Overcoming Challenges to Adoption of Shared Medical Appointments

1 Essential Anthropology , San Jose, California.
Population Health Management (Impact Factor: 1.51). 10/2013; 17(2). DOI: 10.1089/pop.2013.0035
Source: PubMed


Abstract Although research has shown many benefits of Shared Medical Appointments (SMAs) or group visits, uptake by physicians has been quite limited. The objective of this study was to explore the facilitators and barriers to implementing SMAs in a large multispecialty medical group. This was a comparative analysis of SMAs at 3 geographically distinct, semiautonomous divisions of the medical group based on qualitative themes identified in audio recorded key informant interviews with medical and administrative staff (n=12) involved with the implementation of SMAs. Data were collected by conducting key informant interviews focusing on the SMA implementation process, including motivations, history, barriers, and facilitators. Uptake at the 3 divisions was predicated by differing motivations, facilitators, and barriers. Divisions 1 and 2 allocated necessary resources including management support, a physician champion, expert consults, and support staff. These divisions also overcame physician reluctance and financial sustainability challenges. Despite early interest, Division 3 did not devote the time or resources to overcome initial resistance. Without the impetus of management mandate or a champion's enthusiasm, early attempts of SMA implementation faltered and were abandoned. In these cases, a physician champion, management support, and financial sustainability were judged to be the primary enablers of successful implementations of SMAs. Without these enablers and other contributing factors, implementing SMAs was challenging. (Population Health Management 2013; XX:XXX-XXX).


Available from: Dominick L Frosch, Aug 15, 2015
Overcoming Challenges to Adoption
of Shared Medical Appointments
Mary Honodel McCuistion, MA,
Cheryl D. Stults, PhD,
Daniel Dohan, PhD,
Dominick L. Frosch, PhD,
Dorothy Y. Hung, PhD, MA, MPH,
and Ming Tai-Seale, PhD, MPH
Although research has shown many benefits of Shared Medical Appointments (SMAs) or group visits, uptake
by physicians has been quite limited. The objective of this study was to explore the facilitators and barriers to
implementing SMAs in a large multispecialty medical group. This was a comparative analysis of SMAs at 3
geographically distinct, semiautonomous divisions of the medical group based on qualitative themes identified
in audio recorded key informant interviews with medical and administrative staff (n = 12) involved with the
implementation of SMAs. Data were collected by conducting key informant interviews focusing on the SMA
implementation process, including motivations, history, barriers, and facilitators. Uptake at the 3 divisions was
predicated by differing motivations, facilitators, and barriers. Divisions 1 and 2 allocated necessary resources
including management support, a physician champion, expert consults, and support staff. These divisions also
overcame physician reluctance and financial sustainability challenges. Despite early interest, Division 3 did not
devote the time or resources to overcome initial resistance. Without the impetus of management mandate or a
champion’s enthusiasm, early attempts of SMA implementation faltered and were abandoned. In these cases, a
physician champion, management support, and financial sustainability were judged to be the primary ena blers
of successful implementations of SMAs. Without these enablers and other contributing factors, implementing
SMAs was challenging. (Population Health Management 2014;17:100–105)
roup visits or shared medical appointments (SMAs)
show benefits over traditional physician-patient con-
including improved access,
reduced costs,
increased patient and physician satisfaction,
and im-
proved clinical outcomes such as reduced HbA1c
and blood
weight loss,
and fewer hospital admissions.
The American Academy of Family Physicians reported that
the percentage of family physicians who use some form of
group care had doubled from 6% in 2005 to 13% in 2010.
Carrier and Reschovsky estimated that in 2008 approximately
20% of primary care physicians offered group visits.
percentages suggest that the vast majority of primary care
providers have not yet adopted SMAs, raising questions as to
how this model of providing care can be disseminated and
implemented more broadly.
Although only implemented in small numbers, SMAs
have been applauded as an innovation with the potential to
improve health,
but little attention has focused on how
barriers may impede wider acceptance and how these chal-
lenges may be overcome. Kirsh and colleagues
posit that
physicians have been slow to adopt group visits because
SMAs involve major system redesign to accommodate new
workflows and collaborative relationships. Further, physi-
cians may fear that referring their patients to SMA providers
may disrupt their physician–patient relationship.
