Clinical Guidelines: The Gold Standard Connecting Technology to the Point of Care
Cover Story | The current environment of rapid changes in science and care delivery, coupled with increased reliance on and access to mobile technologies, mandates new approaches to how evidence-based science is applied at the point of care.
The ACC and the American Heart Association (AHA) published their first cooperative guideline on cardiac pacemakers in 1984. Since then, the organizations have released more than 20 clinical practice guidelines addressing topics ranging from acute coronary syndromes to vascular medicine. These guidelines remain the gold standard when it comes to synthesizing the latest scientific research into recommendations that cardiovascular professionals can use to inform patient care. Guidelines are so valuable that ACC members spanning across the care team continually rank them among the top benefits of ACC membership.
However, in order to continue to provide the highest quality patient care and remain relevant to the growing cadre of cardiovascular professionals around the globe, there is a clear need to develop new guideline-based tools that leverage new digital technologies while allowing the flexibility to adapt to new technologies on the horizon. Already, prolonged periods between guideline updates and revisions are being relegated to the past, with today’s guidelines published on digital platforms that allow for quicker adjustments and edits when warranted by new evidence. There has also been an expansion of the peer review process, and an accelerated public release of the manuscripts in recent years.
In a recent review of the evolution and future of ACC/AHA clinical practice guidelines, published in the Journal of the American College of Cardiology, authors identified even further changes needed to help clinicians keep up with the progressive developments in medical research and technology. Among the recommendations: a vision for guideline recommendations to be embedded within electronic medical record systems and mobile devices that will be accessible at the point of care; and increased harmonization of guidelines with other organizations in the U.S. and abroad to minimize confusion and enhance adherence to recommendations.
According to Richard Kovacs, MD, FACC, chair-elect of the ACC’s Clinical Quality Committee, the College is already forging ahead to make this vision a reality. “It is the ACC’s responsibility as the most trusted source of information and tools to transform care and improve heart health, to make our guidelines even better,” he says. “Shortening the time from evidence development to evidence in practice is key to helping members keep pace with new knowledge, as well as deal with time-related pressures associated with busy practices and an increased focus on evidence-based clinical outcomes.”
In one of its first efforts to make guidelines more usable at the point of care, the College and the AHA earlier this year debuted the ASCVD Risk Estimator, a mobile app to help health care providers and patients estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD) using the Pooled Cohort Equations and lifetime risk prediction tools. The app – designed as a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk and the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults – provides easy access to recommendations specific to calculated risk estimates. Additionally, it includes readily accessible guideline reference information for both providers and patients related to therapy, monitoring and lifestyle.
The app was so successful that the first month alone saw more than 17,000 downloads from the iTunes and Google Play stores. The number of downloads has since increased to nearly 121,000 and current statistics show an average of more than 9,500 people using the app or its web-based counterpart on a daily basis.
Most recently, the ACC launched its new Guideline Clinical App to serve as the mobile home of clinical guideline content and tools for clinicians caring for patients with cardiovascular disease. Now in the pilot phase, the app allows clinicians to quickly access guideline recommendations and use interactive tools from five guidelines, including heart failure, assessment of cardiovascular risk, treatment of blood cholesterol, valvular heart disease and atrial fibrillation. The app is intended to help clinicians access and implement the guidelines through a variety of functions. Not only does the app reference the guideline recommendation table to help with clinical decision making, patient education tools are also available to help facilitate discussions at the point of care around diagnoses, risk scores, medication choice and dosing, etc. There are also “notes” and email functions to capture thoughts and/or questions at any point within the app and to send them via email.
“User feedback and the success of the pilot will help guide the ACC in expanding the app to the rest of the guideline content in the way that is most useful to clinicians in practice,” says Ty Gluckman, MD, FACC, a member of the ACC’s Best Practices in Quality Improvement (BPQI) Committee, who has helped to develop both the ASCVD Risk Estimator and the Guideline Clinical App. “We’re learning in a space that is pretty new for the College and for our profession and the challenge is to get things right the first time.”
In order to ensure the College is on the right track from the start, the ACC is focused on learning from past efforts, and is taking cues from companies like Apple and Google that have cornered the market on taking immense amounts of content and deriving very intuitive and easy-to-use user interfaces. “If we’ve learned nothing else, the user interface is very critical,” says Andrew Freeman, MD, FACC, chair of the ACC’s Early Career Section and a member of BPQI. “We need to get things right on the first try or people won’t come back.”
Both Gluckman and Freeman note that one of the biggest challenges associated with creating point-of-care tools, particularly those related to clinical guidelines, is how to distill sometimes hundreds of pages of science into usable algorithms and tools featuring the most pertinent information – and doing it quickly. New tools must keep pace with – and adapt to – changes in knowledge in real time. “Going forward, we need to continue to figure out how to shorten the time from guideline publication to getting tools in the hands of members,” Gluckman says. “How do we provide tools in a medium that people can access immediately and move the needle in a meaningful, productive way? That is the big question we’ve only begun to answer.”
According to Kovacs, the key to doing things right lies in being able to prioritize what is most important and recognizing up front that you can’t do it all. “Asking the right questions about a topic and adopting a laser focus on the most important problems and/or the gaps you are trying to close are some of the biggest lessons learned over the last few years from the College’s work in the development of clinical quality toolkits and mobile tools,” he says. “The College is fortunate to be able to leverage NCDR data to help identify gaps in care. Taking greater advantage of registry data for gap analyses and to track progress towards a goal is a priority in overall tool development moving forward.”
A team-based approach to tool development, as well as testing and validating tools properly across a broad span of users (i.e. nurses, physicians, patients, etc.) with varying degrees of technological savviness are other best practices noted by Kovacs, Gluckman and Freeman. Both the ASCVD Risk Estimator and the Guideline Clinical App went through several rounds of user testing by various members of the cardiovascular care team, as well as other medical specialties, before a formal launch. “The College is the source of knowledge for various types of providers and a lot of people beyond cardiology,” says Gluckman. “We have an ability to enlighten a lot of other groups, but we have to make sure we’re offering what they need in a format that is useful.”
Looking ahead, Freeman says he’s excited that the College has “upped the ante” in this area. “It is my hope that mobile point-of-care tools will be as popular as the wall charts and pocket guidelines of years past,” he says. “The College is listening to what members want and delivering.”
Gluckman agrees, noting that as the College continues to engage in the development of mobile tools, he hopes to see more patient-focused resources incorporated as well. “We are patient-centered, thus we need to readily present information for patients in a user-friendly way.” It also will be important for the College’s tools to be adaptable to even newer technologies as they become available and are more readily used by patients and providers alike, he adds.
At the end of the day, Kovacs says he has no doubt that the College will be successful in its efforts to translate the latest evidence-based science into tangible tools that can be used at the point of care. “Never underestimate the power of the ACC membership – they can tackle any problem,” he says. “And never underestimate the power of the ACC staff, they are the most talented and hardworking staff of any professional society in the world.”
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