Welcome to TOTeM's Wiki.
TOTeM (Transmurale zorg voor chirurgische patiënten met ondersteuning door Telemonitoring or Transmural follow-up of surgical patients through Telemonitoring) is a Data Innovation project focusing on early discharge of surgical patients combined with high‑quality remote clinical monitoring at home. The innovation lies in the design and digitalisation of a transmural care pathway using a technology registered with the FAMHP as a Class IIa medical device. This enables, on the one hand, safe and transparent patient assessment and follow‑up from the hospital. On the other hand, the digital care pathway allows every care provider to consult relevant care information from their own electronic record at the right moment. In the case of abnormal measurements or observations, an escalation protocol ensures that the appropriate member of the care team is notified in a timely manner through a 24/7 care centre.
Objectives:
- Development of a new evidence‑based methodology to systematically design and implement transmural surgical care pathways supported by telemonitoring, based on the Telemonitoring Program Design Canvas.
- Application of telemonitoring insights and principles to a new care pathway for a specific patient population, with integrated and structured data collection and data exchange, using a technology registered with the FAMHP as a Class IIa medical device.
- Digital support of the new care pathway, ensuring maximum patient involvement and workflow support through an alert function and integration of data with electronic patient records, both within the hospital and across care settings.
- Strengthening transmural communication between all stakeholders involved.
- Aggregation of (meta)data through the development of dashboards and reporting functionalities to generate clinical and health‑economic insights.
The project was coordinated by Tom Imberechts (tom.imberechts@azsintblasius.be).