This research will use digital health tools leveraging patient-reported outcomes and data from electronic health records to engage individuals with multiple chronic conditions to improve understanding of individualized risk of adverse events during care transitions.
Transitions in Care
This research aims to design and develop novel wearable technologies that can improve care coordination during prehospital encounters and, ultimately, improve patient outcomes and achieve patient-centered care delivery and coordination.
This research will study the effectiveness of a virtual in-home program designed to reduce hospital readmissions among COPD patients post-hospitalization.
This research will examine the factors affecting cancer patients’ use of an electronic patient safety event reporting system to communicate adverse medication-related events to their care team.
Implementing Personalized Cross-Sector Transitional Care Management to Promote Care Continuity, Reduce Low-Value Utilization, and Reduce the Burden of Treatment for High-Need, High-Cost Patients
This research will integrate cross-sector care alerts and interoperable personalized care planning into the existing Coordinating Transitions Intervention (CTI) tool and evaluate the impact of the revised tool on patient burden, care team collaboration, and utilization value for high-need, high-cost patients.
This research aims to determine the effectiveness of a program designed to reduce medication-related issues among patients during the hospital-to-skilled nursing facility transition.
This research’s goal is to show that interoperability, including adoption of regional health information exchanges, improves mortality rates and care efficiency at the population and patient levels.
Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Healthcare Utilization
This research demonstrated primary care providers’ complementary use of “push” and “pull” health information exchange technologies to meet their information needs and provides evidence that “pull” exchange reduces potentially avoidable healthcare utilization.
The research team developed a smartphone application that notifies primary care providers when patients receive care in the hospital or emergency department, allowing for rapid followup care.
This pilot project implemented a Social Knowledge Networking system and concluded that it supported progress toward meaningful use of medication reconciliation technology in an electronic health record.