This document describes a study to develop an automated system to provide primary care physicians (PCPs) information about their patients' care during transitions from hospitals to home. The system utilized the medical group's electronic medical record (EMR) and linkages to other facilities to notify PCPs of new medications, lab monitoring needs, and schedule follow up visits. Key findings were that such a system is feasible but requires strong informatics expertise, cooperation from external facilities, and electronic linkages to share data. Extensive physician time was also needed.