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

What this Trial Is About

Researchers are evaluating the use of real-time symptom monitoring through electronic patient-reported outcomes (ePROs) to predict and reduce adverse events (AEs) after hospital discharge in patients with multiple chronic conditions (MCC). The study aims to develop and validate a predictive model for post-discharge AEs, improve digital health tools integrated with electronic health records (EHR), and assess the impact of this intervention compared to usual care. This large-scale randomized controlled trial is supported by Brigham and Women's Hospital and focuses on improving safety during care transitions for MCC patients. The study includes three main periods: an 18-month baseline period where 450 patients receive usual care to help develop the predictive model, followed by a 30-month randomized controlled trial (RCT) where 850 patients are assigned either to usual care or to the intervention group using an ePRO application. This app is integrated with patient portals and EHR systems to communicate risk and monitor symptoms in real time based on patient-reported questionnaires. It also facilitates communication with clinicians when symptom trends suggest potential risks. Participants will be hospitalized adults with multiple chronic conditions discharged to home or care facilities. They will be monitored for up to 30 days after hospital discharge for actual and preventable adverse events, as well as healthcare utilization such as readmissions and ambulatory visits. The study collects patient-reported outcomes, EHR data, and uses digital tools for symptom tracking and communication. Researchers will also evaluate barriers and facilitators to the intervention's use with the goal of sustainable implementation and wider dissemination.

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