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Interoperability Proving Ground (IPG) submissions within the ONC Tech Lab are submitted by healthcare, technology and development organizations that are invested in Health IT and Interoperability and want to share, learn and collaborate with similar stakeholders in the US, and around the world.

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Acute discharge information to PCP via Direct

Description 
For patients deemed, by algorithm, to be at high risk of readmission, hospital discharge information is pushed via Direct initially to a team that attaches relevant inpatient documentation to support a more thorough transitions of care encounter. That message with multiple attachments is then pushed via Direct to the Patient’s PCP’s Direct mailbox.
  • anupam.goel@uhc.com
Start Date 
01/01/2018
Projected End Date 
05/01/2018
Project Tags 
  • Care Transitions
  • DIRECT
  • Direct Interoperability
  • interoperability
  • Interoperability
  • transitions of care
  • Transitions of Care
Project Point of Contact: kelly.gwynnremove@removedirecttrust.org
Project Results 
For patients deemed, by algorithm, to be at high risk of readmission, hospital discharge information is pushed via Direct initially to a team that attaches relevant inpatient documentation to support a more thorough transitions of care encounter. That message with multiple attachments is then pushed via Direct to the Patient’s PCP’s Direct mailbox.