Publications by authors named "Amanda L Terry"

37 Publications

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.

Objective: Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned.

Methods: IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives.

Results: All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits.

Conclusions: Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted.
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http://dx.doi.org/10.1055/s-0041-1726489DOI Listing
April 2021

Qualitative Study of Long-Haul Truck Drivers' Health and Healthcare Experiences.

J Occup Environ Med 2021 Mar;63(3):230-237

Bayside Medical Centre, Penetanguishene (Dr Johnson); Centre for Studies in Family Medicine, Department of Family Medicine (Dr Vingilis, Dr Terry); Department of Epidemiology & Biostatistics (Dr Vingilis, Dr Terry); Schulich Interfaculty Program in Public Health (Dr Terry), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Objective: Long-haul truck drivers suffer increased health risk, but how they use healthcare is unknown. The objectives of this study were to explore the health experiences of these drivers, their healthcare experiences, and their relationship with their main medical provider.

Methods: In-depth semi-structured interviews were conducted with 13 Canadian long-haul truck drivers. The majority (85%) were men and recruited at a truck stop on a major transport corridor between Canada and the United States.

Results: Through phenomenological analysis of the transcribed interviews, themes of perseverance, isolation, dehumanization, and working in a hidden world emerged as major influences on the health experiences of these drivers. Barriers to their medical provider were also revealed.

Conclusions: Continuous exposure to a stressful work environment and inadequate access to primary care likely negatively affect the health of long-haul truck drivers. Given the experiences of this small group of drivers, improved healthcare and health resource availability might mitigate the risk of this occupational group.
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http://dx.doi.org/10.1097/JOM.0000000000002107DOI Listing
March 2021

Advancing cross-national planning and partnership: Proceedings from the International Multimorbidity Symposium 2019.

J Comorb 2020 Jan-Dec;10:2235042X20953313. Epub 2020 Sep 24.

Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada     .

The International Multimorbidity Symposium was held in November 2019 at Western University to achieve three main objectives: to discuss progress and findings from various jurisdictions; to facilitate collaboration through group discussion to identify strategies to move multimorbidity research forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnership. This event included keynote presentations, elevator pitch presentations and breakout sessions and there was a total of 35 attendees from eight countries, representing diverse disciplines and training levels. The overall themes arising from the event were: the importance of integrating the study and management of multimorbidity from both the primary care and public health perspectives; meaningful engagement and collaboration with patients and caregivers to understand key dimensions of multimorbidity; the considerable benefit of collaborative international partnerships; and the need to spread and scale innovations for health care systems that can better respond to the complex needs of patients and caregivers who are living with multimorbidity. Finally, it was well-acknowledged among the attendees that expanding the collaboration and discussion among international colleagues via in-person and virtual events will be important to move multimorbidity research forward.
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http://dx.doi.org/10.1177/2235042X20953313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525218PMC
September 2020

Development and evaluation of an osteoarthritis risk model for integration into primary care health information technology.

Int J Med Inform 2020 09 1;141:104160. Epub 2020 May 1.

Department of Computer Science, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Department of Statistical and Actuarial Sciences, 1151 Richmond Street, Western University, London, Ontario, N6A 3K7, Canada. Electronic address:

Background: We developed and evaluated a prognostic prediction model that estimates osteoarthritis risk for use by patients and practitioners that is designed to be appropriate for integration into primary care health information technology systems. Osteoarthritis, a joint disorder characterized by pain and stiffness, causes significant morbidity among older Canadians. Because our prognostic prediction model for osteoarthritis risk uses data that are readily available in primary care settings, it supports targeting of interventions delivered as part of clinical practice that are aimed at risk reduction.

Methods: We used the CPCSSN (Canadian Primary Sentinel Surveillance Network) database, which contains aggregated electronic health information from a cohort of primary care practices, to develop and evaluate a prognostic prediction model to estimate 5-year osteoarthritis risk, addressing contextual challenges of data availability and missingness. We constructed a retrospective cohort of 383,117 eligible primary care patients who were included in the cohort if they had an encounter with their primary care practitioner between 1 January 2009 and 31 December 2010. Patients were excluded if they had a diagnosis of osteoarthritis prior to their first visit in this time period. Incident cases of osteoarthritis were observed. The model was constructed to predict incident osteoarthritis based on age, sex, BMI, previous leg injury, and osteoporosis. Evaluation of the model used internal 10-fold cross-validation; we argue that internal validation is particularly appropriate for a model that is to be integrated into the same context from which the data were derived.

Results: The resulting prediction model for 5-year risk of osteoarthritis diagnosis demonstrated state-of-the-art discrimination (estimated AUROC 0.84) and good calibration (assessed visually.) The model relies only on information that is readily available in Canadian primary care settings, and hence is appropriate for integration into Canadian primary care health information technology.

Conclusions: If the contextual challenges arising when using primary care electronic medical record data are appropriately addressed, highly discriminative models for osteoarthritis risk may be constructed using only data commonly available in primary care. Because the models are constructed from data in the same setting where the model is to be applied, internal validation provides strong evidence that the resulting model will perform well in its intended application.
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http://dx.doi.org/10.1016/j.ijmedinf.2020.104160DOI Listing
September 2020

Artificial Intelligence and Primary Care Research: A Scoping Review.

