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Digital technology offers several opportunities to improve access to professional expertise in primary care, and the offer of various “virtual” services has exploded in the past few years. The aim of this study was to evaluate the implementation of a direct-to-consumer on-line pharmacy consultation service (Ask Your Pharmacist - AYP) to a universal phone consultation service led by the universal public health system in Quebec (811 Info-Santé), through a direct bridge. Semi-structured interviews were conducted with clinician users of the service, and stakeholders involved in this pilot project funded by the Ministry of Economy (n = 22); documents were also analyzed, and content of the question was asked through the AYP service. Adoption of the service was low, and it suggests a poor alignment between the need and the service as implemented. Further research should investigate the mechanisms for an appropriate integration of digital services for primary care universal consultation services.

Type 2 diabetes is a complex chronic disease that requires ongoing monitoring by an interprofessional team to prevent complications. The INMED (INterprofessional Management and Education in Diabetes) care pathway was developed by our team to optimize primary care services for these patients and their families. The objective of this study is to describe the preliminary results of its adoption and implementation. The INMED care pathway is organized into four axes: (a) continuing professional education, (b) self-management support, (c) case management, and (d) ongoing evaluation of the quality of diabetes care and services. A multiple-case study is underway to document its effects on practice change using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Preliminary results on the adoption and implementation revealed some strengths: (a) regular patient follow-up by the case manager, (b) scheduling of physician appointments when required, and (c) regular screening for risk factors. Barriers were also identified: (a) lack of clear understanding of the case manager role, (b) lack of referrals to team members, and (c) lack of use of the motivational interview approach. The INMED care pathway is being adopted by primary care teams but challenges need to be overcome to improve its reach and effectiveness.

Supplemental Digital Content is available in the text., Background: Given the wide range of uses for antidepressants, understanding indication-specific patterns of prescription filling for antidepressants provide valuable insights into how patients use these medications in real-world settings. Objective: The objective of this study was to determine the association of antidepressant prescription filling with treatment indication, as well as prior prescription filling behaviors and medication experiences. Design: This retrospective cohort study took place in Quebec, Canada. Participants: Adults with public drug insurance prescribed antidepressants using MOXXI (Medical Office of the XXIst Century)—an electronic prescribing system requiring primary care physicians to document treatment indications and reasons for prescription stops or changes. Measures: MOXXI provided information on treatment indications, past prescriptions, and prior medication experiences (treatment ineffectiveness and adverse drug reactions). Linked claims data provided information on dispensed medications and other patient-related factors. Multivariable logistic regression models estimated the independent association of not filling an antidepressant prescription (within 90 d) with treatment indication and patients’ prior prescription filling behaviors and medication experiences. Results: Among 38,751 prescriptions, the prevalence of unfilled prescriptions for new and ongoing antidepressant therapy was 34.2% and 4.1%, respectively. Compared with depression, odds of not filling an antidepressant prescription varied from 0.74 to 1.57 by indication and therapy status. The odds of not filling an antidepressant prescription was higher among adults filling

The objective of this study was to describe and assess the quality of the direct-to-consumer medical teleconsultation landscape in three Canadian provinces. An environmental scan of primary care teleconsultation platforms was conducted in January 2022 to identify medical teleconsultation platforms in Quebec (Qc), Ontario, and British Columbia (BC). The quality of each teleconsultation platform was assessed using a modified version of the HONcode principles. Nineteen different direct-to-consumer medical teleconsultation platforms were identified across the three provinces. The quality of these teleconsultation platforms was very heterogeneous. The landscape of virtual primary care is changing rapidly in the Canadian ecosystem, and the transparency of current teleconsultation platforms could be improved.

IntroductionAttachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients’ barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec’s 18 administrative regions to implement single points of access for unattached patients (Guichets d’accès première ligne(GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients’ experiences of navigation, access and service utilisation.Methods and analysisA longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients’ experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases.Ethics and disseminationThis study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l’innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

