As the future unfolds, two major issues are challenging the Canadian population: progressive aging and chronic ailing (Montague et al. 2009). The burden of managing these related challenges is complicated by an already-large investment of the national treasury in healthcare that is often perceived as returning less than optimal outcomes, at a cost that constrains investments in other areas of innovation necessary for society's advance.

Optimal return on healthcare investments demands a strategy that effectively and efficiently manages health and disease, particularly for older, community-based citizens with chronic illnesses. To this end, consensus has formed around partnerships of inter-professional and non-professional providers and patients, using regular measurement and feedback of data on gaps between usual and best care, to drive improvements in both clinical and economic outcomes. In this patient-centred health and disease management model, key drivers of success are clinical measurements and their communication. However, widespread adoption is impeded by lack of flexible systems to facilitate the measures of care and cost. Adoption of electronic health/medical record systems (e-health), another care improvement strategy, is also lagging at primary care and community levels, in part because of inadequate investment and user skepticism about clinical benefit and technical flexibility. To address the limitations of these promising, but largely independently deployed, care models we propose an integrated strategy in which community- and team-based, measurement-driven disease management is enhanced by e-health measurement and communication technology. This synergistic model can accelerate the capture and visibility of practical information for all stakeholders – driving improvements in care and outcomes and cultural adoption of disease management and e-health values. In short, it offers promise of the best health for the most people at the best cost.

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