BackgroundIntensive care units are high-acuity environments characterized by time pressure, medical complexity, and organizational demands. These conditions may influence clinicians’ ability to provide patient-centered care and contribute to forms of care perceived as fragmented or dehumanizing.ObjectiveTo examine how ICU clinicians describe and make sense of the pressures shaping everyday critical care practice, and how these pressures give rise to interacting patterns of care, including those described as hurry, blur, burden, and cruelty.MethodsWe conducted a qualitative study using focus groups with ICU clinicians from a large academic health system. Discussions were informed by the concept of the pathologies of care as sensitizing concepts. Four focus groups were held with physicians, nurses, advanced practice nurses, and a social worker (N = 14). Transcripts were analyzed using directed content analysis with both deductive and inductive coding.ResultsClinicians described these patterns not as discrete phenomena but as interrelated, context-dependent processes shaped by shared operational pressures such as time constraints, workload, and information demands. These dynamics were often viewed as inherent to the structure and culture of ICU care and were described as co-occurring and compounding. Communication emerged as both a contributor to and a potential mechanism for mitigation, alongside system-level strategies such as reducing documentation burden and leveraging artificial intelligence to support care delivery.ConclusionsPatterns reflected in hurry, blur, burden, and cruelty are best understood as emergent properties of complex care systems. Addressing these dynamics may require system-level approaches to improve communication, reduce workload pressures, and support more patient-centered, humanizing care.

Shared decision making (SDM) is guideline-recommended for primary prevention of cardiovascular (CV) disease, but there are barriers to routine adoption of tools to promote SDM. This pragmatic trial evaluated the effect of tailored strategies on implementation of an SDM tool (CV Prevention Choice) used during clinical encounters. Fifteen primary care and preventive cardiology sites within three U.S. healthcare systems participated. Outcomes were organized using the RE-AIM evaluation framework and included reach (number, proportion and characteristics of patient encounters), adoption (clinician uptake), implementation (fidelity), and maintenance (sustained use). Effectiveness is not reported here. Data included electronic health record (EHR) encounter data, surveys and interviews with clinicians and administrators, periodic reflections with implementation facilitators, and site visits. Surveys and EHR data were analyzed descriptively. Qualitative data were analyzed using content analysis and the Consolidated Framework for Implementation Research. We explored fidelity by reviewing a sample of video-recorded encounters. Between May 2021 and January 2025, 136 surveys, 38 interviews, 65 periodic reflections, and 6 site visits were completed. CV Prevention Choice was used with 3031 patients. The 76 clinicians (43

Although recommended, shared decision making (SDM) is not widely adopted for primary prevention of cardiovascular (CV) disease. Champions may influence peer adoption if they are enthusiastic and skilled. We describe adoption of an SDM conversation aid for CV risk reduction (CV Prevention Choice) by champions and early adopters in a pragmatic implementation trial and consider their influence on uptake in clinics. We embedded the SDM tool in the electronic health record in three U.S. health care systems. Eight of their 15 affiliated clinics deployed a champion implementation strategy. Adopters used the SDM tool in ≥ 2 routine clinical encounters. Superusers had ≥ 20 encounters. Penetration was the proportion of adopters among eligible clinicians. Adoption and penetration were assessed in the usual care (early adoption), active implementation, and maintenance implementation phases. Thematic analysis methods were used to analyze qualitative data from individual interviews and periodic reflections. Between May 2021 and January 2025, 37 interviews with clinicians and other staff and 65 periodic reflections were completed. Among 176 clinicians, 55

