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Implementation of a novel linkage of primary care electronic medical record data with hospital data in South Eastern Ontario [Big data]

Annals of Family Medicine

Context: Currently, primary care data, community data, and hospital data are not linked in Ontario, resulting in a disconnect in continuity of care. We demonstrated the capacity to implement data-drive QI approaches to support patient care across health care sectors using the novel merged datasets.

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Artificial Intelligence in Health Care

Integrated Care News by CFHA

I believe that as clinicians, educators and supervisors, we are called to guide this shift. 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. For AI in Primary Care, Start With the Problem.

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Electronic Health Record Use and Patient-Centredness [Education and training]

Annals of Family Medicine

Context: Large-scale electronic health record (EHR) programs have reported a number of issues to their implementation in primary care including physician patient-centredness and clinical performance. Setting: An academic primary care clinic based in a hospital.

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Adoption, implementation, and impact of a Diabetes Navigator program based in primary care [Diabetes and endocrine disease]

Annals of Family Medicine

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. Most (n=26) patients requested a referral; twelve referrals were to diabetes education, 11 to nutrition, 9 to pharmacy, and 2 to other services.

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Prioritizing Actionable Implementation Strategies to Support Breast Cancer Follow-up in Primary Care [Cancer research (not screening)]

Annals of Family Medicine

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.

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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Referrals were not placed for patients being discharged to another facility or who already had an outside primary care provider. Intervention: A team was created with an attending physician, care coordinators, and front office staff. Additionally, decreased no-show rates provide for better resident learning and experience.

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A Multisite CFIR Study of Readiness to Implement Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) [Dissemination and implementation research]

Annals of Family Medicine

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.