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A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
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An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in

Jerry H Gurwitz1, Terry S Field, Jessica Ogarek

  • 1Meyers Primary Care Institute, University of Massachusetts Medical School, Reliant Medical Group and Fallon Community Health Plan, Worcester, Massachusetts.

Journal of the American Geriatrics Society
|May 1, 2014
PubMed
Summary

This study found that an electronic health record intervention did not significantly improve timely primary care visits or reduce rehospitalization rates for older adults after hospital discharge.

Keywords:
care transitionsrandomized controlled trialreadmissionrehospitalizationsafety

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Area of Science:

  • Health Informatics
  • Geriatric Medicine
  • Transitional Care

Background:

  • Older adults are at high risk for adverse events after hospital discharge.
  • Effective transitional care interventions are crucial to improve patient outcomes and reduce healthcare costs.
  • Electronic health records (EHRs) offer potential for automated support in transitional care.

Purpose of the Study:

  • To evaluate an EHR-based transitional care intervention.
  • The intervention aimed to improve post-hospitalization care for older adults.
  • Key objectives included increasing timely primary care visits and reducing rehospitalization.

Main Methods:

  • A randomized controlled trial was conducted in a large multispecialty group practice.
  • Participants were individuals aged 65 and older discharged home from the hospital.
  • The intervention group received EHR-generated alerts for primary care providers and staff regarding patient discharge, new medications, drug interactions, and scheduling posthospitalization visits.

Main Results:

  • No significant difference was observed in the rate of primary care visits within 7 days of discharge between the intervention and control groups.
  • The rehospitalization rate within 30 days post-discharge was similar between the intervention (18.8%) and control (19.9%) groups.
  • The hazard ratio for rehospitalization was 0.94 (95% CI, 0.81-1.1), indicating no statistically significant reduction.

Conclusions:

  • The EHR-based transitional care intervention did not significantly improve the timeliness of post-hospitalization primary care visits.
  • The intervention also failed to demonstrate a significant reduction in 30-day rehospitalization risk for older adults.
  • Further research may be needed to optimize EHR-driven transitional care strategies.