An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults

UMMS Affiliation

Meyers Primary Care Institute; Department of Orthopedics; Department of Medicine, Division of Preventive and Behavioral Medicine;Department of Medicine, Division of Geriatric Medicine

Publication Date


Document Type



Aged; Aged, 80 and over; Ambulatory Care; Continuity of Patient Care; *Electronic Health Records; Female; Follow-Up Studies; Humans; Male; Massachusetts; Office Visits; Patient Discharge; Patient Readmission; Primary Health Care; Retrospective Studies


Geriatrics | Health Information Technology | Health Services Administration | Primary Care | Translational Medical Research


OBJECTIVES: To assess the effect of an electronic health record-based transitional care intervention involving automated alerts to primary care providers and staff when older adults were discharged from the hospital.

DESIGN: Randomized controlled trial.

SETTING: Large multispecialty group practice.

PARTICIPANTS: Individuals aged 65 and older discharged from hospital to home.

INTERVENTION: In addition to notifying primary care providers about the individual's recent discharge, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and alerts to the primary care provider's support staff to schedule a posthospitalization office visit.

MEASUREMENTS: An outpatient office visit with a primary care provider after discharge and rehospitalization within 30 days after discharge.

RESULTS: Of the 1,870 discharges in the intervention group, 27.7% had an office visit with a primary care provider within 7 days of discharge. Of the 1,791 discharges in the control group, 28.3% had an office visit with a primary care provider within 7 days of discharge. In the intervention group, 18.8% experienced a rehospitalization within the 30-day period after discharge, compared with 19.9% in the control group. The hazard ratio for an office visit with a primary care physician did not significantly differ between the intervention and control groups. The hazard ratio for rehospitalization in the 30-day period after hospital discharge in the intervention versus the control group was 0.94 (95% confidence interval = 0.81-1.1).

CONCLUSION: This electronic health record-based intervention did not have a significant effect on the timeliness of office visits to primary care providers after hospitalization or risk of rehospitalization. Geriatrics Society.


UMCCTS funding

DOI of Published Version



J Am Geriatr Soc. 2014 May;62(5):865-71. doi: 10.1111/jgs.12798 Link to article on publisher's site

Journal/Book/Conference Title

Journal of the American Geriatrics Society

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Link to Article in PubMed

PubMed ID