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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.
Established an electronic medical record system to enhance communication among area health care organizations and promote safe, high-quality care for patients with chronic illnesses. Initially, the project focused on patients with congestive heart failure.
Developed a regional health IT strategic plan between 28 health care providers, including a comprehensive needs assessment of all of the participating organizations, prioritization of needs, identification of health IT solutions to prioritized needs, and development of appropriate implementation plans.