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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.
Created a secure infrastructure for communication among providers to allow electronic sharing of patient clinical information with hospitals and other physicians/health providers in the county, region, and State; also assessed the effectiveness of the system in improving workflow, timeliness and completeness of information, patient safety, continuity of care, and health outcomes.