Using the avoMD Clinical Decision Support App in Practice

Transcript

Winston Wong:  Good day. Welcome to the "Journal of Clinical Pathways." My name is Winston Wong, and I will be moderating part two of our interview series with avoMD. In part one, we had the opportunity to learn about who our avoMD is, what led to their development, and where their founders see as their future.

In this segment, we're going to explore more about the capabilities of the platform. With that, I will turn it over to avoMD.

Yair Saperstein:  Nice to be back here. Thank you. This is my personal device. As I go into avoMD, looking at screen for avoMD, it has the institutional pathways for our institutional partners, and it also has the public pathways. Anybody that wants to try it, you can just type into the App Store avoMD, and you can try it for free on one of our public pathways.

For this purpose of the demo, I'm going to show you one of our pathways that we built in collaboration with PM pediatrics, which is one of our partnering organizations. I'm going to show you asthma management during COVID.

As I go through this, I'm going to point out some of the features that are within our software and that can be used. The introduction card is, here's where you should be using this pathway to be used for patients more than three years old with a history of wheezing or asthma.

The orange cards are, here's the actions that you should do. Oxygen should be given to all patients to keep the saturations high. For all patients in respiratory distress, you have to wear full PPE, which it explains what it is.

Let's say you need help as far as, how do I open an oxygen tank? Click on one of these little green buttons like opening an oxygen tank over here, which can tell you exactly how to open the oxygen tank.

Of course, these things don't interfere with the flow. If you already know your patients, you know what to do, and you know what the initial asthma score is, just click, for example, 9 to 12. You get taken immediately into the tap to read. You'll find out, "Call EMS hospital transfer team, stabilizes per the asthma protocol." You can get more information below, and you know exactly what to do immediately.

We'll go back here. Of course, if you want to go through the asthma scoring, you can go through your calculator and find out what the asthma score is for your patients. The system is able to smartly take whatever comes in and give you automated questions that can guide you in the way that you're thinking as a clinician as far as what are the next steps to ask, what are the next steps to look for.

Depending on your child's age, let's say, the patient is two to three years, it'll ask you these respiration rate questions. It's 22 to 29 and so on. If a patient is over 13 years, it'll ask you about respiration rate of 14 to 19 because it changes based on how old the patient is.

Let's say our patient is four to five years. Their respiration rate is 20 to 24. However, they're having two retraction features. They can count only four to six in one breath. They're having expiratory wheeze only. That's going to get me a score of six, which is moderate. I hit Submit, and it changes my score to be six.

It tells me I should give some oral dexamethasone, one of the bronchodilator options, repeat the asthma score. This is my action card. I can always click for more like bronchodilator options and find out exactly what I should be giving. If I already know, again, I can skip those little green buttons and just continue on to the second asthma score.

Over here, it's the same calculator. Let's say the patient happens to be at five to eighth, and I don't need the calculator this time. We'll just click on that and tap to read. That'll take me into, "What do I do for this patient now?" For example, if only albuterol was given previously, give the second dose of albuterol.

If I want more details on it, I can either click More or click on the little button on top and get more details. As an example, if only epinephrine was given previously, not albuterol, you're going to give a second dose of epi.

How do I do that? How do I give a second dose? Click on the green card and find out. Here is what I should be giving based on the patient's weight plus some tips of how I can give it.

That is the basics of the software. I'll hit Back out Here to go back out. Of course, you can get for whatever condition you would want for the clinical conditions on hand. It's also fully searchable.

Let's say I have a patient who is coming in with a UTI. I'll search for UTI, and it gives me my acute UTI in adult. If I have UTI for kids, I can click on that pathway depending on which clinical scenario it is and get all of my information there.

Besides for that, we have subscription features which allow the ability to get different packages. If you are adult ENTs, then you can get for adults, you can get [indecipherable 5:24] . If you have a need for other packages, then you can get further packages.

Of course, on the top left, if you're having any issues, you can always contact us to report any bugs, report any errors you may find, or report any issues that you may be having. Then, we can get into immediate contact with you to be able to help.

