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Keuper J, van Tuyl LHD, de Geit E, Rijpkema C, Vis E, Batenburg R, Verheij R. The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review. BMC Health Serv Res 2024; 24:1099. [PMID: 39300456 DOI: 10.1186/s12913-024-11524-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 09/02/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND In recent years, eHealth has received much attention as an opportunity to increase efficiency within healthcare organizations. Adoption of eHealth might consequently help to solve perceived health workforce challenges, including labor shortages and increasing workloads among primary care professionals, who serve as the first point of contact for healthcare in many countries. The purpose of this systematic review was to investigate the impact of general eHealth use and specific eHealth services use on general practice workload in the pre-COVID-19 era. METHODS The databases of CINAHL, Cochrane, Embase, IEEE Xplore, Medline ALL, PsycINFO, Web of Science, and Google Scholar were searched, using combinations of keywords including 'eHealth', 'workload', and 'general practice'. Data extraction and quality assessment of the included studies were independently performed by at least two reviewers. Publications were included for the period 2010 - 2020, before the start of the COVID-19 pandemic. RESULTS In total, 208 studies describing the impact of eHealth services use on general practice workload were identified. We found that two eHealth services were mainly investigated within this context, namely electronic health records and digital communication services, and that the largest share of the included studies used a qualitative study design. Overall, a small majority of the studies found that eHealth led to an increase in general practice workload. However, results differed between the various types of eHealth services, as a large share of the studies also reported a reduction or no change in workload. CONCLUSIONS The impact of eHealth services use on general practice workload is ambiguous. While a small majority of the effects indicated that eHealth increased workload in general practice, a large share of the effects also showed that eHealth use reduced workload or had no impact. These results do not imply a definitive conclusion, which underscores the need for further explanatory research. Various factors, including the study setting, system design, and the phase of implementation, may influence this impact and should be taken into account when general practices adopt new eHealth services. STUDY REGISTRATION NUMBER PROSPERO (International Prospective Register of Systematic Reviews) CRD42020199897; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199897 .
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Affiliation(s)
- Jelle Keuper
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands.
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands.
| | - Lilian H D van Tuyl
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Ellemarijn de Geit
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Corinne Rijpkema
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands
| | - Elize Vis
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Ronald Batenburg
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Department of Sociology, Radboud University Nijmegen, Thomas van Aquinostraat 4, Nijmegen, 6525GD, Netherlands
| | - Robert Verheij
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands
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Wright JR, Madhusudhan DK, Lawrence DC, Watts SA, Lord DJ, Whaley C, Bravata DM. Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers. J Gen Intern Med 2022; 37:3861-3868. [PMID: 35882712 PMCID: PMC9321287 DOI: 10.1007/s11606-022-07724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 06/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers. OBJECTIVE Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers. DESIGN Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers. PATIENTS Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community. INTERVENTION Specialist referral management program implemented by Crossover Health employer-sponsored clinics. MAIN MEASURES Rates and costs of specialist referrals. KEY RESULTS The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001). CONCLUSIONS Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.
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Affiliation(s)
| | - Divya K Madhusudhan
- Crossover Health, San Clemente, CA, USA.,Harvard Medical School Postgraduate Medical Education, Global Clinical Scholars Research Training Program, Boston, MA, USA
| | | | - Sharon A Watts
- Crossover Health, San Clemente, CA, USA.,Watts Writing LLC, Akron, OH, USA
| | | | | | - Dena M Bravata
- Crossover Health, San Clemente, CA, USA. .,Stanford Center for Primary Care & Outcomes Research, Palo Alto, CA, USA. .,, San Mateo, USA.
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Yuan CT, Dy SM, Lai AY, Oberlander T, Hannum SM, Lasser EC, Heughan JA, Dukhanin V, Kharrazi H, Kim JM, Gurses AP, Bittle M, Scholle SH, Marsteller JA. Challenges and Strategies for Patient Safety in Primary Care: A Qualitative Study. Am J Med Qual 2022; 37:379-387. [PMID: 35404306 PMCID: PMC9700196 DOI: 10.1097/jmq.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes. Key safety issues included the lack of interoperability among health information systems, clinician-patient communication failures, and challenges with medication reconciliation. Commonly cited safety strategies leveraged health information systems or involved dedicated resources (eg, providing access to social workers). Patients also identified strategies not mentioned by clinicians, emphasizing the need for their involvement in developing safety solutions. This work provides insight into safety issues of greatest concern to clinicians, staff, and patients and strategies to improve safety in the ambulatory setting.