Ann Fam Med 2020 05;18(3):250-258

Departments of Epidemiology & Biostatistics, Computer Science, Schulich Interfaculty Program in Public Health, Statistical & Actuarial Sciences, Western University, London, Ontario, Canada.

Purpose: Rapid increases in technology and data motivate the application of artificial intelligence (AI) to primary care, but no comprehensive review exists to guide these efforts. Our objective was to assess the nature and extent of the body of research on AI for primary care.

Methods: We performed a scoping review, searching 11 published or gray literature databases with terms pertaining to AI (eg, machine learning, bayes* network) and primary care (eg, general pract*, nurse). We performed title and abstract and then full-text screening using Covidence. Studies had to involve research, include both AI and primary care, and be published in Eng-lish. We extracted data and summarized studies by 7 attributes: purpose(s); author appointment(s); primary care function(s); intended end user(s); health condition(s); geographic location of data source; and AI subfield(s).

Results: Of 5,515 unique documents, 405 met eligibility criteria. The body of research focused on developing or modifying AI methods (66.7%) to support physician diagnostic or treatment recommendations (36.5% and 13.8%), for chronic conditions, using data from higher-income countries. Few studies (14.1%) had even a single author with a primary care appointment. The predominant AI subfields were supervised machine learning (40.0%) and expert systems (22.2%).

Conclusions: Research on AI for primary care is at an early stage of maturity. For the field to progress, more interdisciplinary research teams with end-user engagement and evaluation studies are needed.
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http://dx.doi.org/10.1370/afm.2518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213996PMC
May 2020

Ethical Use of Electronic Health Record Data and Artificial Intelligence: Recommendations of the Primary Care Informatics Working Group of the International Medical Informatics Association.

Yearb Med Inform 2020 Aug 17;29(1):51-57. Epub 2020 Apr 17.

Clnical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Eagle House, 7 Walton Well Road, Oxford, OX2 6ED, UK.

Objective: To create practical recommendations for the curation of routinely collected health data and artificial intelligence (AI) in primary care with a focus on ensuring their ethical use.

Methods: We defined data curation as the process of management of data throughout its lifecycle to ensure it can be used into the future. We used a literature review and Delphi exercises to capture insights from the Primary Care Informatics Working Group (PCIWG) of the International Medical Informatics Association (IMIA).

Results: We created six recommendations: (1) Ensure consent and formal process to govern access and sharing throughout the data life cycle; (2) Sustainable data creation/collection requires trust and permission; (3) Pay attention to Extract-Transform-Load (ETL) processes as they may have unrecognised risks; (4) Integrate data governance and data quality management to support clinical practice in integrated care systems; (5) Recognise the need for new processes to address the ethical issues arising from AI in primary care; (6) Apply an ethical framework mapped to the data life cycle, including an assessment of data quality to achieve effective data curation.

Conclusions: The ethical use of data needs to be integrated within the curation process, hence running throughout the data lifecycle. Current information systems may not fully detect the risks associated with ETL and AI; they need careful scrutiny. With distributed integrated care systems where data are often used remote from documentation, harmonised data quality assessment, management, and governance is important. These recommendations should help maintain trust and connectedness in contemporary information systems and planned developments.
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http://dx.doi.org/10.1055/s-0040-1701980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442527PMC
August 2020

Ratios and determinants of maternal mortality: a comparison of geographic differences in the northern and southern regions of Cameroon.

BMC Pregnancy Childbirth 2020 Mar 31;20(1):194. Epub 2020 Mar 31.

Department of Epidemiology and Biostatistics, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.

Background: While maternal mortality has declined worldwide in the past 25 years, this is not the case for Cameroon. Since there is a predominantly young population in this country, high maternal mortality ratios may persist. Maternal mortality ratios vary within countries, yet it is unknown if the North and South, the most distinct parts of Cameroon, differ in terms of ratios and determinants of maternal mortality.

Methods: This study explored ratios and determinants of maternal mortality in women of childbearing age (15-49 years) and assessed differences between the North and South. We used the Cameroon Demographic and Health Surveys (2004 and 2011) to extract a sample of 18,665 living or deceased women who had given birth. Multivariable logistic regression was used to explore the relationship between maternal mortality and sociocultural, economic and healthcare factors.

Results: Maternal mortality ratios were different for the two regions and increased in the North in 2011 compared to 2004. In the North, any level of education and being Muslim were protective against maternal mortality. Meanwhile, the odds of maternal mortality decreased with increasing age, and having secondary or higher education in the South. Domestic violence and ethnicity were associated with maternal death in the South. Increasing parity was protective of maternal death in both the North and South.

Conclusions: Maternal mortality ratios and determinants varied between women of childbearing age in the North and South of Cameroon. These reinforce recommendations for region specific strategies that will improve health communication, community education programs, curb domestic violence and train more community health workers to connect pregnant women with the health system. Programs to reduce maternal death among women with low parity and little or no education should be national priority.
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http://dx.doi.org/10.1186/s12884-020-02879-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110763PMC
March 2020

Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada.