BACKGROUND AND OBJECTIVES:Multimorbidity, the coexistence of two or more chronic conditions, affects about 40% of all adults and over half of adults over 60 years. The complexity of multimorbidity (MM) often renders traditional trial designs inadequate, unable to account for the context of interventions, including the interplay of multiple health conditions in daily life. This gap reduces the generalizability and applicability of their results. METHODS:This commentary aims to review the current state of trials targeting or involving patients with MM. Highlighting current limitations and drawing on insights from an international dedicated workshop in Bielefeld, Germany, we identify an ongoing and pressing need for innovative, patient-centered approaches to their design and conduct. RESULTS:We propose a shift toward more holistic and integrative experimental approaches, including developing interventions tailored to the characteristics and needs of patients with MM, establishing relevant outcomes, and enhancing data collection and process evaluation. We specifically advocate for adaptive trial designs, prespecified subgroup analyses, and the incorporation of patient-reported outcomes and experience measures such as burden of care to ensure that research is both comprehensive and reflective of the needs of patients living with MM, their caregivers, and of the clinicians participating in their care. Ethical considerations are discussed in our commentary as well, emphasizing the importance of patient safety, data protection, and informed consent. Finally, we call for the development of specific reporting guidance, such as a SPIRIT extension tailored to MM trials, to help researchers adapt standard protocols to the complex and heterogeneous reality of this population. CONCLUSION:This commentary aims to bridge the gap between research and practice, fostering the development of effective interventions that improve patient outcomes and enhance the quality of care for patients living with MM.

Background SGLT2 (sodium‐glucose cotransporter 2) inhibitors reduce major adverse cardiovascular events (MACE) in type 2 diabetes. However, no direct comparison of individual SGLT2 inhibitor drugs has been conducted, particularly among adults with moderate cardiovascular risk who comprise most people with type 2 diabetes. Methods We used data for commercial, Medicare Advantage, and Medicare fee‐for‐service beneficiaries to emulate a target trial of adults (≥21 years) with type 2 diabetes and moderate cardiovascular risk who started canagliflozin, dapagliflozin, or empagliflozin between 2015 and 2020. We estimated propensity scores using the super learner ensemble method and incorporated them as inverse probability of treatment weights into Cox models, estimating risk of MACE, expanded MACE, and hyperglycemic and hypoglycemic crises through December 31, 2022. Results The weighted cohort, balanced on all baseline covariates, included 137 232 patients (mean age 65.7 years [SD, 8.1], 75.3% non‐Hispanic White, 57.0% male, 81.9% on metformin, 11.4% on glucagon‐like peptide‐1 receptor agonists) starting canagliflozin (N=42 877), dapagliflozin (N=17 871), or empagliflozin (N=7648). The risk of MACE was lower among patients starting empagliflozin versus canagliflozin (hazard ratio [HR], 0.92 [95% CI, 0.87–0.97]), driven by reduced risk of all‐cause mortality (HR, 0.86 [95% CI, 0.80–0.94]). There was no difference in MACE between empagliflozin versus dapagliflozin or dapagliflozin versus canagliflozin therapy. There was no difference in remaining outcomes between the three drugs. Conclusions The 3 most used SGLT2 inhibitor medications demonstrate similar effectiveness on cardiovascular outcomes among patients with type 2 diabetes at moderate cardiovascular risk, with differences between these drugs small in magnitude. Clinicians and health systems should prioritize enhancing access to these cardioprotective therapies.

Background:Effective interventions are needed to support co-creation of diabetes care plans that fit patients' lives. We evaluated the QBSafe agenda-setting kit (14 conversation cards) for its impact on care fit and glycemic control when added to usual primary care. Methods:This single-center, clinician-level cluster-randomized, open-label trial was conducted at a federally qualified health center in New Haven, Connecticut ( ClinicalTrials.gov NCT05553912 ). Clinicians and their patients with type 2 diabetes and HbA1c >8% were randomized 1:1 to usual care with or without QBSafe cards. In the intervention arm, patients selected up to 3 cards highlighting concerns about life with diabetes prior to their visit. Primary outcomes were change at 6 months in care fit (Illness Intrusiveness Ratings Scale, IIRS) and HbA1c, analyzed by intention to treat. Secondary outcomes were treatment burden (Treatment Burden Questionnaire, TBQ) and diabetes distress (Diabetes Distress Scale, DDS), and satisfaction with visits. Results:Between February 2023 and July 2024, 143 participants (mean age 56 years; 61% female; 73% Hispanic; mean HbA1c 10%) were enrolled: 74 received usual care with QBSafe, 69 usual care alone. At 6 months, there were no significant between-arm differences in changes in IIRS (-3.9 [95% CI -10.4, 2.6]), HbA1c (-0.2% [95% CI -0.9, 0.5]), TBQ (1.0 [95% CI -16.6, 18.6]), or DDS (-0.1 [95% CI -0.4, 0.2]). Clinicians reported greater satisfaction when using QBSafe. Patient satisfaction was high and did not differ across arms. Conclusions:QBSafe cards improved clinician satisfaction but did not improve care fit or glycemic control. Future tools should focus on helping clinicians respond effectively to patient-identified challenges.

