A Case Study on Streamlining Heart Failure Management in Primary Care with Evidence2Practice Ontario’s EMR Tool

Heart failure represents a significant and growing burden in Canada. Nine out of ten Canadians have at least one risk factor for heart disease, stroke, or vascular cognitive impairment [1]. Annually, around 100,000 individuals are diagnosed with heart failure, and this number is expected to grow exponentially [2].

In Canada, approximately one-fifth of the population resides in rural and remote regions; however, these areas are served by a disproportionately small share of the national physician workforce [3, 4]. Notwithstanding the country’s publicly-funded universal healthcare system, rural populations continue to report persistent barriers to care, including shortages of family doctors, constrained access to specialty care, prolonged wait times, and fragmented care due to lack of interoperable services [3-5].

Extending these systemic challenges, the implementation of patient-centred care (PCC) is further constrained by significant time pressures within healthcare settings [6]. Delivering meaningful PCC requires dedicated time for professional training, resources for patient education, and the development of collaborative relationships with patients, which are time-intensive [6]. Consequently, these persistent system barriers and time constraints highlight the need to develop integrated resources that enhance interoperability across healthcare systems while supporting time-efficient delivery of PCC.

Ontario mirrors national heart failure trends while facing notable regional variation. In 2015, 250,000 Ontarians (1.8%) were living with diagnosed heart failure, and over one-third had four or more comorbidities [8]. Heart failure ranked among the top five causes of hospitalization and 30-day readmissions and was the leading cause of hospitalization for adults 65+ [9]. In 2015/16, timely post-discharge primary care follow-up ranged from 37–55% across OH regions, and 30-day readmissions ranged from 18–24%, highlighting persistent regional disparities and opportunities to reduce avoidable system burden [9].

Impact in Practice

Grounded in OH’s quality standard for managing heart failure, the E2P EMR tool for heart failure supports clinicians in providing the optimal standard of care for patients with heart failure by bringing the most up-to-date evidence to the point of care.  This case study showcases how the E2P EMR tool for hearth failure supports day-to-day clinical operations, interprofessional teamwork, and care coordination within a remote setting. This case study highlights the tool’s practical value in improving efficiency, standardization, and continuity of care to ensure patients living with heart failure receive care that is aligned with best practice evidence, no matter where they live in Ontario.

To better understand the impact of the E2P tool for heart failure, an in-depth case study was conducted involving a Registered Practice Nurse (RPN), Nurse Practitioner (NP), and Pharmacist working in a remote clinic within the All-Nations Health Partners OHT. The clinic serves the local community as well and 12-13 surrounding First Nations communities.

The clinicians adopted the E2P heart failure tool approximately ten months ago, with support from the E2P Change Management team. A qualitative interview was conducted with the RPN to explore the tool’s impact since its implementation, supplemented  by EMR searches and consented usage data used to quantify the number of patients supported with the E2P heart failure tool.

According to one clinician, the most immediate benefit has been time savings through more efficient chart preparation and clinical review. By consolidating relevant clinical data into a single view, the tool reduces the need to manually search across multiple areas of the EMR.

In addition to saving time, the clinician identified that built-in prompts within the tool helped ensure key elements of care were addressed during patients’ encounters, supporting more aligned care with the quality standards.

Beyond time savings and improved encounter preparation, the E2P heart failure tool also supported standardizing the quality of care across the patient’s entire care team. The clinician highlighted this benefit in the context of a highly fragmented care pathway:

The clinician also noted that the consolidated view of the patient information improved care coordination and continuity, particularly in medication management, by reducing fragmentation and supporting clearer communication among clinicians involved in complex, multi-site care.

In addition to standardized and coordinated care, the E2P heart failure tool also facilitated patient education and engagement, driving more towards patient-centric care. The clinician described how the E2P tool supports tailoring education to a patient’s level of understanding and social context.

Conclusion

The E2P heart failure EMR tool has demonstrated meaningful value within a remote primary care setting by improving workflow efficiency, strengthening interprofessional collaboration, and supporting standardized, patient-centred care. By consolidating critical clinical information at the point of care, the tool enables clinicians to navigate fragmented systems more efficiently while delivering care aligned with OH standards, even in settings with limited access to specialty resources.

This case study highlights the E2P heart failure tool as a practical solution for Ontario primary care teams seeking to improve care coordination and equity for patients living with heart failure. With broader adoption and continued system integration, E2P tools have strong potential to support OHTs and primary care teams across Ontario in delivering consistent, evidence informed heart failure care, ensuring that geography does not determine access to high quality management for this complex chronic condition.

Works Cited

1. “Connected by the numbers,” Heart and Stroke Foundation of Canada. Accessed: Dec. 16, 2025. [Online]. Available: https://www.heartandstroke.ca/en/articles/connected-by-the-numbers/
2. “Falling short How Canada is failing people with  heart failure — and how we can change that,” Heart and Stroke Foundation of Canada, 2022. [Online]. Available: https://www.heartandstroke.ca/-/media/pdf-files/canada/2022-heart-month/hs-heart-failure-report-2022-final.pdf?rev=245159ea1726419aaa6f71ae9e7692f3
3. C. Simoneau, “Empowering Healthcare in Rural Areas: The Transformative Role of Regional Development as a Pathway to Territorial Equity,” 2024.
4. A. Jawad, B. Ibhawoh, L. Schwartz, and A. Kapoor, “Barriers to access to healthcare service in rural Ontario: Qualitative study through the lens of the right to development,” J. Rural Stud., vol. 123, p. 104024, Mar. 2026, doi: 10.1016/j.jrurstud.2026.104024.
5. “Promoting Equity in Public Health: Addressing Inequality and Social Disparities – Mamun – 2025 – Health Science Reports – Wiley Online Library.” Accessed: Feb. 06, 2026. [Online]. Available: https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.70821
6. L. Moore, N. Britten, D. Lydahl, Ö. Naldemirci, M. Elam, and A. Wolf, “Barriers and facilitators to the implementation of person-centred care in different healthcare contexts,” Scand. J. Caring Sci., vol. 31, no. 4, pp. 662–673, 2017, doi: 10.1111/scs.12376.
7. V. L. Roger, “Epidemiology of heart failure,” Circ. Res., vol. 113, no. 6, pp. 646–659, Aug. 2013, doi: 10.1161/CIRCRESAHA.113.300268.
8. “Heart Failure – Health Quality Ontario (HQO).” Accessed: Feb. 10, 2026. [Online]. Available: https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-heart-failure-quality-standard-en.pdf
9. “Health Quality Ontario, Ministry of Health and Long Term Care. Quality-based procedures: clinical handbook for heart failure (acute and post acute) [Internet]. Toronto (ON): Queen’s Printer for Ontario; 2015,” Health Quality Ontario. Accessed: Feb. 10, 2026. [Online]. Available: https://www.hqontario.ca/Portals/0/Documents/evidence/clinical-handbooks/heart-failure-02042015-en.pdf
   

This document is not to be reprinted without permission from the Evidence2Practice Ontario program.

Evidence2Practice Ontario (E2P) brings together multi-disciplinary, cross-sector expertise under the joint leadership of the Centre for Effective Practice, Amplify Care, and North York General Hospital. Funding and strategic guidance for E2P is provided by Ontario Health in support of Ontario’s Digital First for Health Strategy.

* Note: We gratefully acknowledge the contributions of Emma Conway and Gillian Morgan, who were part of the Amplify Care team during the time this work was conducted.