Br J Gen Pract 2019 Sep 29;69(686):e647-e656. Epub 2019 Aug 29.

Department of Family Medicine, Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Background: Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed.

Aim: To determine the prevalence, characteristics, and patterns of patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care.

Design And Setting: A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database.

Method: Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations.

Results: Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased.

Conclusion: This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.
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http://dx.doi.org/10.3399/bjgp19X704657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715467PMC
September 2019

Identifying musculoskeletal conditions in electronic medical records: a prevalence and validation study using the Deliver Primary Healthcare Information (DELPHI) database.

BMC Musculoskelet Disord 2019 May 3;20(1):187. Epub 2019 May 3.

Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada.

Background: Musculoskeletal (MSK) conditions are a common presentation in primary care. This study sought to determine the prevalence of MSK conditions in primary care in Ontario and to validate the extent to which health administrative date billing codes accurately represent MSK diagnoses.

Methods: De-identified electronic medical records (EMR) from the DELPHI database in southwestern Ontario, which contains 2493 patients (55.6% female, mean age 50.3 years (SD = 22.2)) and 21,964 encounters (July 1, 2006-June 30, 2010) were used for the analyses. Outcomes included: validation measures of agreement between International Classification of Diseases (ICD-9) diagnostic codes (health administrative data) and International Classification of Primary Care (ICPC) diagnoses defined as the reference standard, time to first ICD-9 code, prevalence, and healthcare utilization.

Results: There were 2940 true positive MSK encounters with primary care practitioners for 998 patients. Performance of the ICD-9 diagnostic codes included sensitivity = 76.5%, specificity = 95.2%, PPV = 94.6%, and NPV = 78.7%, compared to the ICPC reference standard. The majority of 998 patients were coded with both an ICPC and ICD-9 MSK code at their first or second encounter (67.4%). However, 23.5% of patients with the ICPC reference standard MSK were never coded with ICD-9. Four-year prevalence of MSK was 52.3% and varied by age (4.5% 0-17 years, 20.1% 18-44, 42.7% 45-64, and 32.7% 65+). Patients at MSK encounters had a higher number of: investigations (17.9% compared to 9.1%, p < .0001); referrals (17.6% compared to 14.3%, p < .0001); and prescriptions for opioids (17.2% compared to 5.3%, p < .0001).

Conclusions: This study determined the prevalence of musculoskeletal conditions in primary care in Ontario using a reference standard definition. The study highlighted the value of using primary care ICPC codes to validate a definition for musculoskeletal conditions. Health administrative data can be used to ascertain the presence of musculoskeletal conditions; however, ICD-9 codes may underrepresent the prevalence of MSK conditions.
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http://dx.doi.org/10.1186/s12891-019-2568-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6499985PMC
May 2019

Primary care of adults with severe and profound intellectual and developmental disabilities: Family physicians' perspectives on patient-physician relationships.

Can Fam Physician 2019 Apr;65(Suppl 1):S59-S65

Research Manager in the Primary Healthcare Research Unit at Memorial University.

Objective: To explore family physicians' perspectives on the development of the patient-physician relationship with adult patients living with severe or profound intellectual and developmental disabilities (IDD).

Design: Constructivist grounded theory.

Setting: St John's, NL, and across Canada.

Participants: Fifteen family physicians currently caring for patients with severe or profound IDD.

Methods: Data were collected via in-depth, semistructured interviews conducted in-person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data.

Main Findings: From the perspective of family physicians, the core process in the development of the patient-physician relationship was acceptance. This acceptance was bidirectional. With respect to family physicians accepting patients, family physicians had to accept that their patients with severe and profound IDD were as equally deserving of their respect as any other patient-as unique individuals with their own goals and potential. With respect to patients accepting their family physicians, family physicians had to seek out signs of acceptance from their patients to fully appreciate and develop a trusting relationship. This bidirectional process of acceptance required family physicians to adapt the way they practised (eg, by spending more time with the patient and finding alternate forms of communication). It also required family physicians to define their role (eg, building trust and being an advocate) in a relationship that had the patient as the primary focus but simultaneously acknowledged the important involvement of the caregiver.

Conclusion: For family physicians, the process of acceptance seems to underpin the development of the patient-physician relationship with adult patients with severe or profound IDD. Findings highlight the need for family physicians to adapt the way they deliver care to these patients and define their role in these complex relationships. Ultimately, this study highlights family physicians' acceptance of their patients' humanity regardless of the nature of the relationship that was created between them.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501711PMC
April 2019

Artificial Intelligence in Primary Health Care: Perceptions, Issues, and Challenges.

Yearb Med Inform 2019 Aug 25;28(1):41-46. Epub 2019 Apr 25.

Department of Clinical & Experimental Medicine, University of Surrey, Guildford, Surrey, UK.

