AI-Powered Postpartum Clinical Triage & Monitoring Platform

An SMS-first postpartum care platform that helps care teams identify physical, emotional, and social concerns after discharge. AI-assisted response interpretation, human clinical review, and EHR-connected escalation support ongoing monitoring without requiring patients to download an app.

Project Overview

The period between hospital discharge and routine postpartum follow-up can leave care teams with limited visibility into a mother’s recovery. Physical complications, emotional distress, and unmet social needs may emerge while patients are at home, creating a need for accessible outreach and coordinated follow-up. Ditstek developed a postpartum clinical triage platform that uses clinically timed SMS conversations to maintain contact throughout recovery. Configurable programs run from 12 weeks to 12 months postpartum or longer, covering 32 clinical domains. AI helps interpret patient responses using relevant history and clinical guidance, while uncertain classifications receive human review and urgent concerns follow defined escalation pathways. Validated enrollment, separate health-system databases, and EHR integrations connect patient outreach with existing care delivery workflows. The SMS-based experience supports participation without app installation or portal credentials, reducing access barriers for populations including Medicaid beneficiaries and rural patients.

Business Challenges We Addressed

Limited Visibility After Discharge
Care teams needed a way to recognize changes in physical recovery, emotional well-being, and social circumstances between discharge and scheduled appointments.
Ambiguous Patient Responses
Free-text SMS replies could contain unclear descriptions, overlapping concerns, or signals of urgent risk. Automated interpretation required relevant clinical context and a defined review pathway when confidence was insufficient.
Uncertain Postpartum Eligibility
Standard HL7 discharge events did not always establish that a patient had recently given birth. Triggering enrollment from discharge notifications alone could lead to inappropriate outreach.
Health-System Data Isolation
Each health system required separate patient records, clinical protocols, integration settings, and escalation workflows. The platform needed to support shared product capabilities while preserving organizational data boundaries.
Accessible but Clinically Meaningful Outreach
SMS reduced participation barriers but introduced message-length constraints, varied patient language, and consent requirements. Check-ins needed to capture useful information without requiring patients to navigate a portal.
Follow-Up Through Resolution
Generating an alert was only part of the workflow. Concerns needed to reach the appropriate care team, remain visible, and escalate again when acknowledgment or follow-up did not occur within defined timelines.

How We Architected the Solution

Ditstek engineered an SMS-based postpartum care management platform that connects validated enrollment, context-aware AI triage, human oversight, and clinical escalation. Configurable protocols and tenant-specific integrations help health systems adapt monitoring to their care delivery requirements.

AI-Assisted Triage With Human Review

AI interprets patient responses across 32 postpartum domains using relevant conversation history and clinical guidance. Uncertain classifications move to an internal clinical oversight team, while urgent concerns follow established escalation rules.

Validated Event-Driven Enrollment

Inbound HL7 messages are tracked with identifiers, processing status, and payload references. Incomplete messages can be quarantined and replayed, while additional FHIR data helps confirm postpartum eligibility before outreach begins.

Separate Health-System Databases

Dedicated tenant databases isolate patient information, protocols, workflows, and integrations. A central control plane manages platform defaults without combining patient records across health systems.

Accountable Administrative Access

Version-controlled templates support consistent tenant database provisioning. Permission-based, temporary, and logged administrative access works alongside role controls and multi-factor authentication to govern access to clinical information.

Configurable Monitoring and Escalation

SMS programs schedule check-ins at different postpartum stages and support patient-specific adjustments. Urgent concerns follow clinical escalation pathways, while non-emergency needs can be directed toward relevant community resources.

EHR-Connected Care Coordination

CDS Hooks supports alerts within clinical workflows, while SMART on FHIR provides access to monitoring history in the patient’s EHR context. Admission events pause outreach and flag the patient for review.

Core Platform Capabilities

The platform connects patient communication with clinical review, enrollment validation, care-team follow-up, and health-system administration throughout the postpartum monitoring journey.

Personalized Postpartum Programs

Monitoring can be configured at platform, health-system, program, and patient levels. Tenant protocols, individual overrides, and platform defaults support programs spanning 32 postpartum domains.

Stage-Based SMS Check-Ins

Clinically timed questions address early physical risks and continue with mental health and social-needs screening. Patients participate through text messages without installing software or managing portal credentials.

Context-Aware AI Response Analysis

Gemini, Claude, and GPT APIs assist with interpreting anonymized patient responses. PostgreSQL pgvector retrieves relevant conversation history, assessments, clinical protocols, and tenant guidance to support contextual interpretation.

Closed-Loop Clinical Escalation

Uncertain classifications receive internal clinical review. Urgent alerts reach care teams, and unacknowledged concerns can escalate again according to defined service levels and local protocols.

Enrollment Validation and Event Tracking

HL7 event records capture message identifiers, processing outcomes, and source references. Diagnosis, procedure, and service-line information retrieved through FHIR APIs supports postpartum eligibility checks.

EHR-Integrated Monitoring

CDS Hooks surfaces relevant alerts within the clinical workflow. SMART on FHIR gives clinicians access to monitoring history, while admission notifications pause scheduled outreach pending review.

Tenant-Specific Healthcare Integrations

HL7 v2, FHIR R4, Mirth Connect, MLLP/VPN, SFTP, and APIs support connectivity with different health-system environments. Separate integration channels accommodate local EHR and operational requirements.

Patient Data Isolation and Access Controls

Dedicated databases separate tenant patient records, protocols, and integrations. Role-based permissions, multi-factor authentication, row-level security, and logged temporary access support controlled use of sensitive information.

Consent and Care-Team Communication

Consent records capture status, timestamps, sources, terms versions, and supporting evidence. Spruce Health supports secure care-team messaging, while Vital Audio supports video-based vital assessment where applicable.

Tech Implementation

React
Next.js
Tailwind CSS
AWS
Amazon S3
Amazon SQS/SNS
Amazon Cognito
pgvector
Gemini
Anthropic Claude Sonnet
OpenAI
HL7 v2
SMART on FHIR
Notifyre
Epic Integration
Cerner Integration
eClinicalWorks Integration
Spruce Health
Vital Audio

Measurable Business Impact

Broader Visibility Into Patient Needs

Check-ins across physical, emotional, and social domains give care teams a more complete view of concerns emerging during postpartum recovery.

Human Oversight for AI-Assisted Triage

Clinical review gives uncertain interpretations a defined pathway for assessment, helping teams prioritize follow-up while retaining human oversight of consequential decisions.

More Appropriate Patient Outreach

Postpartum eligibility checks and admission-aware messaging help prevent unsuitable outreach. Detailed consent records preserve the history of patient participation and authorization.

Better Follow-Up Visibility

EHR-connected alerts and acknowledgment-based escalation help teams track concerns within existing workflows and maintain visibility into unresolved follow-up.

Adaptable Health-System Deployment

Separate tenant databases and configurable protocols support deployment across health systems, with each organization maintaining its own patient information, integrations, and escalation pathways.