Personalized Disease Prevention

Provider eligibility criteria. Any attending physician, nurse practitioner or physician assistant practicing in internal medicine or family medicine.

Patient eligibility criteria. This study define 2 types of patients, "eligible" patients and "high-priority" patients. "Eligible" patients are a broadly-defined group of patients of the intervention arm providers, for whom the providers will be able to access individualized preventive care recommendations. Eligible patients are subject to a waiver of informed consent. "High-priority" patients are a more narrowly-defined subset of eligible patients, who will be contacted by the study team for follow-up.

Eligible patients will have the following inclusion criteria:

A provider assigned to the intervention arm of the RCT is the patient's primary care physician (PCP) of record in the EHR.
Aged 40-75 years.

High-priority patients are defined as eligible patients who also meet all of the following inclusion criteria:

A modifiable lifestyle factor with a large impact on quality-adjusted life expectancy, assessed by ≥1 of the following:

current smoker
BMI ≥30.0 kg/m^2
BP ≥140/90 mmHg
10-year ASCVD risk ≥10%
HbA1c ≥9%
alcohol/week >4.2 oz (98 g) for female or >8.4 oz (196 g) for male

Eligible for a high number of preventive services, assessed by ≥3 of the following. Factor(s) used to satisfy criteria 1 also count toward satisfying criteria 2:

current smoker
BMI ≥27.0 kg/m^2
systolic BP >130 mmHg
10-year ASCVD risk ≥7.5%
HbA1c ≥7.5%
alcohol/week >4.2 oz (98 g) for female or >8.4 oz (196 g) for male
Overdue or due soon for colorectal cancer screening, as of date that study team confirms "high-priority" eligibility criteria
Overdue or due soon for lung cancer screening, as of date that study team confirms "high-priority" eligibility criteria
Overdue for breast cancer screening for ≥1 year, as of date that study team confirms "high-priority" eligibility criteria
Overdue for osteoporosis screening for ≥1 year, as of date that study team confirms "high-priority" eligibility criteria

Ongoing primary care in the health system, defined as ≥2 visits with a primary care provider in the prior 730 days.

The term "primary care provider" is defined as an attending physician, nurse practitioner or physician assistant in the Department of Internal Medicine or Department of Family Medicine with an established patient panel.
The term "visit" is defined as an in-person or virtual visit encounter.

An eligible encounter with the patient's primary care physician (PCP) of record in the EHR. "Eligible encounter" is defined as follows:

An annual wellness visit (sometimes called a physical) with scheduled length of 40 minutes, or for some practice sites or departments, 30 minutes. These encounters typically focus on preventive care and are more likely to allow enough time to engage in shared decision-making.
For patients without an annual wellness visit in the prior 2 years, a visit with scheduled length at least 30 minutes, or a shorter length directly related to at least one service relevant to the research study (e.g., the EHR notes field indicates that a patient is scheduled for a follow-up of hypertension).

Eligible patients have the following exclusion criteria, defined as ≥1 of the following:

Cancer in the past 3 years (other than non-melanoma skin)
Diagnosis of alcohol abuse in past 3 years
History of myocardial infarction
History of stroke
End-stage renal disease
Moderate-severe congestive heart failure (moderate-severe may be ignored if needed to facilitate automatic data extraction)
Moderate-severe chronic obstructive pulmonary disease (moderate-severe may be ignored if needed to facilitate automatic data extraction)
Other comorbidity with limited life expectancy, in the opinion of ≥2 members of the study team.
Inability to communicate or limited communication (speaking, reading, writing) in the English language.

In addition to the above, high-priority eligible patients also have the following exclusion criteria, defined as ≥1 of the following:

Known current pregnancy.
Known acute care need that is likely to limit time available for discussion of preventive care.
The first primary care encounter since a hospitalization, surgery or emergency department utilization.

There will be no exclusion from the study on the basis of race or ethnicity.