Abstract BackgroundThe promise of artificial intelligence (AI) in medicine depends on its ability to learn from data that reflect what matters to patients and clinicians in the care process. Most existing models are trained on electronic health records (EHRs), which primarily capture biological measures but rarely the interactions and relationships between patients and clinicians. These relationships, central to how care is understood, negotiated, and delivered, unfold across multiple modalities, including voice, text, and video, yet remain largely absent from current datasets. As a result, AI systems trained solely on EHRs risk perpetuating a narrow biomedical view of medicine and overlooking the lived exchanges that define clinical encounters. ObjectiveThis study aims to design, implement, and evaluate the feasibility of a longitudinal, multimodal system for capturing patient-clinician encounters, linking 360° video or audio recordings with postvisit surveys and EHR data, to create a foundational dataset for downstream AI research. MethodsThis single-site study was conducted in an academic outpatient specialty clinic (Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, United States). Adult patients attending in-person visits with participating clinicians were invited to enroll. Encounters were recorded using a 360° 2D monocular video camera and dual-channel audio. After each visit, patients completed a brief survey assessing relational empathy, satisfaction, visit pace, and treatment burden. Demographic and clinical data were extracted from the EHR. Feasibility was assessed using 5 prespecified end points: clinician consent, patient consent, recording success, survey completion, and data linkage across modalities. ResultsRecruitment began in January 2025. By August 2025, 35 of 36 (97%) eligible clinicians and 212 of 281 (75%) approached eligible patients had consented. Of the consented encounters, 162 (76%) resulted in a complete 360° video recording, and the postvisit surveys were completed for 204 of 212 (96%) consented encounters, reflecting 1 survey per encounter. Data collection is ongoing as of December 2025, and further analyses will be reported in subsequent publications. ConclusionsThis protocol describes a longitudinal multimodal encounter capture system that links 360° audio or video with postvisit surveys and EHR data. The study specifies operational definitions, workflows, feasibility end points, and governance procedures to support implementation and replication in other clinical settings.

Introduction and Objective: Glucose-lowering drugs for T2D have variable efficacy, side effect, and administration profiles. Tools that support individualized evidence-based prescribing in primary care are needed. Methods: We developed a decision aid (Figure) to support conversations about choice of T2D therapy, which we evaluated for usability, utility, and implementation in semi-structured interviews with 3 patients with T2D, 5 primary care providers (PCPs), and 3 endocrinologists. Results: The decision aid was well received by all stakeholders. Qualitative findings identified 5 themes to support implementation and use in practice (Table). Conclusion: This decision aid, available publicly, can support evidence-based individualized decisions about T2D drugs. Impacts on therapeutic inertia, guideline-concordant care, T2D outcomes, and satisfaction will need to be assessed. Disclosure A. Hawkins: None. A. Singh: None. U.F. Naeem: None. S. Khalid: None. I.G. Hargraves: None. K. Shepel: None. V. Montori: None. V.M. Montori: None. J.P. Brito: None. M.M. Mickelson: None. R. McCoy: None. Funding Patient-Centered Outcomes Research Institute (PCORI) Award (DB-2020C2-20306)

