Annals of Family Medicine

NOVEMBER 20, 2024

Objective: Describe codesign methods to implement actionable strategies for breast cancer survivorship follow-up care. The resulting intervention was a care quality improvement project that engaged practice champions (n=18) from 6 primary care practices in bi-weekly virtual facilitation and monthly learning collaboratives over 3 months.

Primary Care 130

Primary Care Referral Electronics Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Patients with diabetes who receive structured and integrated care have better control and outcomes; however, care may shift between multiple settings making coordination challenging. Outcome Measures: Number of patients engaged, resulting referrals, Navigator time per patient, and hemoglobin A1c measures across 2-years.

Primary Care 130

Primary Care Diabetes Referral Integrated Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In Canada, most diabetes care is provided within primary care. Primary care experienced challenges during the COVID-19 pandemic, such as reduced access to care. Objective: To understand if the pandemic resulted in changes in care for patients with diabetes.

Primary Care 130

Primary Care Diabetes Finance Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective To develop and validate a novel electronic medical records (EMR)-based UTI case definition that can be applied to elucidate and understand UTI treatment and practice patterns in primary care. Conclusions We developed and validated a novel EMR-based UTI case definition using a pan-Canadian primary care dataset.

Primary Care 130

Primary Care Clinical Practice Electronics Diagnosis 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: The overarching objective of the MU is to enhance the delivery of high-quality care to a broader patient population. Setting or Dataset: Data includes secondary data gathered through Epic electronic medical records system as well as primary data collected from physicians, APPs, and staff working in the MU.

Management 130

Management Primary Care Telehealth Hypertension 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: A severe asthma registry in primary care is needed to determine the population prevalence and best practices in the real world. Setting or Dataset: The University of Toronto Practice-based and Learning Research Network (UPLEARN) in Ontario, Canada, comprises ~400 primary care physicians contributing data on ~400,000 patients.

Asthma 130

Asthma Primary Care Primary Care Physician Family Physician 130

Annals of Family Medicine

NOVEMBER 20, 2024

BACKGROUND: Despite the emphasis of primary care’s (PC) role in breast cancer follow-up improvements have had limited clinical impact. OBJECTIVE: To prioritize implementation strategies to support PC adoption of evidence to guide breast cancer follow-up care. Local PC stakeholders participated in the second panel.

Primary Care 130

Primary Care Screening Education Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Patient portals (PPs) are online healthcare platforms enabling patients access their electronic health records and offering different features to help patients manage their care such as viewing and entering health information, and permitting asynchronous communication between patients and their providers.

Patients 130

Patients Primary Care Appointment Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Setting or Dataset: Electronic health record data from 11 community-based clinics within a safety-net system in the Midwest from 07/01/2021-3/31/2024. Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period. Design and Analysis: Observational study.

Primary Care 130

Primary Care Referral Electronics Individual 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: Evaluate the economic impact of receiving tele-legal services from Medicaid’s perspective with regard to a) fee- for service (FFS) total cost of care; b) FFS cost of primary care; c) utilization for FFS primary care; d) utilization for FFS and capitated behavioral health (BH) and BH emergency department encounters.

Primary Care 130

Primary Care Medical Behavioral Health Services Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context Lifestyle Medicine (LM) is an evidence-based approach to prevention and treatment of chronic disease by addressing six pillars: physical activity, nutrition, sleep and stress management (recovery), connection, and substance use. Objective To assess patient perceptions of a primary care-based LM clinic.

Clinic 130

Clinic Patients Primary Care Chronic Disease 130

Annals of Family Medicine

NOVEMBER 20, 2024

Central tenets of primary care are essential to the delivery of effective MCC care: person & family-centered, comprehensive, equitable, team-based, collaborative, coordinated and integrated. The emergence of FIHR enables the development of interoperable apps to facilitate comprehensive, shared care planning.

Chronic Condition 130

Chronic Condition Patient-Centered Primary Care Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: In response to a call initiated by CIHR in 2023, inviting patient, public, and community participation, the Patient Council of the Canadian Primary Care Research Network (CPCRN) responded with a Report on March 25, 2024. Population Studied: CPCRN Patient Council.