Background: Artificial intelligence (AI) is heralded as an approach that might augment or substitute for the limited processing power of the human brain of primary health care (PHC) professionals. However, there are concerns that AI-mediated decisions may be hard to validate and challenge, or may result in rogue decisions.

Objective: To form consensus about perceptions, issues, and challenges of AI in primary care.

Method: A three-round Delphi study was conducted. Round 1 explored experts' viewpoints on AI in PHC (n=20). Round 2 rated the appropriateness of statements arising from round one (n=12). The third round was an online panel discussion of findings (n=8) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups.

Results: PHC and informatics experts reported AI has potential to improve managerial and clinical decisions and processes, and this would be facilitated by common data standards. The respondents did not agree that AI applications should learn and adapt to clinician preferences or behaviour and they did not agree on the extent of AI potential for harm to patients. It was more difficult to assess the impact of AI-based applications on continuity and coordination of care.

Conclusion: While the use of AI in medicine should enhance healthcare delivery, we need to ensure meticulous design and evaluation of AI applications. The primary care informatics community needs to be proactive and to guide the ethical and rigorous development of AI applications so that they will be safe and effective.
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http://dx.doi.org/10.1055/s-0039-1677901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697547PMC
August 2019

A basic model for assessing primary health care electronic medical record data quality.

BMC Med Inform Decis Mak 2019 02 12;19(1):30. Epub 2019 Feb 12.

Department of Family Medicine, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada.

Background: The increased use of electronic medical records (EMRs) in Canadian primary health care practice has resulted in an expansion of the availability of EMR data. Potential users of these data need to understand their quality in relation to the uses to which they are applied. Herein, we propose a basic model for assessing primary health care EMR data quality, comprising a set of data quality measures within four domains. We describe the process of developing and testing this set of measures, share the results of applying these measures in three EMR-derived datasets, and discuss what this reveals about the measures and EMR data quality. The model is offered as a starting point from which data users can refine their own approach, based on their own needs.

Methods: Using an iterative process, measures of EMR data quality were created within four domains: comparability; completeness; correctness; and currency. We used a series of process steps to develop the measures. The measures were then operationalized, and tested within three datasets created from different EMR software products.

Results: A set of eleven final measures were created. We were not able to calculate results for several measures in one dataset because of the way the data were collected in that specific EMR. Overall, we found variability in the results of testing the measures (e.g. sensitivity values were highest for diabetes, and lowest for obesity), among datasets (e.g. recording of height), and by patient age and sex (e.g. recording of blood pressure, height and weight).

Conclusions: This paper proposes a basic model for assessing primary health care EMR data quality. We developed and tested multiple measures of data quality, within four domains, in three different EMR-derived primary health care datasets. The results of testing these measures indicated that not all measures could be utilized in all datasets, and illustrated variability in data quality. This is one step forward in creating a standard set of measures of data quality. Nonetheless, each project has unique challenges, and therefore requires its own data quality assessment before proceeding.
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http://dx.doi.org/10.1186/s12911-019-0740-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373085PMC
February 2019

Understanding the role of the family physician in early psychosis intervention.

BJPsych Open 2018 Nov 30;4(6):447-453. Epub 2018 Oct 30.

Project Coordinator, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, Canada.

Background: The family physician is key to facilitating access to psychiatric treatment for young people with first-episode psychosis, and this involvement can reduce aversive events in pathways to care. Those who seek help from primary care tend to have longer intervals to psychiatric care, and some people receive ongoing psychiatric treatment from the family physician.

Aims: Our objective is to understand the role of the family physician in help-seeking, recognition and ongoing management of first-episode psychosis.

Method: We will use a mixed-methods approach, incorporating health administrative data, electronic medical records (EMRs) and qualitative methodologies to study the role of the family physician at three points on the pathway to care. First, help-seeking: we will use health administrative data to examine access to a family physician and patterns of primary care use preceding the first diagnosis of psychosis; second, recognition: we will identify first-onset cases of psychosis in health administrative data, and look back at linked EMRs from primary care to define a risk profile for undetected cases; and third, management: we will examine service provision to identified patients through EMR data, including patterns of contacts, prescriptions and referrals to specialised care. We will then conduct qualitative interviews and focus groups with key stakeholders to better understand the trends observed in the quantitative data.

Discussion: These findings will provide an in-depth description of first-episode psychosis in primary care, informing strategies to build linkages between family physicians and psychiatric services to improve transitions of care during the crucial early stages of psychosis.

Declaration Of Interest: None.
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http://dx.doi.org/10.1192/bjo.2018.67DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235978PMC
November 2018

Evolution and 15-year effect of a pan-Canadian training program: Transdisciplinary Understanding and Training on Research-Primary Health Care.

Can Fam Physician 2018 06;64(6):475-476

Distinguished University Professor in the CSFM in the Department of Family Medicine and in the Department of Epidemiology and Biostatistics at the Schulich School of Medicine and Dentistry at Western University.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999248PMC
June 2018

Benefit-risk of Patients' Online Access to their Medical Records: Consensus Exercise of an International Expert Group.

Yearb Med Inform 2018 Aug 22;27(1):156-162. Epub 2018 Apr 22.