Nearly 25 years ago, the Institute of Medicine (now the National Academy of Medicine), envisioned the concepts of a learning health system (LHS) as a path to reduce the discordance between scientifically demonstrable effectiveness of medicine and actual health care delivery by conscientiously leveraging the experiences, perspectives, and priorities of patients and frontline clinicians. Whereas many of the National Academy of Medicine’s aspirational deliverables have not been attained within the time frame anticipated, the value of an LHS has nonetheless been increasingly recognized and continues to gain momentum nationally and internationally.In November 2024, Mayo Clinic Health System organized an LHS symposium with research leaders from Mayo Clinic and the University of Minnesota. The goal was to strategize future collaborative statewide LHS efforts, building on past experiences and lessons learned. Building on a foundation of implementation science and de-implementation principles, attendees contemplated opportunities to collaborate along strategic priorities of Mayo Clinic Health System research, including health equity, rural and population health, artificial intelligence validation and stewardship, and cancer care. The University of Minnesota provided examples of the LHS infrastructure built to support tomorrow’s researchers and health care leadership while contemplating feasible opportunities to build, fund, and sustain a statewide LHS infrastructure. Anticipated future obstacles for LHS were also explored.

Background:The self-management of type 2 diabetes (T2D) typically requires enacting various lifestyle changes, which can challenge people living with T2D. Clinical encounters between people with T2D and their clinicians, however, are often focused on metabolic management, leaving less time available for other self-management topics. The QBSAFE cards help patients articulate aspects of their experience with diabetes and prioritize issues for discussion. Methods:This report details secondary outcomes of a randomized controlled trial; primary outcomes are reported elsewhere. All data was collected at Fair Haven Community Health Care, a federally qualified primary care clinic. 11 clinicians were randomly assigned to provide either usual care or usual care with QBSAFE cards to 155 of their patients with type 2 diabetes and hemoglobin A1c >8%. All patient encounters were video recorded for analysis. Patients and clinicians were not blinded to arm allocation but were kept unaware of the specific aims of the trial. Encounter video reviewers were blinded to arm allocation, but not to specific aims of the trial. The outcomes of interest for this report were the extent to which the QBSAFE cards were used as intended, their effect on the topics of discussion, and whether they enabled clinicians to notice and respond to each patient's situation; comparisons between arms were conducted by a linear mixed model with fixed effect of arm and cluster effect of clinician, analyzed in both intent-to-treat and per-protocol populations. Findings:12 patients were excluded post-randomization (A1c <8%). Of 143 eligible patients, 137 encounters (65 in the usual care arm, 72 in QBSAFE) yielded evaluable videos. QBSAFE was used as intended in 61 (85%) QBSAFE arm encounters. Conversations about burden of treatment related to non-pharmacological interventions (17 vs 33, p = 0·04) and taking medications (11 vs 33, p = 0·0008) and about the patient's challenging environment (2 vs 10, p = 0·04) were more prevalent in the QBSAFE group. There was no difference in the rate of conversations about metabolic management or of new care plans as a result of conversations between groups. Interpretation:While there was a difference in the types of conversations observed between the two study arms, this difference was small and only apparent in a few domains. Future work could aim to modify the QBSAFE cards to more effectively stimulate patient-centered discussions and to further prepare clinicians to respond to a variety of issues raised during the clinical visit. Funding:This work was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK129616).

AIM:This study aimed to identify what young adults with type 1 diabetes (T1D) do to make diabetes care fit in their lives and the impact of diabetes and diabetes care on living. METHODS:Dutch young adults with T1D (18-30 years old) submitted photographed real-life situations of efforts to make care fit and of the impact of care on their lives. Participants organised their photos in themes, which guided the focus group discussions. We added a reflective questionnaire, semi-structured interview and iterative validation to identify participant-defined themes and summarise the data. RESULTS:Participants (N = 18) submitted 240 photographs in total, showing a broad range of situations and emotions. Participants identified 16 themes, grouped into four overarching categories describing their experiences with diabetes: (1) My diabetes: glucose levels, workload, 24/7 present; (2) My life: flow of (daily) life, special and irregular circumstances, life changes, body and health; (3) Support: devices and technology, social network, clinical (diabetes) care; (4) Mental aspects: emotional processes, perspective, being a patient. In the overlap of My diabetes and My life, they identified eating and counting carbohydrates, activity and exercise, recreational substances. CONCLUSION:Young adults with T1D face the complex challenge of fitting their care into their ever-changing lives. While support systems, such as devices, healthcare professionals and social networks can help, they can also create burdens. Participants emphasised the importance of mental health in their lives with T1D. This study highlights the need for diabetes care that acknowledges the emotional, social and practical realities of young adults' lives.