That's a demonstration of our software. I'm going to show you one more, which is atrial fibrillation. Atrial fibrillation, I'll click on atrial fibrillation. Now, I'm asked about the patient's hemodynamic status. If the patient's unstable, it immediately will take me into here's what I do for hemodynamic instability, urgent cardioversion. Here's how to give it.

It's going to be 120 joules if it's biphasic and 200 joules if it's monophasic. Again, I can click on these references like number five and be linked out to the article itself. If I click on the article, then it takes me straight to here's how to do transthoracic cardioversion for A-fib, and I can get more information.

I'll hop right back into the app, then X, and go back. Let's say the patient is stable, then it'll guide me down the algorithm per the ACC/AHA algorithm for atrial fibrillation. It'll ask me about mechanical heart valves or moderate/severe mitral stenosis. I'll hit Yes or No depending on what my patient has.

That little gray text above it is to tell the clinician why they're being asked the question, because when clinicians know why they're being asked questions, then they're able to respond more in kind according to the literature.

Over here, I'll hit No for my hypothetical patient, and I have a CHADS-VASc calculator. Again, I could go through the calculator, or I could just click low/moderate/high if I don't need a calculator. For these purposes, let me click on the calculator. Patient age, let's say, is 78; female with CHF; no hypertension; no stroke; yes, vascular disease; and yes, diabetes. That'll get me a score of six.

Three or greater in women is going to be a higher risk of thromboembolism. It's going to be high. Same idea for a HAS-BLED score. Let's just say it's moderate and skip the calculator. The last question is, is the patient having end-stage CKD or dialysis because they'll have limited therapeutic options? Let's say no.

Tap to read. It has my inputs on the top. These are the question inputs that I gave answers to. Then my summary, here's what I should be doing for these patients. I can always get more information. Let's say rate control. I click on it. It says that the guidelines are going to determine the goal target resting heart rate based on the presence or absence of symptoms.

If the patient's symptomatic -- let's say they are symptomatic -- my goal is less than 80. Asymptomatic, the goal is less than 110. Again, I can get further info here, like what I should give just by clicking on each of these green highlights, for example, intravenous medications. Here's what I can give, and I can be sourced to the direct source by clicking on the references.

That can give me the actual article itself where I can hop right back. That's my demo of the point-of-care software.

Winston:  Curiosity, you showed that you can click on the various references as well as the various societal guidelines and even up to date, which I know it basically requires a subscription from a public standpoint. Is there a subscription that's required to access it from your software, or do you have maybe a corporate license or something that allows you to see those guidelines and information?

Yair:  The way that we allow institutions to customize is that whatever they have access to, whether it would be to fill out a specific form, or they have access to other software, then they can include that kind of information within the workflow processes of these clinical decision supports of our software.

If they want to link out to some private, other resources that they have, then that can certainly be included. That's what I was showing how you can really have a link within the software here to incorporate whatever resources the institution has.

Winston:  In terms of data collection, is there any type of data collection that you have that measures satisfaction or even whether the clinician agrees or disagrees with what you're calculating and what the results are?

Yair:  Our analytics layer is able to capture which pathways each individual provider is using. It's able to capture how many times they use it, how long they spend on it, and how often they're returning to it. You can get some feeling of how much people are using it and therefore how much they liked it.

Separately, we often suggest in ourselves to speak with providers to assess for their satisfaction and specifics about their satisfaction to continually improve the software. Some of the work that we've done beforehand include...

We did a trial at Englewood Hospital using the system usability scale. Our score in the high 80s was definitely higher than being for Cerner and Epic, which is in the in the high 50s or so.

Winston:  You wanted to move on to another demo?

Yair:  I wanted to show you, first of all, that it's cross-platform. Over here, with software being cross-platform, you can access the same things that you had on the phone right on the computer. For an example, as a management during COVID, it's the same exact thing that you saw on the phone. You now have access to it on the computer.

The second thing that I wanted to show is the builder. Over here, in the builder, this is the same thing with the builder side. Within the builder side, it's exactly what you saw from the software side, from the point of care tool, except that you can also drag and drop anything that you may need into here.

If you want to add another choice, you can just drag and drop it directly into the builder to build in another choice. You can add calculators. For each of the answer choices, each of those will correlate with the next question that appears based on which of the answer choices you're choosing to drag to the next question.

