A Novel Primary Care Planning Informatics Tool Informed by Data-Driven Multimorbidity Grouping…

StudyJMIR formative research· Dec 2025

A Novel Primary Care Planning Informatics Tool Informed by Data-Driven Multimorbidity Grouping: User-Centered Design and Feasibility Testing.

Linnaea Schuttner, Karin Daniels, Srinidhi Venkatesh … Ann-Marie Rosland

Chronic Disease ManagementStudyClinical practiceQ2IF 2.6

Primary care teams using new planning tool reviewed 80% of high-risk patients

A Novel Primary Care Planning Informatics Tool Informed by Data-Driven Multimorbidity Grouping: User-Centered Design and Feasibility Testing.

Linnaea Schuttner … Ann-Marie Rosland

JMIR formative research · Dec 2025 · Q2 in General Medicine

Background

With multimorbidity have complex health care needs and are at high risk for adverse health outcomes.

Purpose

The study aimed to iteratively adapt VET-PATHS with user input, then test feasibility and acceptability by frontline primary care teams for empaneled patients at high risk.

Methods

After the national tool release, we conducted a pilot intervention study in 2023-2024 with 6 primary care teams at 4 sites using VET-PATHS during asynchronous regular meetings.

n = 34,

80%

Results

80%

teams actively reviewed most high-risk patients flagged by the tool

n = 34,

More results

Tool use prompted 127 new actions for 91 unique patients (33% of patients reviewed) and documentation of >1 new care plan for 19% of patients reviewed.

Common actions included requests to return to the clinic (n=34, 27%), referrals (n=25, 20%), or vaccinations (n=24, 19%).

Of the 127 actions planned, 53 (42%) were received by patients.

More results

Four generalist teams (n=11 interviews) described higher acceptability.

“

Conclusion · 1 of 2

User-centered improvements to VET-PATHS were designed to help clinicians process and use complex information about patient multimorbidity to efficiently create new care plans.

Conclusion · 2 of 2

Subsequently, VET-PATHS was acceptable and feasible to frontline primary care teams, particularly with more general patient panels, and led to concrete changes to clinical care delivery.

A Novel Primary Care Planning Informatics Tool Informed by Data-Driven Multimorbidity Grouping: User-Centered Design and Feasibility Testing.

A Novel Primary Care Planning Informatics Tool Informed by Data-Driven Multimorbidity Grouping: User-Centered Design and Feasibility Testing.

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