Introduction To assess the within-class variation in kidney outcomes following initiation of sulfonylurea therapy.Research design and methods We used claims data of enrollees in commercial, Medicare Advantage, and traditional Medicare health plans between 2014 and 2021 to emulate a target trial including adults ≥21 years with type 2 diabetes at moderate cardiovascular risk to compare initiation of glimepiride, glipizide, or glyburide on the incidence of chronic kidney disease (CKD) stage 3 or worse, including initiation of kidney replacement therapy (primary outcome); secondary outcomes examined incident CKD stages 3-4, kidney failure (including kidney replacement therapy), all-cause mortality, and hypoglycemia requiring emergency department or hospital care. Random treatment assignment was emulated using propensity scores, estimated using the super learner ensemble method, and incorporated as inverse probability of treatment weights into proportional hazards models.Results The weighted study cohort included 295 092 individuals starting glimepiride (n=134 926), glipizide (n=145 984), and glyburide (n=14 182). One year after treatment initiation, stage 3 or worse CKD developed in 2.1% of patients in the glimepiride group, 2.2% in the glipizide group, and 1.8% in the glyburide group. Glyburide was associated with a lower risk of kidney complications compared with both glimepiride (HR 0.84, 95% CI 0.76 to 0.92) and glipizide (HR 0.81, 95% CI 0.73 to 0.89), despite a higher risk of severe hypoglycemia (HR 1.47, 95% CI 1.27 to 1.71 vs glipizide and HR 1.22, 95% CI 1.05 to 1.42 vs glimepiride). In contrast, the risk of kidney complications was modestly increased with glipizide compared with glimepiride use (HR 1.04, 95% CI 1.00 to 1.07).Conclusions Glyburide was associated with a modestly lower risk of kidney complications, despite a higher risk of hypoglycemia, while glipizide was associated with a higher risk of kidney complications. These hypothesis-generating findings suggest important within-class differences that warrant consideration in clinical decision-making and future research. Despite rigorous prespecified causal inference analytic methods, the risk of unmeasured confounding and bias by indication with the use of observational data remains.Trial registration number NCT05214573.

INTRODUCTION:To examine within-class sulfonylurea safety, we compared risks of major adverse cardiovascular events (MACE) and severe hypoglycemia among adults with type 2 diabetes (T2D) and moderate cardiovascular risk following sulfonylurea initiation. RESEARCH DESIGN AND METHODS:We conducted a target trial emulation including adults ≥21 years old with T2D and moderate cardiovascular risk who initiated glimepiride, glipizide or glyburide between 2014 and 2021, using claims data from Optum Labs Data Warehouse and the Medicare fee-for-service 100% sample. Study outcomes were MACE (primary), expanded MACE and its components and emergency department or hospital encounters for hypoglycemia, ascertained during follow-up through 2022. Inverse probability of treatment weighting (IPTW) was applied using propensity scores estimated using the super learner ensemble, and outcomes were examined using IPTW Cox proportional hazards models. RESULTS:The weighted study cohort comprised 314 699 patients (mean age 66.9 years, 52.0% men, 76.6% non-Hispanic white). At 1 year, MACE was experienced by 2.5%, 2.7% and 2.8% of patients starting glimepiride, glipizide and glyburide, respectively. Compared with glimepiride, glyburide and glipizide were associated with higher risk of MACE (HR 1.10, 95% CI 1.05 to 1.16 for glyburide; HR 1.05, 95% CI 1.03 to 1.07 for glipizide). At 1 year, severe hypoglycemia was experienced by 0.3%, 0.3% and 0.4% of patients starting glimepiride, glipizide and glyburide, respectively. Glyburide was associated with a greater risk of severe hypoglycemia compared with glipizide (HR 1.43, 95% CI 1.23 to 1.65), while glipizide was associated with a lower risk compared with glimepiride (HR 0.82, 95% CI 0.77 to 0.87). CONCLUSIONS:Among adults with T2D and moderate cardiovascular risk, glimepiride was associated with lowest risk of MACE and glipizide with lowest risk of severe hypoglycemia. These results can help inform treatment selection if sulfonylureas are used for glucose-lowering.

