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  1. pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-27-ehr-and-pcmh.pdf
    September 01, 2015 - management, billing, group visits, in-house labs, post-visit follow-up, health education attendance, and medication … cohorts by condition, demographic variables, or risk level; monitor adherence to care plans; track medication

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