SMAs also
require providers to practice differently from their usual
clinical routines, using new modes of interacting with pa-
tients. Furthermore, some physicians may be concerned
about the quality of care they can provide in a group setting.
Lastly, there is no Current Procedural Terminology code for
SMAs, although it is billable depending on level of docu-
mentation and patient complexity.
Essential Anthropology, San Jose, California.
Palo Alto Medical Foundation Research Institute, Mountain View, California.
Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California.
Department of Medicine, University of California Los Angeles, Los Angeles, California.
Gordon & Betty Moore Foundation, Palo Alto, California.
Volume 17, Number 2, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/pop.2013.0035
Page 1
These challenges raise the issue of how to address resis-
tance to widespread adoption of SMAs and what kinds of
disruptions, if any, SMAs bring to medical practice. To date,
however, little empirical research has examined these
As part of a larger mixed-methods project studying the
implementation of components of patient-centered medical
homes, the authors examined the deployment and execution
of shared medical appointments at 3 semiautonomous divi-
sions of a large multidisciplinary medical group. This study
sought to understand the challenges and facilitators to in-
stituting SMAs in a community-based, nonacademic clinic
setting. This article offers an examination of 3 case studies of
SMA implementation to shed light on necessary facilitators
and how barriers can be overcome to potentially increase
SMA uptake in other health care delivery organizations.
The setting is a large, nonprofit, multispecialty medical
group practice in Northern California. The group includes 3
divisions, 2 of which have offered SMAs since early 2000.
The third division tried SMAs for a brief time but chose not
to continue them. The 2 divisions that offer SMA programs
differed in many respects, including patient demographics
and motivations, facilitators, barriers, and resources for
SMAs. Drawing contrasts with the unsuccessful im-
plementation process at the third division allows consider-
ation of which factors may be necessary to embed SMAs into
This physician-led practice underwent a merger in 2008,
changing what had been a loose affiliation of relatively au-
tonomous medical groups into a more centralized practice
comprising 3 divisions. Combined, the group employs about
1000 physicians with a payer mix of approximately 80% fee
for service and 20% capitated. With this background and
demographic information as backdrop, the 3 divisions in-
dependently developed SMA programs and ultimately chose
their level of commitment to SMAs.
Research team
The multidisciplinary research team consisted of 2 soci-
ologists (DD, CS), an anthropologist (MHM), 2 health ser-
vices researchers (MTS, DH), and a health psychologist (DF),
all of whom have extensive experience conducting qualita-
tive studies.
Data were collected from 2010 to 2011 by conducting 12,
Institutional Review Board approved, key informant inter-
views with medical and administrative staff regarding the
SMA implementation motivations, history, barriers, and fa-
cilitators. The interviews were conducted by one of the lead
interviewers (MHM, MTS, or DD) and, generally, another
member of the team. Participants were chosen purposively
from among administrative and clinical staff for their
knowledge of SMA implementation and to provide a cross-
divisional perspective. No compensation was offered. The
purpose of these interviews was to provide context and
background for the SMAs. Written informed consent was
secured and the interviews were audio recorded, profes-
sionally transcribed, and de-identified.
To facilitate analysis, all transcripts were entered into
ATLAS.ti version 6.2 (ATLAS.ti Scientific Software Devel-
opment GmbH, Berlin, Germany). The study team met bi-
weekly to discuss study progress, sampling, and emergent
themes. A codebook was created based on the study aims
and modified iteratively based on input from the coders and
project team. Transcripts were coded at the paragraph level
and analyzed thematically. Reports were created that were
then summarized by themes or area of interest and distrib-
uted to the team for further in-depth analysis. Disagreements
regarding coding were discussed until consensus was
reached. Pseudonyms were used to maintain anonymity.
The road to SMA
The key informants revealed how 3 divisions indepen-
dently implemented or attempted to implement SMAs with
very different motivations, deployment processes, and results.
Division 1 was motivated by the need to address patient ac-
cess challenges and decided to hire a nationally known SMA
expert to design the implementation. Division 2’s SMA history
has 2 stages. It started with the desire of a few physicians to
provide better care, and operated for 10 years with no addi-
tional resources for their efforts. A few years after the merger,
a pilot program allowed the physician champion to expand
SMA offerings. This study’s analysis of Division 2 distin-
guishes between these initial efforts and the formal program
that followed. Conversely, Division 3 made limited attempts
to implement SMAs. In the absence of management support
and lacking a physician champion, early efforts dissolved.
