As a long-time practicing family physician, I have a deep respect for the importance of primary care practices and providers in improving health. In my roles as provider, teacher, and researcher I have focused on making primary care better – for both patients and providers. I have worked with community primary care practices from the start of my academic career to ground my research in the ‘real world’, from exploring the clinical epidemiology of common presenting symptoms in primary care to developing simple health information technology tools to support the work of primary care clinicians to creating clinical programs to extend the capacity of the primary care office.

I am now focused on applying that research knowledge to the messy process of health care redesign and clinical transformation. For several years I worked to achieve clinical transformation of a community-wide health system (Jackson, Michigan) to integrate its business community, community health improvement organization, social and behavioral health, and medical care delivery system; this partnership culminated in the selection of Jackson County as a Community Health Innovation Region in the CMS-sponsored Michigan State Innovation Model demonstration from 2016-2020. This work has made it clear to me that we must develop, test, translate, and “scale up” practical approaches to support integrated, person-centered care within the primary care medical home and across the community at-large if we are to make real progress in addressing health disparities. I am now working across the state of Michigan and with the national Gravity Project to develop and implement the human and technical infrastructure necessary to support cross-sector care coordination.

1. Health information technology to support community-based primary care.
I have led work on development of scalable health information technology solutions for primary and community care, ranging from theoretical work to design and testing of software applications for use in primary care and behavioral health settings. Our team developed and licensed ClinfoTracker, a clinical quality management application eventually used in hundreds of practices in the US, and the MDOCC Clinical Record, a multipurpose application supporting behavioral health care management workflow and outcomes measurement, now in use in several Michigan communities. Our experience with these applications led to work on community health information exchange, culminating in the development of the Jackson Care Hub IT platform in 2018 to support cross-sector care data exchange by connecting medical practices and community social services organizations in several Michigan communities. Since 2018, our research / implementation team has followed a sociotechnical design approach to convene community stakeholders and assist them in co-design of local solutions to enhance care. We are active in several communities in Michigan and across the country.

2. Standards development to support primary care and cross-sector care.
In order to assess the value of whole-person care, it has been necessary to develop standards to enable the accurate capture and measurement of the core activities carried out in primary care and community settings. I led international work in this area for many years, serving as the Chair of the World Organization of Family Doctors’ International Classification Committee (WICC) and as liaison to WHO and IHTSDO on primary care classification and terminology issues. In those roles I led work to develop and revise the International Classification of Primary Care (ICPC), maintain interoperability between ICPC, ICD, and SNOMED CT.
I currently work nationally with the Gravity Project, Direct Trust, and Civitas to develop and implement interoperable standards for data exchange to support cross-sector care, with a focus on capturing and exchanging social care data at the point of care. Our local research and implementation team has taken a sociotechnical design approach, convening community stakeholders to co-design local solutions to enhance care in several communities in Michigan and across the country.

3.Depression treatment in primary care settings.
From the Michigan Depression Project (1990s) through the Depression in Primary Care initiative (2000s) and later community-based extensions, I have led research teams exploring questions of diagnostic accuracy, treatment effectiveness, and long-term clinical and economic outcomes for primary care patients with mental health problems. In this work we developed the ‘competing demands’ framework, innovative approaches to assess long-term outcomes of care, and efficient and flexible care management support interventions that have been adopted by multiple health systems.

4. Metrics to assess health care quality.
Assessing the value of health care interventions, or the impact of clinical redesign, requires expanding the toolbox beyond individual disease-specific measures. I have worked to improve clinical quality assessment by designing and testing new assessment tools and methodologies, focusing first on behavioral health and now extending to whole-person and community outcome metrics. This work supports our efforts to determine the most effective ways to carry out comprehensive health care redesign.