When you finally get to your answers -- this is the answer page -- then it's also going to be correlated from a final question and a final answer choice, which is going to then tell you what your answer pages.

Laurence Coman:  If I may just get some context to this. This is a tool for our hospital and physician partners so that they can instantly create, update, and review their own interactive guidelines on the point-of-care app. Relative to a lot of other clinical decision support tools, this requires no coding knowledge, no technical knowledge to be deployed at our institutional partners.

For us, it can take us an hour to create one of these digital guidelines because we're very familiar with the tool. To our institutional partners, that may take a little bit longer, but we really think the power of our platform and the ability to create content, it resides in this piece that will ultimately fit with and be autonomously used by our end users and clinical partners.

Winston:  Quick question then. This is great because I think this is what you're referring to in our first meeting where you talked about the background being the treatment guidelines and recommendations that are out there nationally. Then this is how the individual institutions go and put their own treatment pathways or whichever into the system, and you can compare the two.

What you talked about was you can set up. It takes you about an hour to go instead of at least the basics. Are you having your clients put their own pathways in, or do you support that entry as well?

Laurence:  The model is highly flexible. If our partners want to own all the digitalization piece and all the building piece themselves, they have the ability to do that. Our tool is usable and user-friendly, such that they can do that. The other end of that model or the other part of that scale is where this tool sets with our team.

Two of the cofounders on the line right now are physicians. One is in implementation. We have two other informatics folks on our team. We have the ability to do all this on our own and almost provide that service to our partners.

Because we've been doing this for a while, we tend to have a good eye for usability, what are the right steps, and how to structure these digital guidelines, so we can provide the service as well.

Winston:  Great. Was there another part of the demo you wanted to move on to?

Yair:  That was it that I wanted to show for the demo, but the highlights of what I wanted to bring out from the demo are that our institutional partners who often have guidelines or algorithms that they're using but are having difficulty in getting their providers to actually use it are often looking for a solution to increase adherence but still having their providers like their guidelines and to use it.

The purpose of our software from the institution standpoint, from the hospitals, from the urgent cares is that they can increase the unification of care and the reduced care variation and actually make it that the evidence-based medicine care pathway is are followed by using an app and using software that the clinicians love and really take to.

What we've demoed is that, number one, the point-of-care tool has the ability for the clinicians to easily get to the information that they need and be in a checklist way, like "The Checklist Manifesto" by Atul Gawande, or have as much information as needed so that people that may not have all that info don't get lost and can still give patients the best care.

It's also a simple act to use. It allows for quick access to the information when needed from the clinician standpoint. From the institution standpoint, there's the ability to put all the information needed into this algorithm that then gets synced to the app and to the desktop as needed because it's cross-platform.

I wanted to bring out from that the ability for institutions to customize it as much as needed with the support and guidance of our team to be able to get all that information up and running almost immediately.

It allows institutions to have their providers use their guidelines and use their pathways in a way that suits them where it's customizable, something that really is not happening otherwise because it can be customized to the hospital to reduce care variation but still be local and specific.

Winston:  That is great. I think I see two applications for your platform. You've got institutions out there that fall in one of two buckets. One bucket is that they just don't want to go and tell their physicians how to go on practice medicine. They just rely on their physicians to go and practice based upon the national guidelines.

Then you have other institutions that are maybe a little more aggressive. They take the guidelines. As you mentioned, they go and put their own treatment pathways in on the name of trying to go and decrease the variability of care that's being offered, whichever way you go, be it their own pathways, their own treatment guidelines, or even going with the standard.

Quite often, as you said, the buy-in from the physicians are really iffy, simply because they just don't have access to the guidelines that they think it should be going to. I think either right on the nose, you try and go and decrease the variability in terms of how your physicians are practicing.

Ultimately, what hopefully happens is that you do have a higher or a better clinical outcome because you're practicing evidence-based medicine and at the end of the day, hopefully, helping to control costs. I thank you very much for this demo.

I would like to go and thank our viewers for taking the time to listen. Thank you to the Journal of Clinical Pathways for organizing this discussion. Please check out www.journalofclinicalpathways.com for the latest updates on issues related to development, implementation, and evaluation of clinical pathways.