Post-Discharge Telemonitoring
Sector: Hospitals, post-acute care
The scenario
Imagine a cardiology department that wants to reduce 30-day readmissions of heart failure patients. Patients who go home without structured follow-up may deteriorate unnoticed and return to the emergency department in worse shape. A phone call program at 48 hours and 7 days helps, but doesn't scale and can miss changes between calls.
You want patients to report daily weight, blood pressure and symptoms from home, and you want care coordinators to see the patients who need attention, not a raw stream of readings.
What goes wrong without the right tool
- Home readings end up in a separate system from the hospital record, so when the patient is readmitted, someone has to reconcile them by hand.
- The alert logic lives in a custom monitoring database nobody else can maintain.
- Extending the program to another department (for example orthopedics after joint replacement) means building it again.
How Atomik can be used
- Use the patient's existing EHR. Patients discharged with heart failure already have an EHR. Home data is added to that same EHR.
- Collect from a patient app. A patient-facing app, built by you, commits daily readings (weight, blood pressure, a structured symptom checklist) as compositions through the REST API.
- Define the alert as a combined query. For example, weight up by more than a threshold within 72 hours (one composition query) and dyspnea reported in the last symptom checklist (another), combined (Combined Queries, a premium feature).
- Run it and surface it. Your application or scheduler runs the query on a cadence and shows the resulting list to care coordinators. Atomik provides the data and the query; the dashboard and the notification path are yours.
- Give the ED the full picture on readmission. Because the home data is in the same EHR as the admission, the admitting physician can see the post-discharge trend in the patient's record.
- Reuse it for other programs. Another department adds its own template (for example pain scores, range of motion, and wound photos referenced as multimedia) on the same infrastructure.
How CaboLabs can help
Connecting the patient app and the hospital record to Atomik is integration and API design work that CaboLabs, the builder of Atomik, can help with: see HIS Integration and API Design. Atomik doesn't require CaboLabs services.
What this gives you
Home data and hospital data in one record, alert logic that clinical staff can adjust, and a pattern you can reuse for other programs.
Why Atomik fits
Home readings that live apart from the hospital chart are just another silo. Atomik keeps them in the same patient record as the admission, so the care team sees one story and nothing has to be reconciled by hand.