SHM Converge Scientific Abstract ePoster Gallery-Mypostdischargepal: An Ehr-Interoperable App for Adverse Event Surveillance During Transitions

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MyPostDischargePal is an EHR-interoperable app designed to monitor adverse events (AEs) in patients with multiple chronic conditions during the high-risk period after hospital discharge. Post-discharge AEs affect about 19–28% of patients and can lead to emergency visits or readmissions, so the app aims to detect early warning signs such as new or worsening symptoms (NWS).<br /><br />The app uses Fast Healthcare Interoperability Resources (FHIR) APIs to pull after-visit summary (AVS) information from the EHR in real time, including medications, follow-up appointments, pending test results, and guidance on whom to contact. Patients then complete daily symptom and global health questionnaires for 7 days after discharge. Their responses are combined with EHR data in an escalation algorithm that triggers three risk levels, with Level 3 indicating high-risk symptoms that may require urgent attention. The app also links patients to education resources such as MedlinePlus.<br /><br />The prototype was developed from feedback from 13 hospitalized patients and 12 clinicians, then refined through 12 rounds of mock testing with researchers, clinicians, patient advisors, and other stakeholders. In a pilot study of 15 discharged patients, 12 (80%) completed at least one questionnaire, and 9 of those completed at least 70% of the questionnaires, suggesting good feasibility and adherence. Patient interviews found the app easy to follow, well timed, and supportive. Clinicians noted the need to clarify responsibility for escalation between attending physicians and primary care providers.<br /><br />Among three patients who triggered high-risk escalation, two had an emergency room visit within 7 days, supporting the potential value of the approach. Next steps include improving prediction using more EHR data and symptom trends, using generative AI to help interpret patient-reported outcomes, clarifying clinician workflows, and testing the app in a randomized controlled trial.

Asset Subtitle

Anuj K. Dalal

Meta Tag

Author List Abhishek Goyal, Anant Vasudevan, Anuj K. Dalal, Jorge A. Rodriguez, Madeline Smith, Marie H. Leeson, Pamela M. Garabedian, Robert S. Rudin, Savanna Plombon

Category Innovations

Concept Adverse Effect Surveillance

Concept Post-Discharge Period

Concept Patient-Reported Outcome

Concept Symptom Monitoring

Concept Chronic Condition

Distinguished Non-Finalist

Presenter Organization Brigham and Women's Hospital

Presenting Author Anuj K. Dalal

Track Technology in Hospital Medicine

Keywords

post-discharge adverse events

EHR interoperability

FHIR APIs

after-visit summary

symptom monitoring

new or worsening symptoms

risk escalation algorithm

patient questionnaires

hospital discharge

readmission prevention

Adverse Effect Surveillance

Post-Discharge Period

Patient-Reported Outcome

Symptom Monitoring

Chronic Condition