Abstract 13358: A Platform for the Personalized Management of Diabetes and Cardiovascular Disease at Population Scale With Data From Multiple Sensors

Introduction: The American Heart Association has identified the design of mobile health (mHealth) tools to improve the management of diabetes and cardiovascular disease and to prevent unplanned hospital readmissions as a priority. Methods: We developed HEART, an open source platform for personalized telehealth at population scale based on data from internet-connected health sensors and data extracted from the electronic medical record (EMR). Health sensors include scales, blood pressure monitors, activity monitors, continuous glucose monitors, and insulin pumps. EMR data include gender, age, race, reason for admission, all surgical procedures performed, and all medications prescribed upon discharge. We collected admission and readmission data for all cardiology patients at an academic pediatric medical center over the last 7 years. Results: HEART has five independent modules (Figure): 1) a data processing module that pulls data in from a variety of devices and EHR feeds, 2) an algorithm module that identifies reasons why a provider may want to contact a patient and ranks patients for contact, 3) a visual interface module that summarizes population data and provides additional details for patients selected by the provider, 4) an intervention module that facilitates messages being sent to providers and documented in the EMR, and 5) a user tracking module that monitors providers use. HEART ranks the entire population cared for by a clinic and allows providers to identify easily those patients who may benefit most from a secure message, telemedicine contact, or in-person visit. There were 5,011 admissions to cardiology among 2,916 patients, with 1000 urgent readmissions for 512 patients and 35,300 outpatient clinic visits. Conclusions: HEART is a population-level framework to facilitate personalized mHealth with data from a variety of sensors and EMR data feeds. It may facilitate outpatient monitoring as part of an effort to prevent unplanned hospital readmission.