The challenge we were solving

During the COVID-19 pandemic, cardiac surgery patients – already at high risk – faced limited access to in-person follow-up care. The challenge: how to ensure safe, continuous monitoring without hospital visits, while maintaining quality of care and reducing the risk of complications.

This project aimed to address that challenge by developing an AI-based telemonitoring system to support clinicians in the remote follow-up of cardiothoracic surgery patients after discharge.

Project partners

    

Project goals

  1. Develop an AI-powered digital system to support remote follow-up care.
  2. Enable early detection of post-surgical complications using predictive algorithms.
  3. Use patient-generated health data (PROMs and CROMs) to enhance communication.
  4. Improve resource allocation by identifying patients who benefit most from telemonitoring.
  5. Evaluate the cost-effectiveness and clinical impact of remote patient monitoring.

 

Patient flow within CardioFollow.AI.

Our role

At the Cardiothoracic Surgery Service of Hospital de Santa Marta, VOH.CoLAB:

  • Co-designed the telemonitoring workflow;
  • Integrated IoT devices and intelligent algorithms into patient follow-up;
  • Supported the development of a web platform and mobile app for collecting PROMs (Patient-Reported Outcome Measures) and CROMs (Clinician-Reported Outcome Measures);
  • Contributed to the value-based analysis of remote monitoring in both pandemic and non-pandemic contexts.

Lead researcher at VOH

Federico Guede, PhD

Head of AI-based Multimodal Systems

Project outcomes and impact

  • Implemented an AI-based telemonitoring system for post-cardiothoracic surgery care.
  • Deployed a machine learning algorithm for predicting 3-month complication risk.
  • Collected over 26,991 PROMs via devices and 23,512 via questionnaires, focusing on symptoms like dyspnea, palpitations, and edema.
  • Improved patient-clinician communication through digital PROMs/CROMs interface.
  • Remote patient monitoring (RPM) had higher satisfaction, with 32% requesting more frequent follow-ups.
  • Cost analysis showed €122 in direct costs and 4 hours of provider time per patient added with RPM – providing key insights into health system efficiency and value.

Publications

  • Martins, A., Londral, A., Nunes, I., & Lapão, L. V. (2024). Unlocking human-like conversations: Scoping review of automation techniques for personalized healthcare interventions using conversational agents. International Journal of Medical Informatics, 185, 105385. https://doi.org/10.1016/j.ijmedinf.2024.105385
  • Santos, R., Ribeiro, B., Sousa, I., Santos, J., Guede-Fernández, F., Dias, P., Carreiro, A. V., Gamboa, H., Coelho, P., Fragata, J., & Londral, A. (2023). Predicting post-discharge complications in cardiothoracic surgery: A clinical decision support system to optimize remote patient monitoring resources. International Journal of Medical Informatics, 105307. https://doi.org/10.1016/j.ijmedinf.2023.105307
  • Pereira, C., Guede-Fernández, F., Vigário, R., Coelho, P., Fragata, J., & Londral, A. (2023). Image analysis system for early detection of cardiothoracic surgery wound alterations based on artificial intelligence models. Applied Sciences, 13(4), 2120. https://doi.org/10.3390/app13042120
  • Curioso, I., Santos, R., Ribeiro, B., Carreiro, A., Coelho, P., Fragata, J., & Gamboa, H. (2023). Addressing the curse of missing data in clinical contexts: A novel approach to correlation-based imputation. Journal of King Saud University-Computer and Information Sciences, 35(6), 101562. https://doi.org/10.1016/j.jksuci.2023.101562
  • Azevedo, S., Guede-Fernández, F., von Hafe, F., Dias, P., Lopes, I., Cardoso, N., Coelho, P., Santos, J., Fragata, J., Vital, C., Semedo, H., Gualdino, A., & Londral, A. (2022). Scaling-up digital follow-up care services: collaborative development and implementation of Remote Patient Monitoring pilot initiatives to increase access to follow-up care. Frontiers in digital health, 4, 1006447. https://doi.org/10.3389/fdgth.2022.1006447
  • Londral, A., Azevedo, S., Dias, P., Ramos, C., Santos, J., Martins, F., Silva, R., Semedo, H., Vital, C., Gualdino, A., Falcão, J., Lapão, L. V., Coelho, P., & Fragata, J. G. (2022). Developing and validating high-value patient digital follow-up services: a pilot study in cardiac surgery. BMC health services research, 22(1), 680. https://doi.org/10.1186/s12913-022-08073-4
  • Fragata, J. (2022). Vou ser operado ao coração, e agora? Guia para uma rápida recuperação. Editora d’IDEIAS.
  • Londral, A., Azevedo, S., Santos, J., & Coelho, P. (2021). CardioFollow.AI – A digital follow-up service expanded beyond the hospital walls. HealthManagement.org, 21(6). https://healthmanagement.org/c/healthmanagement/issuearticle/cardiofollow-ai-a-digital-follow-up-service-expanded-beyond-the-hospital-walls