Patients 130

Patients Community Primary Care Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Setting: Three academic health systems with EPIC and Oracle electronic health records. Population Studied: Primary care team members involved in high blood pressure management. Intervention: COACH — a patient-facing decision support tool integrated into the electronic record.

Electronics 130

Electronics Patient-Centered Hypertension Primary Care 130

Integrated Care News by CFHA

MAY 1, 2025

That small win reminded me that artificial intelligence is already shaping the way our patients (and our families) search for health advice. Three reasons why learning Artificial Intelligence in health care may be a responsibility and not an option: 1. Evidence‑informed care was literally at his fingertips.

Patient-Centered 130

Patient-Centered Integrated Care Primary Care Healthcare Professional 130

Annals of Family Medicine

NOVEMBER 20, 2024

Objective: Our study investigates ID prevalence in Alberta from 2010 to 2022 and its association with patient and provider characteristics. Study Design: Retrospective analysis of electronic medical data obtained from the Canadian Primary Care Research Network, Southern Alberta Primary Care Research Network (SAPCReN-CPCSSN).

Clinic 130

Clinic Primary Care Electronics Individual 130

Annals of Family Medicine

MAY 27, 2025

PURPOSE Increased workload associated with electronic visits (eVisits) in primary care could potentially be decreased by the use of artificial intelligence (AI); however, it is unknown whether this use of AI would be acceptable to staff and patients. We analyzed verbatim transcripts using thematic analysis.

Primary Care 130

Primary Care Electronics Patients Appointment 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Mental health conditions have increasing prevalence, co-occurrence, and high management burden within primary care settings. Objective: To validate and apply electronic medical record (EMR)-based definitions for mood and anxiety disorders (inc. depression, anxiety, bipolar disorder), and schizophrenia. spec, 80.7,

Primary Care 130

Primary Care Electronics Medical Mental Health 130

Annals of Family Medicine

NOVEMBER 20, 2024

To promote early management of frailty, we developed an electronic Frailty Index based on deficit accumulation in a Comprehensive Geriatric Assessment (eFI-CGA) from electronic health records. Here, we examined the feasibility, reliability, and validity of the eFI-CGA by primary care providers (PCP). and 0.28 ±0.12).

Primary Care 130

Primary Care Electronics PCP PCP 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context Ten percent of patients using prescription drugs experience adverse drug events (ADE). Objective The aim of this study was to explore the role of PGx in primary care (i.e. family medicine) and the need for education in this area. Recurrent themes were identified.

Primary Care 130

Primary Care Education Family Medicine DO 130

Annals of Family Medicine

NOVEMBER 20, 2024

Study Design and Analysis: Retrospective chart search of the electronic medical records of a specific sub-group of patients at UNMC. Number of patients who meet inclusion criteria at Family Medicine Clinics: 6,551 Patients. Conclusion: There is a need for more screening for AAA in primary care.

Internal Medicine 130

Internal Medicine DO Family Medicine Screening 130

Annals of Family Medicine

NOVEMBER 20, 2024

Study design and analysis: In this observational study, we compared the distribution of screening modalities by 1) FQHC and year and 2) patient characteristics by screening modalities using chi-squared and t-tests. Population Studied: Average-risk females ages 21-64 with ≥1 medical encounter and ≥1 routine CCS during 2012-2017.

Screening 130

Screening Insurance Patient-Centered Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Electronic health records (EHR) and patient portal systems have resulted in an unrestricted, undefined, and often uncompensated workload for Primary Care providers. Objective: Quantify portal messaging patterns across the Rochester, MN Primary Care practices in 2022.

Electronics 130

Electronics Primary Care Provider Relationship 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Given limited critical care resources and an aging population, early interventions to prevent critical illness are vital. In this interdisciplinary collaboration, primary care and critical care clinician researchers came together with informatics and implementation experts to design this community-based pilot project.

