Background:  A small population of patients disproportionately consume an increasing share of medical resources.  These super-utilizers often have complex medical and psychosocial conditions that require carefully coordinated, individualized care.  As this population drives unplanned readmissions, programs to reduce readmissions may create unintended incentives to direct super-utilizers to another hospital system.   This study was designed to [...]

Background:  Transitions of care, whether between or within institutions, are an important source of errors, inefficiency, and unnecessary costs.  Inter-hospital transfers are complicated by incongruent information systems, indirect and asynchronous communication, and geographical distance all in settings of high patient complexity and acuity.  We developed a large database of patients transferred between hospitals to identify [...]

Background:  As electronic health records (EHR) become ubiquitous, the impact on patient outcomes remains largely unknown.  One major communication barrier during patient transfers is the lack of interoperability between EHR systems.  Inter-hospital transfers involve transitioning high acuity patients between hospital systems that may not be able to directly communicate with one another, creating the ideal [...]