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Affiliation(s)
- Christina T. Yuan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
| | | | | | - Susan M. Hannum
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
| | - Elyse C. Lasser
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Johns Hopkins Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health
| | - JaAlah-Ai Heughan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | - Vadim Dukhanin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | - Hadi Kharrazi
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
- Johns Hopkins Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health
| | - Julia M. Kim
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
- Department of Pediatrics, Johns Hopkins School of Medicine
| | - Ayse P. Gurses
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
| | - Mark Bittle
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | | | - Jill A. Marsteller
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
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Odisho AY, Lui H, Yerramsetty R, Bautista F, Gleason N, Martin E, Young JJ, Blum M, Neinstein AB. Design and development of referrals automation, a SMART on FHIR solution to improve patient access to specialty care. JAMIA Open 2020; 3:405-412. [PMID: 33215075 PMCID: PMC7660949 DOI: 10.1093/jamiaopen/ooaa036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background Referring patients to specialty care is an inefficient and error-prone process. Gaps in the referral process lead to delays in patients' access to care, negative patient experience, worse health outcomes, and increased operational costs. While implementation of standards-based electronic referral options can alleviate some of these inefficiencies, many referrals to tertiary and quaternary care centers continue to be sent via fax. Objective We describe the design process and architecture for a software application that has been developed and deployed to optimize the referrals intake process by automating the processing and digitization of incoming specialty referral faxes, extracting key data elements and integrating them into the electronic health record (EHR), and organizing referrals. Methods A human-centered design approach was used to identify and describe the inefficiencies in the external referral process at our large, urban tertiary care center. Referrals Automation, an application to convert referral faxes to digital referrals in the EHR, was conceptualized based on key stakeholder interviews and time and motion studies. This application was designed using Substitutable Medical Applications and Reusable Technologies (SMART) and Fast Healthcare Interoperability Resource (FHIR) platforms to allow for adaptability into other healthcare organizations. Results Referrals Automation software was developed as a healthcare information technology solution to streamline the fax to referral process. The application was implemented into several specialty clinics. Metrics were built-in to the applications to evaluate and guide the further iteration of these features. Conclusions Referrals Automation will enhance the referrals process by further streamlining and organizing the patient referral process.
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Affiliation(s)
- Anobel Y Odisho
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Urology, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Hansen Lui
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ramakrishna Yerramsetty
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Felicisimo Bautista
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Nathaniel Gleason
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Edwin Martin
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Jerry J Young
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Michael Blum
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aaron B Neinstein
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
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Cohen DJ, Wyte-Lake T, Dorr DA, Gold R, Holden RJ, Koopman RJ, Colasurdo J, Warren N. Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs. J Am Med Inform Assoc 2020; 27:690-699. [PMID: 32134456 PMCID: PMC7647291 DOI: 10.1093/jamia/ocaa010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs; and to propose principles for redesigning electronic health records (EHR) to address these needs. MATERIALS AND METHODS In this observational study, we interviewed and observed care teams in 9 community health centers in Oregon and Washington to understand their use of the EHR when caring for patients with complex medical and socioeconomic needs. Data were analyzed using a comparative approach to identify EHR users' information needs, which were then used to produce EHR design principles. RESULTS Analyses of > 300 hours of observations and 51 interviews identified 4 major categories of information needs related to: consistency of social determinants of health (SDH) documentation; SDH information prioritization and changes to this prioritization; initiation and follow-up of community resource referrals; and timely communication of SDH information. Within these categories were 10 unmet information needs to be addressed by EHR designers. We propose the following EHR design principles to address these needs: enhance the flexibility of EHR documentation workflows; expand the ability to exchange information within teams and between systems; balance innovation and standardization of health information technology systems; organize and simplify information displays; and prioritize and reduce information. CONCLUSION Developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. The identified information needs and design principles should inform developers and implementers working in community health centers and other settings where complex patients receive care.