Department of Clinical & Experimental Medicine, University of Surrey, GUILDFORD, Surrey, UK.

Background:  Patients' access to their computerised medical records (CMRs) is a legal right in many countries. However, little is reported about the benefit-risk associated with patients' online access to their CMRs.

Objective:  To conduct a consensus exercise to assess the impact of patients' online access to their CMRs on the quality of care as defined in six domains by the Institute of Medicine (IoM), now the National Academy of Medicine (NAM).

Method:  A five-round Delphi study was conducted. Round One explored experts' (n = 37) viewpoints on providing patients with access to their CMRs. Round Two rated the appropriateness of statements arising from Round One (n = 16). The third round was an online panel discussion of findings (n = 13) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups. Two additional rounds, a survey of the revised consensus statements and an online workshop, were carried out to further refine consensus statements.

Results:  Thirty-seven responses from Round One were used as a basis to initially develop 15 statements which were categorised using IoM's domains of care quality. The experts agreed that providing patients online access to their CMRs for bookings, results, and prescriptions increased efficiency and improved the quality of medical records. Experts also anticipated that patients would proactively use their online access to share data with different health care providers, including emergencies. However, experts differed on whether access to limited or summary data was more useful to patients than accessing their complete records. They thought online access would change recording practice, but they were unclear about the benefit-risk of high and onerous levels of security. The 5-round process, finally, produced 16 consensus statements.

Conclusion:  Patients' online access to their CMRs should be part of all CMR systems. It improves the process of health care, but further evidence is required about outcomes. Online access improves efficiency of bookings and other services. However, there is scope to improve many of the processes of care it purports to support, particularly the provision of a more effective interface and the protection of the vulnerable.
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http://dx.doi.org/10.1055/s-0038-1641202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115222PMC
August 2018

Patient-centred primary care of adults with severe and profound intellectual and developmental disabilities: Patient-caregiver-physician relationship.

Can Fam Physician 2018 04;64(Suppl 2):S63-S69

Research Manager in the Primary Healthcare Research Unit at Memorial University.

Objective: To explore the process of the development of the patient-physician relationship in adult patients with severe or profound intellectual and developmental disabilities (IDD), from the perspective of the patients' caregivers.

Design: Constructivist grounded theory.

Setting: St John's, NL.

Participants: Thirteen primary caregivers (5 males, 8 females) of 1 or more adults with severe or profound IDD.

Methods: Data were collected via in-depth, semistructured interviews conducted in person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data.

Main Findings: From the perspective of the caregivers, the core process in the development of the patient-physician relationship was protection. This process began as a result of the caregiver's recognition of the patient's vulnerability and moved through a number of stages before resulting in the development of a dynamic triangular interaction between the patient, caregiver, and family physician. First, the caregiver provides extreme nurturing to the patient, which results in the development of a strong bond between them. The patient and caregiver approached the family physician together as one unit, and then decided together on whether or not to open the patient-caregiver bond to the physician. The resultant dynamic triangular interaction formed the starting point from which 1 of 4 different relationship-development trajectories began. Which trajectory was taken and, therefore, the character of the relationships that developed was determined by how the caregiver and patient experienced their interaction with the family physician.

Conclusion: Findings highlight the process of protection and the centrality of the patient-caregiver bond within the development of a triadic relationship involving the patient with IDD, the caregiver, and the family physician. How a physician approaches this bond can influence the trajectory of the resulting relationship.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5906777PMC
April 2018

Towards optimal electronic medical record use: perspectives of advanced users.

Fam Pract 2018 09;35(5):607-611

Centre for Studies in Family Medicine, Department of Family Medicine, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada.

Background: While primary health care electronic medical record (EMR) adoption has increased in Canada, the use of advanced EMR features is limited. Realizing the potential benefits of primary health care EMR use is dependent not only on EMR acquisition, but also on its comprehensive use and integration into practice; yet, little is known about the advanced use of EMRs in primary health care.

Objective: To explore the views of advanced primary health care EMR users practising in a team-based environment.

Methods: A descriptive qualitative approach was used to explore the views of primary health care practitioners who were identified as advanced EMR users. Twelve individual semi-structured interviews were held with primary health care practitioners in Southwestern Ontario, Canada. Field notes were created after each interview. Interviews were audio recorded and transcribed verbatim. Researchers independently coded the transcripts and then met to discuss the results of the coding. We used a thematic approach to data analysis.

Results: Three themes emerged from the data analysis: advanced EMR users as individuals with signature characteristics, advanced EMR users as visionaries and advanced EMR users as agents of change. In any one participant, these elements could overlap, illuminating the important interplay between these themes. Taken together, these themes defined advanced use among this group of primary health care practitioners.

Conclusions: To realize the potential benefits of EMR use in improved patient care and outcomes, we need to understand how to support EMR use. This study provides a necessary building block in furthering this understanding.
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http://dx.doi.org/10.1093/fampra/cmy002DOI Listing
September 2018

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data.

J Innov Health Inform 2017 Nov 17;24(4):888. Epub 2017 Nov 17.

Western University.