PurposeArtificial intelligence (AI) raises many expectations regarding its ability to profoundly transform health care delivery. There is an abundant literature on the technical performance of AI applications in many clinical fields (e.g. radiology, ophthalmology). This article aims to bring forward the importance of studying organizational readiness to integrate AI into health care delivery.Design/methodology/approachThe reflection is based on our experience in digital health technologies, diffusion of innovations and healthcare organizations and systems. It provides insights into why and how organizational readiness should be carefully considered.FindingsAs an important step to ensure successful integration of AI and avoid unnecessary investments and costly failures, better consideration should be given to: (1) Needs and added-value assessment; (2) Workplace readiness: stakeholder acceptance and engagement; (3) Technology-organization alignment assessment and (4) Business plan: financing and investments. In summary, decision-makers and technology promoters should better address the complexity of AI and understand the systemic challenges raised by its implementation in healthcare organizations and systems.Originality/valueFew studies have focused on the organizational issues raised by the integration of AI into clinical routine. The current context is marked by a perplexing gap between the willingness of decision-makers and technology promoters to capitalize on AI applications to improve health care delivery and the reality on the ground, where it is difficult to initiate the changes needed to realize their full benefits while avoiding their negative impacts.

This paper describes the development and evaluation of a Canadian drug ontology (OCRx), built to provide a normalized and standardized description of drugs that are authorized to be marketed in Canada. OCRx aims to improve the usability and interoperability of drugs terminologies for a non-ambiguous access to drugs information that is available in electronic health record systems. We present the first release of OCRx that is described in Web Ontology Language and aligned to the Identification of Medicinal Product (IDMP) standards. For comparison purposes, OCRx is mapped to RxNorm, its US variant.

The Centre Hospitalier Universitaire Sainte-Justine (Montreal, Canada) is a pediatric academic tertiary hospital that has begun the implementation of a commercial computerized provider order entry system (CPOE) in October 2019. The objectives of this paper are 1) to estimate the impact of the CPOE system on medication errors, and 2) to identify vulnerability issues related to the configuration of the CPOE system’s design. Using a pre-post implementation methodology measuring medication errors captured by clinical pharmacists revealed that the implementation of a CPOE has eliminated all prescription conformity (e.g., missing fields) and legibility errors. Pharmacists have continued to detect medication errors, especially inappropriate dosing instructions, and to intervene in similar clinical situations (medication reconciliation, deprescribing, adjusting orders). Additionally, the vulnerability analysis, based on typical clinical order test cases in an inpatient pediatric setting, highlighted the need to configure a clinical decision support system that can identify inappropriate dosing instructions for pediatric patients.

Timely access to care is a persistent challenge for health care systems. Providing the right care to the right patient at the right time is important to reduce inappropriate use and improve the performance of healthcare services. The complexity of accessing primary care contributes to the high usage of emergency rooms for not-urgent conditions. Many digital tools try to offer a better access to care for patients and reduce ER overuse. This environmental scan of the digital tools available in Quebec identifies those digital tools and some of their limitations. The results reveal the complexity of mobilizing digital tools in the healthcare sector and highlight the need for all stakeholders to work together to enhance access to care.

Timely access to care is a persistent challenge for health care systems. Providing the right care to the right patient at the right time is important to reduce inappropriate use and improve the performance of healthcare services. The complexity of accessing primary care contributes to the high usage of emergency rooms for not-urgent conditions. Many digital tools try to offer a better access to care for patients and reduce ER overuse. This environmental scan of the digital tools available in Quebec identifies those digital tools and some of their limitations. The results reveal the complexity of mobilizing digital tools in the healthcare sector and highlight the need for all stakeholders to work together to enhance access to care.

This paper describes the development and evaluation of a Canadian drug ontology (OCRx), built to provide a normalized and standardized description of drugs that are authorized to be marketed in Canada. OCRx aims to improve the usability and interoperability of drugs terminologies for a non-ambiguous access to drugs information that is available in electronic health record systems. We present the first release of OCRx that is described in Web Ontology Language and aligned to the Identification of Medicinal Product (IDMP) standards. For comparison purposes, OCRx is mapped to RxNorm, its US variant.

Artificial intelligence in general, and machine learning (ML) techniques in particular, hold the promise of enormous benefits to medication management, both in the hospital or in the community setting. The potential of ML techniques to support the decision making of patients, clinicians, managers and/or policy-makers is massive. However, the learning will only be as good as the data, and the frame problem around medication is still to be addressed. While ML techniques offer a promising response to the various challenges in medication management, their implementation to help daily care faces many barriers. Data quality is key and must be improved, specifically at the point of capture (standardized data, shared data model, etc.), not only in electronic health records but also for all health-related information (e.g., home electronics). In addition, to fully exploit the potential of ML techniques in medication management, specific challenges need to be addressed to ensure that the tools based on these techniques are effective and can be deployed in daily care. This chapter will present key challenges that must be faced in the development and implementation of ML algorithms for medication management, specifically to estimate exposition to medication, as well as positive and negative outcomes associated with such exposition. Finding ways to describe and include the variability of exposure, and the uncertainty of reactions as part of the development of algorithms will be crucial to make sure the potential can unravel both at the individual and population level.