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Affiliation(s)
- Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
| | - Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David A Dorr
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
| | - Rachel Gold
- Center for Health Research, Kaiser Permanente, Portland, Oregon, USA
- Department of Research, OCHIN Inc, Portland, Oregon, USA
| | - Richard J Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richelle J Koopman
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Joshua Colasurdo
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
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Lo YS, Yang CY, Chien HF, Chang SS, Lu CY, Chen RJ. Blockchain-Enabled iWellChain Framework Integration With the National Medical Referral System: Development and Usability Study. J Med Internet Res 2019; 21:e13563. [PMID: 31799935 PMCID: PMC6920914 DOI: 10.2196/13563] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/13/2019] [Accepted: 10/11/2019] [Indexed: 12/19/2022] Open
Abstract
Background Medical referral is the transfer of a patient’s care from one physician to another upon request. This process involves multiple steps that require provider-to-provider and provider-to-patient communication. In Taiwan, the National Health Insurance Administration (NHIA) has implemented a national medical referral (NMR) system, which encourages physicians to refer their patients to different health care facilities to reduce unnecessary hospital visits and the financial stress on the national health insurance. However, the NHIA’s NMR system is a government-based electronic medical referral service, and its referral data access and exchange are limited to authorized clinical professionals using their national health smart cards over the NHIA virtual private network. Therefore, this system lacks scalability and flexibility and cannot establish trusting relationships among patients, family doctors, and specialists. Objective To eliminate the existing restrictions of the NHIA’s NMR system, this study developed a scalable, flexible, and blockchain-enabled framework that leverages the NHIA’s NMR referral data to build an alliance-based medical referral service connecting health care facilities. Methods We developed a blockchain-enabled framework that can integrate patient referral data from the NHIA’s NMR system with electronic medical record (EMR) and electronic health record (EHR) data of hospitals and community-based clinics to establish an alliance-based medical referral service serving patients, clinics, and hospitals and improve the trust in relationships and transaction security. We also developed a blockchain-enabled personal health record decentralized app (DApp) based on our blockchain-enabled framework for patients to acquire their EMR and EHR data; DApp access logs were collected to assess patients’ behavior and investigate the acceptance of our personal authorization-controlled framework. Results The constructed iWellChain Framework was installed in an affiliated teaching hospital and four collaborative clinics. The framework renders all medical referral processes automatic and paperless and facilitates efficient NHIA reimbursements. In addition, the blockchain-enabled iWellChain DApp was distributed for patients to access and control their EMR and EHR data. Analysis of 3 months (September to December 2018) of access logs revealed that patients were highly interested in acquiring health data, especially those of laboratory test reports. Conclusions This study is a pioneer of blockchain applications for medical referral services, and the constructed framework and DApp have been applied practically in clinical settings. The iWellChain Framework has the scalability to deploy a blockchain environment effectively for health care facilities; the iWellChain DApp has potential for use with more patient-centered applications to collaborate with the industry and facilitate its adoption.
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Affiliation(s)
- Yu-Sheng Lo
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University Hospital, Taipei, Taiwan
| | - Cheng-Yi Yang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Hsiung-Fei Chien
- Preventive and Community Medicine Department, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shy-Shin Chang
- Preventive and Community Medicine Department, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Ying Lu
- Preventive and Community Medicine Department, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ray-Jade Chen
- Taipei Medical University Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Nabelsi V, Lévesque-Chouinard A, Liddy C, Dumas Pilon M. Improving the Referral Process, Timeliness, Effectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Study. JMIR Med Inform 2019; 7:e13354. [PMID: 31293239 PMCID: PMC6652123 DOI: 10.2196/13354] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/22/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Access to specialty care remains a major challenge in the Canadian health care system. Electronic consultation (eConsult) services allow primary care providers to seek specialist advice often without needing the patient to go for a face-to-face consultation. It improves overall access to specialists and the referral process using an electronic care consultation service in urban and rural primary care clinics. This study describes the preliminary results of a pilot study with an eConsult service across 3 regions in the province of Quebec, Canada. OBJECTIVE The main objective of this study was to provide a 1-year snapshot of the implementation of the eConsult Quebec Service in rural and urban primary care clinics to improve access to care and the specialty referral process for primary care providers (PCPs). METHODS We established an eConsult service that covers urban and rural communities in 3 regions of Quebec. We conducted a quantitative analysis of all eConsult cases submitted from July 4, 2017, to December 8, 2018. RESULTS For over a year, 1016 eConsults have been generated during the course of this study. A total of 97 PCPs submitted requests to 22 specialty groups and were answered by 40 different specialists. The most popular specialty was internal medicine (224/1016, 22%). Overall, 63% (640/1016) of completed cases did not require a face-to-face visit. PCPs rated the service as being of high or very high value for themselves in 98% (996/1016) of cases. CONCLUSIONS The preliminary data highlight the success of the implementation of the eConsult Quebec Service across 6 primary care clinics. The eConsult platform proves to be effective, efficient, and well received by both patients and physicians. If used more widely, eConsult could help reducing wait times significantly. Recently, the Ministry of Health and Social Services of Quebec has identified developing a strategic plan to scale eConsults throughout other regions of the province as a top priority.
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Affiliation(s)
- Véronique Nabelsi
- Département des Sciences Administratives, Université du Québec en Outaouais, Gatineau, QC, Canada
| | - Annabelle Lévesque-Chouinard
- Groupe de Médecine de Famille Universitaires de Gatineau du Centre Intégré de Santé et des Services Sociaux de l'Outaouais, Gatineau, QC, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, ON, Canada.,CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Maxine Dumas Pilon
- Department of Family Medicine, McGill University, Montréal, QC, Canada.,Collège Québécois des Médecins de Famille, Montréal, QC, Canada
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