Five Questions and an Elevator Pitch: ContinuuMed

1. What is the need that your project seeks to address?

Romal: When a patient is admitted to a hospital, they receive constant attention from clinicians and nurses. When it is time for their discharge, however, this high level of assistance and support abruptly diminishes. Although there is some follow-up care after their hospital visit, it is often unstandardized and difficult to maintain for long periods of time. In a sense, we noticed that the continuum of care extends only to the point of hospital discharge, which is inadequate, especially for geriatric patients navigating this alone.

Madhuhaas: At the time of discharge, geriatric patients are often not in an ideal condition to process the medical information needed to safely navigate their care at home. Geriatric patients are often physically and mentally exhausted from their stay in the hospital, which can cause patients to enter a state of delirium that is not conducive to comprehension of new information, like their discharge plan. They often do not ask questions or have the confidence to advocate for themselves during this care transition process. And, unfortunately, the lack of treatment adherence can lead to otherwise avoidable hospital readmissions.

Katie: We are looking to improve health plan adherence and coordination of care, during and following hospital discharge for geriatric patients, to prevent hospital readmissions associated with post-discharge treatment errors. The current transition process often compromises the geriatric patient's ability to adhere to their treatment plan and to navigate their care independently, which results in a negative impact on the patient's quality of care. We found in prior studies that, following discharge from a hospital visit, up to 60% of seniors either misunderstood the indication dose or the frequency of their medications. And about 50% of these patients had at least one discordant medication, which is just a staggering statistic!

Romal: We also found that the prevailing view of the hospital staff teams who conduct transition of care is that the current process of moving hospitalized seniors back home is very decentralized and poorly organized. The timeline for these transition of care teams to actually get in touch with patients is very scattered.

2. How does your solution work?

Madhuhaas: Our solution is an AI-powered virtual companion and advocate designed to aid geriatric patients during their transition from hospital to home. The goal is to improve patient retention and understanding of their discharge information, while also reducing the workload of the responsible transition of care team. The tool uses patient-nurse conversations and generates personalized discharge summaries for the patient using medical terminology that is clear, digestible, and tailored to each patient's needs.

What really sets our solution apart is that patients can continue receiving guidance through an integrated AI-assistant that answers follow-up questions and helps them navigate their care plan by acting as an interface between the patient and the transition of care team, improving communication between patients, caregivers, and physicians.

Romal: We anticipate that the use of this AI tool will eventually save time for clinicians and transition of care staff in clarifying information, as patients would have already addressed the main areas of concern and routine questions in the discharge summary provided by the tool. It also will help the teams prioritize patients that are most in need of personalized follow-up care to prevent avoidable readmissions.

Katie: We definitely want to integrate this tool as seamlessly as possible into the existing hospital workflows. Our need criteria include its accessibility, to make sure the tool is compatible with different devices; an easy-to-use design with geriatric patients in mind; its personalized responses; and its adherence to the nurse or physician's recommendations.

3. What motivated you to take on the project? And what activities have you undertaken?

Madhuhaas: My motivation for this project came from volunteering in a hospital, where I saw how patients often leave without getting all their questions answered. I’ve also experienced personally not having enough time during appointments to ask questions and having to turn to Google for answers. I believe new technologies, especially AI, can help bridge that gap of access to information from the hospital to the patient’s home.

To better understand the problem, we’ve conducted over 30 interviews with stakeholders ranging from geriatricians and skilled nursing facility managers to patients and caregivers. We’ve tapped into Stanford Biodesign’s network for mentorship and support, including our university experts like Dr. Katherine Ward, the clinical chief of geriatrics in the department of medicine at Stanford. We’re now refining our prototype based on all this input, iterating on the product to make sure it truly meets the patient’s needs.

Romal: When I learned about the Biodesign for Digital Health class, it felt like the perfect intersection of everything I was passionate about: biology, innovation, and computer science. I was especially motivated by the opportunity to innovate in the digital health space, making health data more accessible—not just to patients, but also to caregivers and physicians—which I believe is a huge part of the future of healthcare. We’re currently developing the platform and plan to launch a qualitative improvement pilot study to assess its effectiveness. Ultimately, we hope to integrate our tool directly into the existing hospital system platforms.

Katie: I was mainly just shocked to learn about how disorganized the hospital discharge process can be when we interviewed stakeholders. I think we all quickly realized that this was a key spot to home in on.

4. What’s the most important thing you learned in advancing your project?

Romal: My biggest takeaway has been realizing how resistant the medical field can be to change. Rather than trying to reinvent the wheel or design an entirely new system, it's crucial to innovate within the existing framework. This means identifying real problems first and then developing solutions.

Madhuhaas: From my experience with this project, I've learned that the best solutions combine technological innovation with a deep understanding of real-world needs and incorporate the perspectives of different stakeholders. These solutions are usable, accessible, and built with the patient's needs in mind.

Katie: One of the biggest takeaways for me has been the importance of flexibility when building this type of solution. This was emphasized during the Biodesign for Digital Health course, but it became especially clear as we developed our solution.

5. What advice do you have for other aspiring health technology innovators?

Madhuhaas: My biggest advice would be to always start with a clear problem and understanding of what is needed before jumping into solutions. I recommend talking to as many stakeholders as possible to understand their viewpoints because your solution will impact their lives and workflows. Remember that your first solution may not be your final one—there's always room to improve, grow, and incorporate new feedback to better address the issue.

Romal: When innovating in the medical space, it's crucial to consider regulatory aspects early on, such as FDA approval and HIPAA compliance. These factors significantly shape your product development, and addressing them from the beginning can help you avoid major changes later. It’s also important to think about how your solution can grow and scale in the future.

Katie: Also, build a strong team and leverage each member's strengths. Romal, Madhuhaas, and I were fortunate to form a complementary team, with each person bringing unique skills and perspectives. These problems are complex and difficult to tackle alone, so definitely reach out to your network and assemble a team with skills that complement each other.