Division 1: Creating access, acclimating physicians,
balancing costs
Implementation motivators and facilitators. In 2000, Di-
vision 1, located at the northern edge of the medical group’s
service area, was concerned about access. ‘People could not
get an appointment with their physician,’ an SMA coordi-
nator recalled. The physician who championed the innova-
tion added,
‘The motivation at that time really was about im-
proving access because this was before we did our big
initiative on going to same-day access. So it was a re-
ally nice tool that helped patients get in more quickly.’
Encouraged by the physician champion and with upper
management support, the first SMA was held by a rheu-
matologist. A few years later, as the pressure to improve
access increased, an SMA expert (Ed Noffsinger) was hired
as a consultant. A staff primary care physician was recruited
to help reduce the backlog of periodic health exams (ie,
physicals) for men. The coordinator recalled that, ‘something
like 460 male physicals.[were] clogging the books.[The
primary care physician] worked them down.’
Barriers. Before the SMA program could expand at Di-
vision 1, several barriers needed to be overcome. Physicians
Page 2
resisted the idea of leading a group visit because they would
‘feel like a talk show host,’ as one manager told us. Another
difficulty was recruiting enough patients from their panel to
populate an SMA. A manager informant related, ‘‘Some
of the physicians were concerned that they might lose a
However, physicians could see the value of referring their
patients to language- and culture-specific SMAs. An ad-
ministrator recalled that physicians understood they ‘don’t
speak Spanish. It would be better if they go to the SMA.
Everybody in there speaks Spanish and shares things in
Spanish.’ The idea of sharing cultural experiences facilitated
general physician acceptance of SMAs. The administrator
explained that, ‘they’re willing to let their patients go; so
they can just put in a referral’ and patient attrition was no
greater than what already occurred with specialist referrals.
Finances. SMAs had to cover administrative and clinical
staff expenses. The medical group approached the issue of
administrative staff costs by incorporating their time into
the price of overhead. Initially there were additional im-
plementation costs. As an administrator described, ‘They
had a [SMA] project manager who was working on getting
everything together. There was a lot more outreach and
marketing at the very beginning. She went on to say that,
‘Over the years we’ve just trimmed, trimmed, trimmed,
trimmed until we had [support staff costs] down to the bare
bones.’ One of the ways that management kept costs down
was to give the jobs of recruiting SMA patients to reception-
ists. A senior administrator explained, ‘Now that’s all rote
and it’s now frontline clerical people who can maintain that.’
The clinical staff costs also needed to be addressed as the
chief executive officer mandated that SMAs be budget neu-
tral. Finding the right number of participants to balance costs
of additional support (eg, a behaviorist with a master’s de-
gree) proved challenging. After watching profit and loss
figures for about 2 years, the chief financial officer arrived at
the formula for budget neutrality: (1) determine the physi-
cian’s usual number of patient appointments for the time of
the SMA, (2) double the number of patients participating in
the SMA. The coordinator further explained that if the phy-
sician, ‘[could] see two patients in an hour.his goal is to see
four patients every SMA.’
Resources. In addition to finding the optimum financial
model, Division 1 had 2 resources that contributed to es-
tablishing SMAs: behaviorists, medical assistants (MAs), and
dedicated SMA rooms. The behaviorist and MAs are present
to help the physician SMA leader manage charting, take vital
signs, and address psychosocial issues. The behaviorists fill
an important role in Division 1 SMAs by managing patient
conversations. The coordinator described this task as,
‘Sometimes because one person could go on the whole time
about this, and then what about this?’ In these cases, the
behaviorist functions as the moderator or, ‘Truly the traffic
cop, and just kindly telling people, ‘You’ve had your turn.
Now, we need to move on.’ Another important role is
complementing the physician’s effort to ‘smooth’ things out
(eg, the behaviorist would say to a patient, ‘Okay, so you ate
a bag of potato chips. That’s probably not the best choice.
Can you tell me a little bit about what prompted you, or why
you felt like you.’) which built a bridge to discuss psy-
chosocial issues. The division leadership dedicated 2 suites
for SMAs—large group meeting rooms and attached private
examination rooms—removing any scheduling conflicts or
space issues.