Illness 130

Illness Electronics Primary Care Nurse Practitioner 130

Annals of Family Medicine

MARCH 24, 2025

We examined how well chlamydia and gonorrhea treatment in primary care settings adhered to guidelines. METHODS We used electronic health records from the PRIME registry to identify patients with diagnosis codes or positive test results for chlamydia and/or gonorrhea from 2018 to 2022.

Primary Care 130

Primary Care Patients Patient-Centered Families 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Primary care providers in Canada face significant workload challenges, including managing prescriptions, referrals, and laboratory tests alongside patient visits. This study aims to analyze electronic medical record (EMR) data to understand these workload dynamics. 0.9SD) encounters per patient since 2007.

Primary Care 130

Primary Care Referral Provider Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

A patient partner from the Deaf community collaborated on each step of this project. Reviews were identified through a search of scientific electronic databases: MEDLINE, CINAHL, PsycInfo, AMED, Healthcare Administration Database, ABI/INFORM Collection, Cochrane Database of Systematic Reviews, Epistemonikos, and Scopus.

Finance 130

Finance Community Consulting Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Team-based models of care have become an integral part of the primary care system and is increasingly regarded as a key feature in achieving high-quality primary care by providing integrated, comprehensive, and continuous person-centred care.

Primary Care 130

Primary Care Electronics Individual Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Weight loss is desired by many patients, but many primary care practices struggle to provide this care. PATHWEIGH is an integrated approach to support primary care practices in delivering evidence-based weight loss care to patients as part of regular health care.

Primary Care 130

Primary Care Management Electronics Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Integration of patient reported social risk questionnaires in electronic health records allows for assessment of individual-level SES, but this data is frequently missing. A housing asset-based measure of SES (HOUSES) can provide individual-level SES without need for patient questionnaires. live in rural areas.

Primary Care 130

Primary Care Patients Transportation Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context Administrative activities, including work related to caring for individual patients and clinic administration, may play a substantial role in understanding changes to primary care workload. Results/Findings Information management is central to health care delivery, but often not valued or actively supported.

Primary Care 130

Primary Care Management Nurse Practitioner Family Physician 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Pre-consultation questionnaires designed to provide rapid assessments of the physical, social, mental and cognitive health of older adults may support effective primary care management and improved patient outcomes for this population. Study Design and Analysis: Multi-center, 1:1 individually randomized trial design.

Primary Care 130

Primary Care Consulting Patient-Centered Electronics 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Since many patients with Major Depressive Disorder (MDD) have anhedonia and can be reluctant to engage in treatment, many practices struggle to engage patients with depression in regular follow up and care. Eligible patients had a diagnosis of MDD, but had not filled out a PHQ9 in the past 2 weeks to 6 months.

Electronics 130

Electronics Patients Mental Health Primary Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context: Primary care delivery was significantly impacted by COVID-19, with rapid deployment of telehealth after the United States’ national public health emergency (PHE) declaration in March 2020. Population Studied: 1,792,934 adult patients with at least 1 telehealth (phone, video) or in-person primary care visit.

Primary Care 130

Primary Care Screening Telehealth Community 130

Annals of Family Medicine

NOVEMBER 20, 2024

Delivering parental tobacco treatment during pediatric primary care visits may help to reduce the effects of these structural barriers, thereby increasing the likelihood of parental tobacco cessation and reducing children’s tobacco exposure in these populations. Setting: Primary care clinics in the Minneapolis-St.

Primary Care 130

Primary Care Screening Clinic Preventive Care 130

Annals of Family Medicine

NOVEMBER 20, 2024

to complete an analysis of qualitative data collected from primary care clinician and staff perspectives on the use of anti-obesity medications. Population Studied: Practice members from 57 primary care practices in one Colorado health system who participated in the PATHWEIGH study.

Primary Care 130

Primary Care Electronics Provider Management 130

Annals of Family Medicine

NOVEMBER 20, 2024

Context Social determinants of health (SDOH) such as access to care and economic stability negatively impact colorectal cancer (CRC) screening rates. Implementation of electronic health record SDOH questionnaires is more common in health care institutions and allows for individual-level assessment of social risk in a primary care setting.

Screening 130

Screening Primary Care Relationship Transportation 130