The development of artificial intelligence (AI) systems to support diagnostic decision-making is rapidly expanding in health care. However, important challenges remain in executing algorithmic systems at the frontlines of clinical practice. Hence, most often, these systems have not been trained with local data nor do they fit with context-specific patterns of care. This research examines the implementation of an AI-based decision support system (DSS) in the emergency department of a large Academic Health Center (AHC) in Canada, focusing specifically on the question of end-user adoption. Based in an interpretative perspective, the study analyzes the perceptions of healthcare managers, AI developers, physicians and nurses on the DSS, so as to make sense of the main barriers to its adoption by emergency physicians. The study points to the importance of considering interconnections between technical, human and organizational factors to better grasp the unique challenges raised by AI systems in health care. It further emphasizes the need to investigate actors' perceptions of AI in order to develop strategies to adequately test and adapt AI systems, and ensure that they meet the needs of health professionals and patients. This research is particularly relevant at a time when considerable investments are being made to develop and deploy AI-based systems in health care. Empirically probing the conditions under which AI-based systems can effectively be integrated into processes and workflow is essential for maximizing the benefits these investments can bring to the organization and delivery of care.

Multimorbidity increases care needs among people with chronic diseases. In order to support communication between patients, their informal caregivers and their healthcare teams, we developed CONCERTO+, a patient portal for chronic disease management in primary care. A user-centered design comprising 3 iterations with patients and informal caregivers was performed. Clinicians were also invited to provide feedback on the feasibility of the solution. Several improvements were brought to CONCERTO+, and it is now ready to be implemented in real-life setting.

Objectives Multimorbidity increases care needs and primary care use among people with chronic diseases. The Concerto Health Program (CHP) has been developed to optimise chronic disease management in primary care services. However, in its current version, the CHP primarily targets clinicians and does not aim to answer directly the needs of individual patients and their informal caregivers. This study aims to develop, implement and evaluate a user-centered, multifunctional and personalised eHealth platform (CONCERTO+) to promote a more active patient role in chronic disease management and decision-making. Method This ongoing project uses a collaborative research approach and has 3 major phases: 1) the development of a multi-module eHealth platform combining scientific evidence and user-centered design; 2) a feasibility study of the CONCERTO+ solution through a pilot cluster randomised controlled trial where patients with multiple chronic diseases from a primary healthcare practice will receive CONCERTO+ during 6 months and be compared to patients from a control practice receiving usual care; and 3) an analysis of CONCERTO+ potential for scaling up. Results The first phase of the project was the development of the user-centered solution. A first prototype was developed in Fall 2018 and tested with 10 patients and caregivers. Their comments led us to develop a second prototype that was tested with 10 patients and caregivers in Spring 2019. Following these 2 iterations, a final version of CONCERTO+ was developed and integrated to a large eHealth portal that enables information exchange and communication between health care providers and patients. The next phase, which consists of a pilot trial with diabetic patients followed in primary care practices, is ongoing. Conclusions Digital health solutions such as patient portals have been found to improve self-management for chronic care conditions. By fostering a more active role of patients, it is hypothesised that a solution like CONCERTO+ could optimise the use of health care services and decrease emergency visits.

Background and Objective Many countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx. Methods The prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial. Results Users identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P Conclusion High rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

