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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 developed, implemented, and evaluated a care transition information transfer system to improve provider-to-provider communication and standardize the discharge process.
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.
The project team successfully developed and implemented an automated system for measuring the rate of adverse drug events in pediatric patients.
Facilitates transfer of information among providers and patients in the Presque Isle community; implements a model of chronic care management; and educates area health care providers on how best to use current information systems to communicate with each other.
Develops a patient Master Visit Registry (MVR), addressing the need for better information sharing among clinical organizations and enhancing their ability to give patients continuous high-quality care when they change providers. The MVR will expand upon an existing patient record-keeping system, while improving local handling and exchange of records.
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.
Intended to improve chronic care health management in Northern, Eastern, and Central Maine by planning for the standard exchange of clinical information for patient transitions from acute to non-acute care.
Created a detailed assessment of the feasibility of health IT implementation including the development of an implementation plan, specification of clinical and organizational needs, identification of goals, and identification of barriers and ways to address those barriers.
Integrated an office-based EMR within an acute care hospital, rural community health centers, a community mental health center, a family medicine residency, private physician practices, and a home nursing service for improving use of the EMR as a clinical tool, integrate clinical data, and increase access to the data.