AIM:This study aims to assess the treatment burden and health-related quality of life (HRQoL) in young adults with type 1 diabetes (T1D). METHODS:Online survey on experienced treatment burden (Treatment Burden Questionnaire, TBQ, 0-150, higher scores indicate higher burden) and HRQoL (Type 1 Diabetes and Life questionnaire for ages 18-25 and 26-45, T1DAL, 0-100, higher scores indicate better HRQoL) among Dutch young adults with T1D (aged 18-30). RESULTS:In total, 294 young adults with T1D completed the survey. Mean TBQ score was 59.5 (SD = 24.9). Regular medical care reminding participants of their health problems scored highest. Mean T1DAL scores were 55.9 (SD = 12.9) for ages 18-25, and 62.1 (SD = 13.2) for ages 26-30. Lowest scores were in the subcategory 'Emotional experiences and daily activities' (18-25: median = 41.7, IQR = 24.9; 26-30: median = 47.8, IQR = 22.5). TBQ was strongly negatively correlated with T1DAL (r = -0.69, 95% CI [-0.74, -0.62], p < 0.001). Characteristics associated with higher treatment burden and lower HRQoL included female gender, lower time in range and dissatisfaction with diabetes management approach. CONCLUSION:Young adults with T1D report considerable treatment burden and moderate HRQoL, suggesting a high impact of diabetes care on their lives. Treatment burden is particularly affected by regular medical care activities, whereas diabetes affects the daily functioning and emotional experiences domains of HRQoL. Further research is needed to understand how young adults make care fit and to improve care for these patients, resulting in minimally disruptive care plans. While cautiously interpreted, this may be especially relevant for women and those with adverse clinical outcomes.

Background and Aims:Burnout affects millions of healthcare workers worldwide, from food service and nurses to physicians and leaders, impairing worklives and threatening health system stability. Methods:An international collaborative, PREVAIL, was created to reduce burnout globally. Leaders from six continents shared structured insights into the local state of wellness and burnout contributors and mitigators, which were then subjected to a formal thematic (qualitative) analysis to identify common and region-specific themes. Results:Across continents, findings showed the global state of well-being was in danger, though threats varied by region: long shifts in Africa, heavy workloads in Asia, austerity-prone environments in Europe and financially driven care in North America. Vulnerable worker groups included women, nurses, and primary care. Mitigators included workload and schedule adjustments (Africa), shift policies with fair pay (Asia), leader support and regular well-being assessments (Australia), improved psychosocial services (Europe), organizational wellness support and career development (North America), and trainee support (South America). Conclusions:A proposed "common pathway" framework explains shared drivers of poor workforce well-being and provides actionable steps for promoting compassionate, supportive environments worldwide. Implications/Learning Points:Adopting a coordinated international approach may prevent devastating workforce shortages over the comingdecades. Burnout assessment and reduction in the global workforce is a high priority.