Background Admission to hospital provides the opportunity to review patient medications; however, the extent to which the safety of drug regimens changes after hospitalization is unclear. Objective To estimate the number of potentially inappropriate medications (PIMs) prescribed to patients at hospital discharge and their association with the risk of adverse events 30 days after discharge. Design Prospective cohort study. Setting Tertiary care hospitals within the McGill University Health Centre Network in Montreal, Quebec, Canada. Participants Patients from internal medicine, cardiac, and thoracic surgery, aged 65 years and older, admitted between October 2014 and November 2016. Measures Abstracted chart data were linked to provincial health databases. PIMs were identified using AGS (American Geriatrics Society) Beers Criteria®, STOPP, and Choosing Wisely statements. Multivariable logistic regression and Cox models were used to assess the association between PIMs and adverse events. Results Of 2,402 included patients, 1,381 (57%) were male; median age was 76 years (interquartile range [IQR] = 70-82 years); and eight discharge medications were prescribed (IQR = 2-8). A total of 1,576 (66%) patients were prescribed at least one PIM at discharge; 1,176 (49%) continued a PIM from prior to admission, and 755 (31%) were prescribed at least one new PIM. In the 30 days after discharge, 218 (9%) experienced an adverse drug event (ADE) and 862 (36%) visited the emergency department (ED), were rehospitalized, or died. After adjustment, each additional new PIM and continued community PIM were respectively associated with a 21% (odds ratio [OR] = 1.21; 95% confidence interval [CI] = 1.01-1.45) and a 10% (OR = 1.10; 95% CI = 1.01-1.21) increased odds of ADEs. They were also respectively associated with a 13% (hazard ratio [HR] = 1.13; 95% CI = 1.03-1.26) and a 5% (HR = 1.05; 95% CI = 1.00-1.10) increased risk of ED visits, rehospitalization, and death. Conclusions Two in three hospitalized patients were prescribed a PIM at discharge, and increasing numbers of PIMs were associated with an increased risk of ADEs and all-cause adverse events. Improving hospital prescribing practices may reduce the frequency of PIMs and associated adverse events. J Am Geriatr Soc 68:1184-1192, 2020.

Over 3 million hospitalizations and 17 million ER visits occur in Canada each year. A substantial proportion of these encounters are preventable and attributable to medication non- adherence. Non-adherence to medication changes during discharge increases the risk of adverse events post-discharge. A mobile application was developed to improve medication management of post-discharge patients. A pilot randomized controlled trial was conducted to assess the application's usability and efficacy in decreasing non-adherence to medication changes made at discharge.

In this study, we sought to develop an automatic parser tool for unstructured free-text electronic prescriptions, focusing specifically on defining the daily dose. We manually coded a set of electronic discharge prescriptions and established the most reliable rules to structure the medication data. A named-entity recognition (NER) parser tool was implemented, which was capable of identifying 90% of the doses and 86% of the frequencies from 255 dosage instructions.

Health information exchange (HIE) is implemented in Quebec, Canada to improve the exchange and use of clinical information for decision making in the province's health care system. The objective of this mixed-method approach study was to evaluate the usage, usability, and usefulness of an electronic health record (EHR) to access and import clinical information from a centralized HIE. First, a heuristic analysis was performed of three different commercial EHRs, using end users to analyze the integration feature through think aloud protocols. Second, interviews were conducted with advanced users to describe the usefulness. Third, usage data were analyzed to describe the level of use of each data domain, per EHR and user. The results show that usefulness is high for medication data; leading to greater use of this domain, its relation to integration, and meets the needs of general practitioners. Difficulties in the implementation processes reduced the potential of this system.

Health information exchange (HIE) is seen as an essential technology for improving health care quality and efficiency by allowing exchange of patient-centered data over time and across organizations. The objective of this study was to evaluate the usage and the perceived usefulness of a nationwide HIE in a centralized model that was implemented in 2013 in the province of Quebec, Canada. A mixed-method study was conducted with a longitudinal descriptive analysis of usage data combined with in-depth comparative case study in four selected primary care organizations and two emergency departments. Perceived benefits were reported by users across all dimensions of care performance, including accessibility, efficiency, quality and safety, and patient experience; however, the experience of users was very heterogeneous and strongly associated with the commercial electronic record system available in their work place and the implementation strategy.

Electronic prescribing, defined as the electronic generation and transmission of a medication order for community-dwelling patients, is presented as an essential technology to improve medication use. The objective of this study was to evaluate a nationwide e-prescribing system in Quebec, Canada. A mixed-method study was conducted from July 2017 until June 2018. A descriptive analysis of e-prescription usage was performed using aggregated usage data, combined with an exploratory descriptive analysis of the e-prescribing system from the perspective of users of two electronic health records (EHR) and pharmacy management systems (PMS) (n=9 prescribers; 8 pharmacy technicians and 11 pharmacists). Overall, the adoption of the system was low, with only 2% of prescriptions being electronically transmitted and retrieved during the study period. Alignment problems were identified on the prescriber's and receiver's side, generating safety issues, and hindering the potential for benefits realization.