Developing resources to support population health approaches in primary care

Population Health in Primary Care


Policy makers and health planners have embraced Population Health as a means to transform health care and improve patient outcomes. However, incorporating this approach in the day-to-day delivery of primary health care has been difficult to implement.

We are working with Primary Care Providers to better understand what they think about population health, and what they see as their role in this domain, with the ultimate goal of ensuring they have the population health tools required to help support the health of their patients and communities.

To begin, we chose to focus our work on Family Physicians working in primary care. Using service design methods, we sought to: 

  • Better understand family physicians’ perspective towards population health approaches; and,

  • Identify the key needs, barriers, and opportunities to influence family physicians’ behaviours to utilize population health approaches in their clinical practice.

To learn more about our findings, please see our Project Overview.

Small change can result in big rewards! Why a Panel Management Tool?

Being able to pull a list of names helps both physicians and their patients. A list helps:

  • clarify who is part of the practice population.

  • identify patients who may be overdue for care, require follow-up, or could benefit from additional services.

  • develop processes to make sure patients do not fall through the cracks and get connected to the services they need.

One of the suggestions proposed by Family Physicians was to better leverage the existing capacity of Electronic Medical Records (EMRs) to support primary care practice and population health. To advance this idea, we developed a short Panel Management Tool to provide guidance on how to pull the list of patients rostered or that have seen a particular family physician from the EMR.

Related resources and tools:

  • The Project Overview provides a brief description of the project, including objectives, activities and findings.

  • The Panel Management Tool outlines how to pull a patient list from the most common EMRs used in primary care.


  • OntarioMD