Results. With the assistance of an enthusiastic support
staff, including a full-time administrative coordinator, a half-
time program coordinator, and a part-time lead behaviorist,
Division 1’s SMAs expanded to include topics like diabetes
management, newborn baby well checks, bariatric therapy,
congestive heart failure support, general dermatology, psy-
chiatric medicine, and successful aging.
Division 2: Better patient care, increased support
from management
Implementation motivators and facilitators. In about
2001, a few physicians began offering educational-style
group visits with foci such as chronic pain management and
heart disease prevention. One family practice physician in
particular wanted to provide ‘better quality of care.’ With
no support from management, he struggled to recruit en-
ough patients to fill his pain management classes. Referring
to those early days he noted, ‘I had been doing this for 10
years on my own just because I believed in it. I had very little
help. It was all a struggle.’’
At Division 2 in early 2010, only the family practice phy-
sician was still offering regular group appointments. One of
the other early adopter physicians, also an administrator,
told us, ‘In the past year or so, I’ve only done a couple
because of.inertia—no other reason.’ However, he believed
in the concept of SMAs and pushed for a management
commitment of resources. Division 2 management decided
to start an SMA pilot program to expand the limited existing
efforts. The pioneering family physician agreed to champion
the pilot and was introduced to the work of one of the
founders of SMAs: Ed Noffsinger. He recalled his excitement
at finding another framework for a group visit,
‘I read the entire book [Noffsinger’s Running Group
Visits in Your Practice
], had the opportunity to meet
with Ed Noffsinger, and really get an idea of how this
can be better organized. And it could better serve the
patient’s needs than how I had been doing it.’
With this new knowledge, he continued as the lone physician
offering SMAs at Division 2; however he now had manage-
ment support and resources at his disposal.
Barriers. Before 2009, physicians faced a lack of support
and resources, which limited implementation of SMAs. The
physician champion reported few barriers to implementing
and increasing the use of SMAs in the pilot program. He
mentioned that schedulers sometimes forgot to mention the
SMA option to patients. His solution was to invite schedulers
to attend an SMA. This approach seemed to help but re-
ceptionists remembering ‘remains a somewhat limiting fac-
tor.’ Although he was comfortable with the group visit
format, ‘I have a lot of confidence in my ability to take a
group of 15 people and have it run efficiently and engage
people,’ he conceded that, ‘other physicians may feel lack-
ing in that one particular area.’’ He also was comfortable
working with MAs and without the help of a behaviorist,
Page 3
although he admitted that he was unable to complete his
notes during the SMA and had to finish them later.
Finances. For both stages at Division 2, financing SMAs
was less of a barrier. The physician champion arranged and
offered SMAs without management support, so there was no
additional staff to finance. Later, with his experience as a
teacher, the champion felt he did not require the added ex-
pense of a behaviorist. Therefore, as a physician adminis-
trator told us, ‘If you get more than six [patients], it pencils
out as being positive on the cost side, even with two MAs,
because the hourly cost of a medical assistant is very mini-
mal.’ Still, the champion expressed that possible financial
benefit was not a motivator:
‘The key point that I would make is the revenue is a
secondary or added benefit to what we perceive as a
better quality of care. I really believe that in almost all
the groups that I do, people are walking away feeling
like their health care needs are better met.’
Resources. Physicians were not provided with any re-
sources from management. During the development stage of
the pilot, Division 2 management struggled with how much
support to provide the SMA champion. A physician ad-
ministrator recalled thinking, ‘‘We can’t hire 20 or 30 [med-
ical assistants] to be calling people into 20 or 30 shared
medical appointments every week. That won’t work.’
Management finally settled on 1 coordinator as administra-
tive support staff. An energetic individual, she ensured that a
sufficient number of patients attended the SMAs. Additional
resources included use of a conference room in the main
clinic with private examination rooms in an adjacent de-
partment. The champion was assigned MAs and nurse
practitioners to ensure an efficient and productive appoint-
ment for patients and provider.