Background:   A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. OBJECTIVE:  To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. METHOD: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location.  Proportion of variance in referral rates attributable to the patient and practice levels. RESULTS:  On average, males had 0.26, and females 0.31 referrals in a 12-month period.  Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p<.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. CONCLUSIONS:  Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time.
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http://dx.doi.org/10.14236/jhi.v24i4.888DOI Listing
November 2017

Measuring Electronic Health Record Use in Primary Care: A Scoping Review.

Appl Clin Inform 2018 01 10;9(1):15-33. Epub 2018 Jan 10.

Background: Simple measures of electronic health record (EHR) adoption may be inadequate to evaluate EHR use; and positive outcomes associated with EHRs may be better gauged when varying degrees of EHR use are taken into account. In this article, we aim to assess the current state of the literature regarding measuring EHR use.

Objective: This article conducts a scoping review of the literature to identify and classify measures of primary care EHR use with a focus on the Canadian context.

Methods: We conducted a scoping review. Multiple citation databases were searched, as well as gray literature from relevant Web sites. Resulting abstracts were screened for inclusion. Included full texts were reviewed by two authors. Data from the articles were extracted; we synthesized the findings. Subsequently, we reviewed these results with seven EHR stakeholders in Canada.

Results: Thirty-seven articles were included. Eighteen measured EHR function use individually, while 19 incorporated an overall level of use. Eight frameworks for characterizing overall EHR use were identified.

Conclusion: There is a need to create standardized frameworks for assessing EHR use.
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http://dx.doi.org/10.1055/s-0037-1615807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801885PMC
January 2018

Stepping Up to the Plate: An Agenda for Research and Policy Action on Electronic Medical Records in Canadian Primary Healthcare.

Healthc Policy 2016 11;12(2):19-32

Professor, Department of Family Medicine, Department of Epidemiology & Biostatistics, Director, Schulich Interfaculty Program in Public Health, The University of Western Ontario, London, ON.

Building on a previous study, which identified gaps in primary healthcare electronic medical record (emr) research and knowledge, a one-day conference was held to facilitate a strategic discussion of these issues. This paper offers a multi-faceted research agenda and suggestions for policy actions as a way forward in bridging the gaps. one facet focuses on the need for research. The second facet focuses on harnessing the knowledge of primary healthcare emr stakeholders. finally, the third facet focuses on policy actions. this paper offers consensus-based suggestions with a view to improving the overall primary healthcare emr landscape in canada.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221709PMC
November 2016

Examining the prevalence and patterns of multimorbidity in Canadian primary healthcare: a methodologic protocol using a national electronic medical record database.

J Comorb 2015 22;5:150-161. Epub 2015 Dec 22.

Department of Epidemiology and Biostatistics; and Department of Family Medicine, Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada.

In many developed countries, the burden of disease has shifted from acute to long-term or chronic diseases - producing new and broader challenges for patients, healthcare providers, and healthcare systems. Multimorbidity, the coexistence of two or more chronic diseases within an individual, is recognized as a significant public health and research priority. This protocol aims to examine the prevalence, characteristics, and changing burden of multimorbidity among adult primary healthcare (PHC) patients using electronic medical record (EMR) data. The objectives are two-fold: (1) to measure the point prevalence and clusters of multimorbidity among adult PHC patients; and (2) to examine the natural history and changing burden of multimorbidity over time among adult PHC patients. Data will be derived from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The CPCSSN database contains longitudinal, point-of-care data from EMRs across Canada. To identify adult patients with multimorbidity, a list of 20 chronic disease categories (and corresponding ICD-9 codes) will be used. A computational cluster analysis will be conducted using a customized computer program written in JAVA. A Cox proportional hazards analysis will be used to model time-to-event data, while simultaneously adjusting for provider- and patient-level predictors. All analyses will be conducted using STATA SE 13.1. This research is the first of its kind using a pan-Canadian EMR database, which will provide an opportunity to contribute to the international evidence base. Future work should systematically compare international research using similar robust methodologies to determine international and geographical variations in the epidemiology of multimorbidity.
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http://dx.doi.org/10.15256/joc.2015.5.61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5636032PMC
December 2015

Understanding multimorbidity in primary health care.

Can Fam Physician 2015 Oct;61(10):918, e489-90

Canada Research Chair in Health Services Research and is Professor in the Department of Family Medicine and the Department of Epidemiology and Biostatistics and is Director of the Schulich Interfaculty Program in Public Health.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607340PMC
October 2015

Gaps in primary healthcare electronic medical record research and knowledge: findings of a pan-Canadian study.

Healthc Policy 2014 ;10(1):46-59

Professor, Centre for Studies in Family Medicine, Department of Family Medicine and Department of Epidemiology and Biostatistics, Director, Schulich Interfaculty Program in Public Health, The University of Western Ontario, London, ON.