OBJECTIVE:To compare major adverse cardiovascular event (MACE) risks among available dipeptidyl peptidase-4 inhibitors among adults with type 2 diabetes at moderate cardiovascular risk. METHODS:Using claims data of enrollees in commercial, Medicare Advantage, and traditional Medicare plans between 2014 and 2021, we identified adults (≥21 years) with type 2 diabetes, moderate cardiovascular risk, and not requiring insulin who initiated alogliptin, linagliptin, saxagliptin, or sitagliptin. Random treatment assignment was emulated using propensity scores estimated using the super learner ensemble and incorporated as inverse probability of treatment weights into Cox models examining MACE (myocardial infarction, stroke, all-cause mortality), heart failure hospitalization (HHF), arterial revascularization, and hypoglycemia requiring emergency department/hospital use, with weighted median follow-up times calculated for each treatment arm. RESULTS:The weighted study cohort included 184,660 patients starting alogliptin (N= 2541), linagliptin (N= 42,433), saxagliptin (N= 15,649), and sitagliptin (N= 124,038) with median weighted follow-up of 39.5 (95% CI 35.8-41.6), 40.9 (95% CI 40.5-41.3), 42.6 (95% CI 41.7-43.3), and 42.4 (95% CI 42.2-42.6) months, respectively. One year after DDP4i initiation, MACE rates were 2.2%, 2.2%, 2.0%, and 1.7% for sitagliptin, linagliptin, saxagliptin, and alogliptin, respectively; HHF rates were 0.42%, 0.41%, 0.41%, and 0.37%; and hypoglycemia rates were 0.2%, 0.2%, 0.2%, and 0.2%. Saxagliptin was associated with modestly decreased risk of MACE vs sitagliptin (HR 0.94; 95% CI 0.88-0.99) and linagliptin (HR 0.94; 95% CI 0.87-1.00). There was no significant difference in HHF or hypoglycemia risk among the study drugs. CONCLUSION:Risks of MACE, HHF, and hypoglycemia were comparable with all DPP4i. Choice of medication may be determined based on local availability.

Asynchronous messaging (AM), including patient messages, lab results, specialist correspondence, and internal team communications, is now routine in primary care, offering patients timely access while reducing the need for in-person visits. However, AM has generated substantial workload and is thought to contribute to clinician burnout. Despite its increasing role in primary care, limited empirical work has examined how AM can be intentionally designed to sustainably support compassionate relational care. This study aimed to co-design compassionate and sustainable approaches to asynchronous electronic messaging in primary care by engaging patients, clinicians, clinic staff, and health system leaders in identifying challenges and developing feasible solutions for communication workflows, standards, and platform design. We conducted sequential co-creation workshops between June 2025 and January 2026 as part of a multi-phase, design-led qualitative study. Separate workshops were held with (i) patients; (ii) medical office assistants, nurses, and staff; and (iii) family physicians; followed by (iv) a final multi-stakeholder workshop including patients, clinicians, health system leaders, and digital health stakeholders. Workshops built on prior ethnographic observations and semi-structured interviews across multiple primary care clinics. Structured ideation methods and digital collaboration tools were used to generate, cluster, and refine ideas, which were iteratively synthesized. Participants (N=69) from each group described a shared need for convenient, timely communication outside clinical encounters, but focused on different opportunities and challenges. Patients (n) emphasized access, usability, and frustration with opaque messaging processes. Clinic staff (n) highlighted message volume, triage complexity, and workflow burden, while family physicians (n) emphasized emotional labour, tension between patient-centred care and burnout, and the invisibility of messaging work. Through the co-creation process, participants identified three interrelated solution areas: (1) an information-flow management role or software to triage, categorize, and prioritize messages; (2) electronic communication standards that clarify appropriate use, response expectations, and responsibilities; and (3) user-centred messaging platforms . In the final multi-stakeholder workshop, participants underscored that sustainable funding, provincial policy direction, and coordinated governance are prerequisites for implementation. AM can support compassionate primary care when messaging is guided by shared standards, supported by active inbox management, and embedded in team-based, well-designed platforms. Clear roles, expectations, and enabling infrastructure may reduce clinician hesitation, expand capacity, and strengthen equitable, patient-centered care. Not applicable