Using HIE generated ADT alerts to reduce hospital readmissions

Many health information exchanges benefit from Admission, Discharge, and Transfer (ADT) messages automatically generated in hospital systems. With the inclusion of a provider directory it is possible to automatically alert physicians associated with a particular patient. In Prince George’s County Maryland these are alerts are used in provider practices to contact patients that have recently been hospitalized and discharged. The workflow and practices varies depending upon who is assigned the task of dealing with the alerts. If clerical staff respond the focus of the intervention is to have the patient come in for primary care visit. Practices may also triage these alerts depending upon the severity of the problem. Some EHR systems have the ability to consume these alerts and present them to the provider. Some alerts are sent to the wrong provider, and some are not sent to any providers. Prince Georges County Maryland health department works with hospitals in the area to identify those patients and to engage them with the community health worker. These are all patients who have no primary care provider and often no means to pay for healthcare services. As the county has worked with these patients have discovered that they have multiple needs in addition to health care. Presenters will describe the IT system that issues to track progress with these patients and how they make that information available to primary care providers.