While the barriers to electronic medical record (EMR) adoption by physicians are well-known, we have much less knowledge about the broader challenges regarding EMR use faced by primary healthcare (PHC) EMR stakeholders in Canada. Therefore, we conducted interviews (from June 2009 to September 2010) and consultation sessions (in October and November 2009) with these stakeholders, as well as carrying out a research capacity assessment, to identify, describe and prioritize gaps in PHC EMR knowledge and research. Twelve thematic gaps emerged; four were identified as the most important: the need to ascertain the value of EMRs, the need to better understand elements of EMR implementation and adoption, the need to develop innovative data entry and extraction procedures, and a lack of agreement and understanding of data sharing. To advance EMR use, Canada needs to address these gaps; yet, we currently have a lack of research capacity with which to accomplish this.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4253895PMC
July 2015

Results of a mixed-methods evaluation of partnerships for health: a quality improvement initiative for diabetes care.

J Am Board Fam Med 2013 Nov-Dec;26(6):711-9

the Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada; and Renison University College, The University of Waterloo, Waterloo, Ontario, Canada.

Purpose: Quality improvement (QI) initiatives have been implemented to facilitate transition to a chronic disease management approach in primary health care. However, the effect of QI initiatives on diabetes clinical processes and outcomes remains unclear. This article reports the effect of Partnerships for Health, a QI program implemented in Southwestern Ontario, Canada, on diabetes clinical process and outcome measures and describes program participants' views of elements that influenced their ability to reach desired improvements.

Methods: Part of an external, concurrent, comprehensive, mixed-methods evaluation of Partnerships for Health, a before/after audit of 30 charts of patient of program physicians (n = 35) and semistructured interviews with program participants (physicians and allied health providers) were conducted.

Results: The proportion of patients (n = 998) with a documented test/examination for the following clinical processes significantly improved (P ≤ .005): glycosylated hemoglobin (A1c), cholesterol, albumin-to-creatinine ratio, serum creatinine, glomerular filtration rate, electrocardiogram, foot/eye/neuropathy examination, body mass index, waist circumference, and depression screening. Data showed intensification of treatment and significant improvement in the number of patients at target for low-density lipoprotein (LDL) and blood pressure (BP) (P ≤ .001). Mean LDL and BP values decreased significantly (P ≤ .01), and an analysis of patients above glycemic targets (A1c >7% at baseline) showed a significant decrease in mean A1c values (P ≤ .01). Interview participants (n = 55) described using a team approach, improved collaborative and proactive care through better tracking of patient data, and increased patient involvement as elements that positively influenced clinical processes and outcomes.

Conclusions: QI initiatives like Partnerships for Health can result in improved diabetes clinical process and outcome measures in primary health care.
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http://dx.doi.org/10.3122/jabfm.2013.06.120211DOI Listing
July 2014

Joint replacement recipients' views about health information privacy.

Health Expect 2015 Oct 1;18(5):1519-29. Epub 2013 Oct 1.

Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada.

Background: Researchers are concerned about the possibility of restricted access to data as a result of specific consent requirements in privacy legislation, potentially resulting in smaller samples and a lack of representativeness which could bias results. In addition, there is uncertainty about what influences individuals to give consent for the use of their personal health information.

Objective: To measure joint replacement recipients' health information privacy views and to assess potential predictors of these views.

Design: Cross-sectional survey.

Setting And Participants: Potential joint replacement recipients from two teaching hospitals in London, Ontario, Canada.

Main Variables: Age, gender, education, employment status, anticipated joint replacement, and expectations for surgery.

Main Outcome Measures: Privacy concerns as measured by the Concern Scale.

Results: The response rate was 182/253 or 72%. The mean Concern score was 143.9/235.0 for the total sample (range = 82-216). Women had higher levels of privacy concerns than men on slightly over half of the individual questionnaire items. In women, surgical joint, age and employment explained 15% of the variance in concerns about personal health information privacy (P = 0.001). The model explained 6% of the variance in concerns in men (P = 0.138) and was not statistically significant.

Discussion And Conclusion: This study indicates that demographic characteristics and health-care experiences play a role in the variability of health information privacy concerns. A greater understanding of patients' privacy views about health information could lead to a greater harmonization among privacy rules, research and data access, and the preferences of health-care consumers.
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http://dx.doi.org/10.1111/hex.12142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5060881PMC
October 2015

Perspectives on electronic medical record implementation after two years of use in primary health care practice.

J Am Board Fam Med 2012 Jul-Aug;25(4):522-7

Department of Family Medicine, Centre for Studies in Family Medicine, and the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada.

Purpose: This qualitative study explored the experiences of primary health care providers and staff who had moved beyond the stage of implementing electronic medical records (EMRs) in their practices to using this technology on an on-going basis.

Methods: A descriptive qualitative approach was used. Semistructured interviews were conducted with 19 participants. Data analysis was iterative and interpretive.

Results: Factors that hindered and motivated ongoing EMR use emerged. Factors that hindered use included (1) information technology challenges such as learning to use the EMR and the computer, electronic connectivity, and scanning; and (2) variability in on-going EMR use. Two factors motivated ongoing use: (1) improved efficiency in patient care, and (2) confidence with computers and EMR software.

