Long-Term Impact of an Electronic Health Record-Enabled, Team-Based, and Scalable Population Health Strategy Based on the Chronic Care Model. - Kensaku Kawamoto; Kevin J. Anstrom; John B. Anderson; Hayden B. Bosworth; David F. Lobach; Carrie McAdam-Marx; Jeffrey M. Ferranti; Howard Shang; Kimberly S. Hawblitzel Yarnall (AMIA, 2016)