Real-Time Symptom Monitoring Using ePROs to Prevent Adverse Events During Care Transitions

Using real-time patient-reported outcomes of hospitalized patients has the potential to reduce adverse events during care transitions by improving the identification of at-risk patients with multiple chronic conditions.

Project Details -
Ongoing

Adverse events (AE) during care transitions threaten patient safety and increase readmissions. Risks are heightened for patients with multiple chronic conditions (MCCs). Collecting electronic patient-reported outcomes (ePROs) and combining them with data from electronic health records (EHRs) has the potential to improve risk identification to better inform communication for patients, their caregivers, and the care team. While ePROs are increasingly being used in ambulatory care settings, using them for real-time symptom monitoring and identification of those at risk during care transitions is relatively new and may transform the way care is delivered to patients with MCCs.

The researchers will develop and validate a predictive model of post-discharge AEs for hospitalized patients with MCCs using relevant ePRO questionnaires and EHR-derived data. Digital tools will be enhanced with these data and integrated with an existing patient portal that will allow patients to report PROs, and care teams to monitor them.

The specific aims of the research are as follows:

  • Develop and validate a predictive model of post-discharge AEs for hospitalized MCC patients.
  • Combine, adapt, extend, and iteratively refine patient-centric, interoperable digital health tools.
  • Conduct a randomized controlled trial to evaluate the impact of ePRO symptom monitoring on post-discharge AEs and healthcare utilization for MCC patients during care transitions.
  • Use mixed methods to evaluate barriers and facilitators of implementation and use of ePRO symptom monitoring.

The researchers hypothesize that compared to usual care, monitoring of ePROs will reduce post-discharge AEs and post-discharge healthcare resource utilization, which will be evaluated in a randomized controlled trial examining patients with MCCs during care transitions. In addition, the research will evaluate barriers and facilitators of this approach using mixed methods and disseminate the findings to other institutions with different EHR vendors.