Conclusions: Different issues in the use of EMRs surface as primary health care providers and staff mature in their use of this technology. Ongoing use of the EMR may be facilitated by confidence with the technology as well as providers' perceptions of efficiency in patient care. Optimal use of the EMR could be facilitated through assessing and enhancing computer skills, working toward consistent data entry and use of the EMR, and developing strategies to address issues such as scanning and electronic connectivity.
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http://dx.doi.org/10.3122/jabfm.2012.04.110089DOI Listing
November 2012

You and your EMR: the research perspective: part 4. Optimizing EMRs in primary health care practice and research.

Can Fam Physician 2012 Jun;58(6):705-6

Centre for Studies in Family Medicine, 100 Collip Circle, Suite 245, University of Western Ontario Research Park, London, ON N6G 4X8.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3374693PMC
June 2012

Feedback and training tool to improve provision of preventive care by physicians using EMRs: a randomised control trial.

Inform Prim Care 2011 ;19(3):147-53

DELPHI Project, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, Canada.

Background: Electronic medical records (EMRs) have the potential to improve the provision of preventive care by allowing general practitioners (GPs) to track and recall eligible patients and record testing for feedback on their service provision.

Objective: This study evaluates the effect of an educational intervention and feedback tool designed to teach GPs how to use their EMRs to improve their provision of preventive care.

Methods: A randomised controlled trial comparing rates of mammography, Papanicolaou tests, faecal occult blood tests and albumin creatinine ratios one-year pre- and post-intervention was conducted. Nine primary care practices (PCPs) representing over 30 000 patients were paired by practice size and experience of GPs, and randomly allocated to intervention or control groups. Physicians at the four intervention practices received a two-hour feedback session on their current level of preventive care and training to generate eligible patient lists for preventive services from their EMR database.

Results: One-year post-intervention results provided no evidence of a difference. The intervention was not a significant predictor of the one-year postintervention test rates for any of the four tests. On average, the intervention practices increased postintervention test rates on all tests by 16.8%, and control practices increased by 22.3%.

Conclusion: The non-significant results may be due to a variety of reasons, including the level of intensity of the educational intervention, the cointervention of a government programme which provided incentives to GPs meeting specific targets for preventive care testing or the level of recording of tests performed in the EMR.
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http://dx.doi.org/10.14236/jhi.v19i3.807DOI Listing
July 2012

How does Canada stack up? A bibliometric analysis of the primary healthcare electronic medical record literature.

Inform Prim Care 2012 ;20(4):233-40

Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.

Background: Major initiatives are underway in Canada which are designed to increase electronic medical record (EMR) implementation and maximise its use in primary health care. These developments need to be supported by sufficient evidence from the literature, particularly relevant research conducted in the Canadian context.

Objectives: This study sought to quantify this lack of research by: (1) identifying and describing the primary health care EMR literature; and (2) comparing the Canadian and international primary healthcare EMR literature on the basis of content and publication levels.

Methods: Seven bibliographic databases were searched using primary health care and EMR keywords. Publication abstracts were reviewed and categorised. First author affiliation was used to identify country of origin. Proportions of Canadian- and non-Canadian-authored publications were compared using Fisher's exact test. For countries having 10 or more primary healthcare EMR publications, publications per 10 000 researchers were calculated.

Results: After exclusions, 750 publications were identified. More than one-third used primary healthcare EMRs as a study data source. Twenty-two (3%) were Canadian-authored. There were significantly different publication levels in three categories between Canadian- and non-Canadian-authored publications. Based on publications per researchers, the Netherlands ranked first, while Canada ranked eighth of nine countries with 10 or more publications.

Conclusions: A relatively small body of literature focused on EMRs in primary health care exists; publications by Canadian authors were low. This study highlights the need to develop a strong evidence base to support the effective implementation and use of EMRs in Canadian primary health care.
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http://dx.doi.org/10.14236/jhi.v20i4.2DOI Listing
September 2013

Primary health care teams' experience of electronic medical record use after adoption.

Fam Med 2011 Oct;43(9):638-42

Department of Family Medicine, University of Western Ontario, Canada.

Background And Objectives: This study explored the views and perspectives of primary health care providers participating in the DELPHI (Deliver Primary Healthcare Information) project regarding their experiences using electronic medical records (EMRs) in their practices 2 years after adoption. This research was conducted in follow up to a previous qualitative study looking at early EMR implementation experiences.

Methods: This descriptive qualitative study explored the experiences of 19 participants. Semi-structured interviews were conducted. Both individual and team analyses were performed.

Results: Emergent from the data were five interwoven elements of team behavior when using the EMR. Consistent data entry was imperative to successful EMR utilization. The EMR software was utilized differently depending on the role of the team member. Team members continued to seek out a team champion/problem solver to help overcome obstacles. Communication was enhanced by using the common messaging system within the EMR. Finally, success with certain functions such as communication, champion enthusiasm, and recognition of the value of the EMR encouraged others to learn additional features and advanced the adoption process.

Conclusions: These findings illuminate important elements of team behavior that promoted EMR adoption and provide insight for primary health care providers moving through the continuum of initial to advanced EMR adoption.
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October 2011