Results. Overcoming small challenges, motivated by
Noffsinger’s approach, and with the support of his coordi-
nator maintaining ample patient participation, the champion
has had well-attended men’s physical, pain management,
and cardiovascular risk reduction SMAs. Given patient sat-
isfaction ratings along with encouragement from the new
coordinator and upper-level management, 5 other physicians
have begun conducting SMAs for diabetes management
and bariatric surgery.
Division 3: Too many barriers, not enough
motivators = short-lived attempt
Implementation motivators and facilitators. At Division
3, an administrator related that her introduction to SMAs
came from a presentation and that her reaction was positive,
‘I remember going somewhere with [the medical director]
and him talking about it. We went and saw a presentation
and we got all excited about it.’ When he tried to bring the
idea back to the management at Division 3, she explained
‘I think he went to a couple of internal med meetings
or whatever the meetings were and it just sort of fell
flat, and I’m not sure why. Even with all the redesign
of the primary care design work that’s being done, it’s
not been something that’s been brought up as some-
thing to explore. I don’t think anybody said it won’t
work, I just don’t think anybody was particularly in-
terested in doing it that way.’
Barriers. The Division 1 coordinator reached out to Di-
vision 3 to offer them support in building their own SMA
program. The Division 1 coordinator recalled, ‘They weren’t
interested.’ The lack of interest from physicians, limited
management support, no physician champion, and patient
resistance resulted in little effort funneled into SMA im-
Exploring this reluctance, it appears that Division 3 did
offer SMAs for a brief time. One administrator told us that,
‘We tried it in sleep [medicine].we hired a nurse practi-
tioner who was going to help people with the use of the
CPAP [continuous positive airway pressure] machine. At the
same time, the doctor was going to see patients to actually
use the machine.’ Unfortunately, the patients were resistant,
‘We actually couldn’t get them all in the same room for that;
they didn’t want to do that.’ She also admitted that, ‘We
may not have given it everything it needed.’ However, the
consensus was that, ‘It was clunky; it just didn’t make sense
to do it the way we had thought it would work.’ She reit-
erated that, ‘Patients didn’t respond to that group setting.’
Neither did physicians or administrators. Our informant
administrator at Division 3 mused, ‘No one has ever come to
me or any of the directors that I know of and said, ‘I really
think this would work in this particular situation.’ Because
physicians weren’t promoting group visits, administration
saw no need to press for them, ‘‘We haven’t driven it from an
operations perspective, and I haven’t heard the physician
requesting it or seeing where the value might be even.’ She
admitted that, ‘‘I’ve watched videos of them, and I’ve seen it,
and I’ve thought that there was real value for certain
things.but it’s not been [adopted].’
A physician administrator elaborated that lack of a phy-
sician champion further hampered SMA uptake,
‘I think [the top-level administrator’s] personal feeling
around this was if he didn’t have somebody who really
had passion for it, he didn’t think it was worthwhile to
try telling somebody to make it happen. He couldn’t
really get anybody to bite with either the shared
medical appointments or any of these other programs.
SMA acceptance at Division 3 was stymied by the lack of
administrator and physician interest, making it unlikely that
a physician champion would take on responsibility for SMA
Finances. Division 3 administrators saw no financial
benefits to implementing SMAs. In fact, an administrator
informant told us, ‘I think the reimbursement right now
definitely favors one on one.’ She allowed that, ‘As time goes
on and we start to look at a number of ways to spread our
resources more effectively and manage larger populations of
people with the same resources, [SMA use] may come up
again as something that we should at least be evaluating.’
Results. With no support from management, no stress-
ors from physicians or patients, and no physician champion,
Page 4
at of the time of the present study, no efforts were made to
investigate the possibility of offering SMAs. Although ad-
ministrators conceded that something like a group visit
could someday have value, there were no compelling moti-
vators or financial incentives to propel SMAs beyond the
uncomfortable initial hurdles.
Data from interviews with key informants illustrated how
3 medical divisions of a large multidisciplinary practice
approached the implementation of SMAs, given different
circumstances, motivations, and approaches. Division 1 was
driven by access issues; management devoted the resources
to hire an industry expert to help them initiate an SMA
program. Physicians at Division 2 chose the group format as
a way of delivering better care for their patients. More re-
cently, a formal program was developed that included ad-
vice from a consultant from Division 1, along with additional
resources and personnel. This allowed the physician cham-
pion to more fully develop the program at Division 2, which
now includes several other physicians conducting SMAs.
