Illustrative scenario · Health systems
Following cardiology patients after discharge
A hospital cardiology service wanted better visibility of patients in the 90 days after discharge.
Challenge
The scenario's data and workflow challenges
- Follow-up relied on phone calls to every patient.
- Changes in symptoms or activity reached the team late.
Data sources
Data sources in the illustrative workflow
- EHR discharge records
- Weight and blood pressure devices
- Symptom check-ins
- Wearable activity
Approach
The proposed collection and integration approach
1
EHR integration
Discharge data flowed in from the record system.
2
Daily signals
Patients shared activity, weight and symptom check-ins.
3
Outreach list
Care managers received a prioritized daily list.
Workflow
- Discharge
- App enrollment
- Daily signals
- Prioritized list
- Care manager call
Outputs
Illustrative outputs for each team
- Care managers
- Who to contact today, and why
- Cardiologists
- 90-day trajectory at follow-up
- Executives
- Population view of post-discharge follow-up
Outcomes
Results, once confirmed
We only publish measured outcomes that have been confirmed and approved.
- Outcomes are reviewed with the program and published only after confirmation.
- Readmission outcomes tracked for review
More scenarios
Related scenarios
Request a demo
Explore disease, treatment and behavior together
Explore how clinical, treatment and behavioral information align around your program and the research or review questions your team needs to answer.
Book a demo
Opens the Calendly booking page in a new tab.
Prefer to write first? Send an inquiry and the team will reply.