Advancing the Science of Patient-Centred Measurement in Team-Based Care

Project Summary

Our study aims to develop new methods of including patient-generated data in a team-based primary care clinic.

Examples of patient-generated data are measures that ask patients about their experience with their care teams, and about their quality of life.

We specifically looked at measures that focus on mental health. Using a knowledge sharing approach (integrated knowledge translation), we explored new methods as to how this patient-generated data could be completed, accessed, and used by patients and their care team.

Project Stages

For our study, the patient’s care team included a doctor, nurse, social worker, and medical office assistant. We created a set of scenarios to show how patient-generated data can support decisions with the care team. The scenarios were discussed with healthcare providers and patient partners to understand how to integrate patient-generated data into team-based clinic processes.

Working with our industry partner and patient partners, we co-developed an online patient-centred platform (i.e. portal) that was specific to our study. We worked with the providers and patient partners in selecting the measures for the portal.

The portal contained two patient-reported outcome measures (PROMs) for mental health (e.g., GAD-7, PHQ-9) and one for self-efficacy (PROMIS® self-efficacy), a patient-reported experience measure, and a depression self-action plan. We also incorporated over thirty articles on evidence-based mental health online educational resources, as well as information on local programs and services.

Our patient partners selected the material, reviewed the articles, and tested the portal.

Patients and providers used the portal for four months. We interviewed them over this time-period to support further iterations of the portal and integration of patient-generated data into team-based care. We asked patients and healthcare providers about how they could use these measures to improve communication and decision making during care visits and manage care between visits.

The data we have gathered are in the form of documents, interviews, healthcare provider team discussions, care workflow diagrams, and team-based scenario maps.  Our analysis of the data resulted in a narrative summary.

The final output will be in the form of an online guidance document (in development at that is accessible to patients, healthcare providers, quality improvement analysts, decision-makers, researchers, and technical staff. The guide will provide information on how patient-generated data can be integrated into team-based primary care using digital health technologies for patients and providers.

Project Findings

We conceptualized five team-based PCM methods through this study:

  1. PCM Team Mapping, as a technique to provide greater clarity of care-team roles and responsibilities in data collected through PCM.
  2. Longitudinal Care Alignment to guide the care-team on incorporating PCM into ongoing provider-patient interactions.
  3. Digital Tool Exploration to evaluate care-team members’ readiness toward digital tool adoption, and the impact of these tools.
  4. Team-based Quality Improvement in engaging teams in patient-centered quality improvement.
  5. Shared Learning promotes provider-patient interactions that validate patient’s perspectives of their care.


The adoption of team-based primary care within Patient Medical Homes provides an opportunity to conceptualize team-based PCM methods in new ways to advance patient-oriented research and patient-centered care.


More information about our study is available at


Antonio, M.G., Davis, S., Smith, M. Burgener, P., Price, M., Lavallee, D., Fletcher, S., & Lau, F., (2022). Advancing digital patient-centered measurement methods for team-based care. SAGE Digital Health.

Davis S, Antonio M, Smith M, Burgener P, Lavallee DC, Price M, Fletcher SC, Lau F. Paving the way for electronic patient-centred measurement in team-based primary care: an integrated knowledge translation approach. JMIR Formative Research. 30/12/2021:33584


Sept 2021: Patient Advisory Committee of the KB Division of Family Practice/Interior Health Collaborative Services Committee

Sept 2021: Methods Matters Webinar (see below)

This project is part of the Patient-Centred Measurement Cluster.


Francis Lau, co-PI
Selena Davis, co-PI ✉︎
Marcy Antonio, co-I ✉︎
Mindy Smith
Paul Burgener
Morgan Price
Danielle Lavallee
Sarah Fletcher
Bruce Forde
Leila Dale

Methods Matters Webinar

Watch the featured animation & two snack-size highlights:

Duration: 5:41

Duration: 1:00

Duration: 2:26

Watch the full webinar:

Duration: 56:02

After the webinar, our team reviewed and answered all questions from the live Q&A.
Download a PDF of our responses.