Despite some limited early interest, Division 3 did not
really try to implement SMA. By not devoting time or re-
sources, early attempts quickly faltered and were abandoned
Despite differences in motivators, facilitators, and re-
sources, both Divisions 1 and 2 report overall success with
instituting SMAs. Since implementing the first SMA at Di-
vision 1, the program has grown to offer more than a dozen
different SMAs. Division 2 SMAs, while still in the early
stages of the pilot program, show promising attendance and
increased physician participation. The resistance to refer
their patients to SMA providers, expressed initially by phy-
sicians at Division 1, proved to be a nonissue as physicians
found they were no more likely to lose a patient to an SMA
than to a specialist.
This study has several limitations. Primarily a case study
intending to highlight the experiences of physicians and
administrative staff in 1 large medical group, it does not
cover the experience of patient participants. Also, no inter-
views were conducted with physicians who chose not to
offer SMAs. However, the opinions and recollections of ad-
ministrators at Division 3 illustrate some of the barriers to
acceptance prevalent in clinics resistant to the idea of SMAs.
The barriers to SMA uptake are more surmountable than
current usage would indicate. These case studies provide
evidence that, given adequate resources, SMAs are a viable
and potentially generalizable delivery model, as a small
number of providers are beginning to discover.
A com-
mitted physician champion is critical for the successful im-
plementation of SMAs, as is management support in the
form of staff support and clinic space. Beyond that, it seemed
to matter little whether the motivation was practical (im-
proving access) or benevolent (improving care).
Directions for future research
The intent of this article was to highlight facilitators and
barriers to SMA implementation at a medical group. It re-
presented the doctors’ and administrators’ perspectives. As
part of the larger study, focus groups also were conducted
with SMA patients. The qualitative data collected hinted at
important patient reactions to this new form of interaction,
which will be the subject of a future article. Many studies
have looked at quantitative indices and outcomes; few, if
any, have tackled the patient’s experience. Future research
must be conducted from the perspective of patients to reveal
the impact of SMAs on the patient-doctor relationship and
patient-reported outcomes. As an innovative way to deliver
medical care, SMAs may be at the tipping point on the dif-
fusion curve of innovations.
Insights from this line of re-
search on experiences of early adopters can inform its
We would like to acknowledge the work of Sukyung
Chung, PhD, for co-leading some of the interviews and
providing valuable comments on earlier drafts of the man-
uscript. We are grateful to the key informants who donated
their valuable time to contribute their experiences to this
Author Disclosure Statement
Drs. Sutlts, Dohan, Frosch, Hung, Tai-Seale, and Ms.
McCuistion declared the following potential conflicts of in-
terest and financial support with respect to the research,
authorship, and/or publication of this article: Ms. McCuis-
tion currently works as a principal researcher at the consul-
tancy Essential Anthropology. At the time this study’s
research was conducted she was a research associate at Palo
Alto Medical Foundation Research Institute. The other au-
thors report no conflict of interest. This work was funded by
grant R18 HS019167 (Tai-Seale, PI) from the Agency for
Healthcare Research and Quality.
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Address correspondence to:
Ming Tai-Seale, PhD, MPH
Palo Alto Medical Foundation Research Institute
2350 W. El Camino Real, Room 446
Mountain View, CA 94040-1456
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    [Show abstract] [Hide abstract] ABSTRACT: The Affordable Care Act has extended coverage for uninsured and underinsured Americans, but it could exacerbate existing problems of access to primary care. Shared medical appointments (SMAs) are one way to improve access and increase practice productivity, but few studies have examined the patient's perspective on participation in SMAs. To understand patient experiences, 5 focus group sessions were conducted with a total of 30 people in the San Francisco Bay Area. The sessions revealed that most participants felt that they received numerous tangible and intangible benefits from SMAs, particularly enhanced engagement with other patients and physicians, learning, and motivation for health behavior change. Most importantly, participants noted changes in the power dynamic during SMA visits as they increasingly saw themselves empowered to impart information to the physician. Although SMAs improve access, engagement with physicians and other patients, and knowledge of patients' health, they also help to ease the workload for physicians. (Population Health Management 2015;xx:xxx-xxx).
    Full-text · Article · Jun 2015 · Population Health Management