide
Remote Patient Monitoring for Chronic Disease Management
Discover how remote patient monitoring improves chronic disease management, offering real-time insights and empowering proactive healthcare
Read the guide
How to Communicate Effectively with Patients
Learn how to communicate effectively with patients using proven strategies such as teach-back, plain language, and shared decision-making for stronger care.
Read the guideSee a chronic care program run end to end
Open the chronic care trial EMR and look at Min Kang, sixty, managing COPD and Crohn's disease at the same time. Five demo patients are loaded, each carrying several conditions.
