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This study aimed to improve care transitions for low-income patients with multiple chronic conditions using health information exchange, and found significant reductions in inpatient and emergency department utilization.
This project built an automated intervention that recognized critical imaging results that require additional testing and populated a discharge summary with recommendations, resulting in improved patient followup.
The project team implemented a Web-based service clinical decision support application to detect care transitions, and produce and send care event summary reports to patients, patients’ assigned medical homes, and care managers.