By Shiv Gaglani

In last month's Health Tech column, I reviewed the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator, a free app that helps clinicians and patients calculate and understand their relative risks of having an ASCVD event, and—most importantly—develop a plan of action to mitigate those risks. Shortly thereafter I had the opportunity to speak with two ACC committee members and physicians, Richard J. Kovacs, MD, and Tyler J. Gluckman, III, MD, about the development of the app and the College's overall mobile strategy.

Can you describe the impetus for developing the ASCVD app?

Dr. Kovacs: Ty and I both serve on a committee of the ACC called "Best Practices & Quality Improvement" (BPQI). It is a small group of 10 members and one of our charges is to create usable tools for members to improve their practices, based on the variety of efforts across the College. In particular, the guidelines are a major focus and extremely useful, though sometimes daunting to use at the point-of-care. The purpose of the ASCVD app was to make it easier to understand and follow the ACC/AHA's guidelines while seeing patients.

Dr. Gluckman: Part of the work that the BPQI committee is doing is to identify gaps in care. We actually have a very prescriptive process to do gap analyses, through which we ask questions such as: Where are the areas where care is pretty well delineated? How do we identify tools that occur in different modalities to close any gaps? We have a process of assessing how people perform before and after any interventions, and are doing our best to arm our colleagues and members of the College with the best tools for closing those gaps.

What was the rationale for choosing an app format for this guideline?

Dr. Gluckman: We recognized that there's been a paradigm shift over the last few years in the tools clinicians are using. Smartphones and tablets have become ubiquitous, and we decided that they created an opportunity to close the gaps I mentioned before. Historically we've relied on many tools including wall charts, pocket guides, and published papers, among others. We recognize more providers of care, not just physicians, are reliant on an electronic medium to access that information. I think there is increasing recognition by the College that this is what people wanted, and this seemed like a logical next step to help inform decision-making at the point-of-care. That's where the development of apps in general came from, and I think the ACC is ramping up our efforts in this area.

What was the development process of the app like?

Dr. Kovacs: It was a sequential development process. We knew that the latest guideline was going to be published, and we created the app at the end of that process. The original tool was a spreadsheet posted on the ACC/AHA website, which was not ideal since it did not contain the wealth of information that the app does nor could it be used at the point-of-care as seamlessly as the app.

Dr. Gluckman: All of the development work was done internally as a joint effort between the ACC/AHA. The College in particular is developing a core group of individuals who are involved with digital strategies. Much of the work in terms of the content was developed in conjunction with clinicians from the ACC/AHA, including the chairs and co-chairs of the four main preventive guideline groups. In addition CardioSmart, the patient-centered arm of the ACC, made sure we had appropriate content for a patient-centered approach. Even though the app has been released, the College has developed a review board to make this an iterative process whereby members of the public or College can provide feedback, whether through Google Play, iTunes, or directly on CardioSource. We already have a spreadsheet filled with feedback that we plan on incorporating to make this as useful a tool as possible.

How are you measuring success?

Dr. Gluckman: We are certainly monitoring the usage statistics of the app, which went live in February and by the middle of March had been downloaded over 20,000 times (#8 in terms of medical downloads on the app store). We are averaging over 4,000 sessions per day. While we are still in the early stages, we do have a process of assessment and will likely begin this once we build out our toolkit, of which the first part was the ASCVD app. This analysis will be informed by the fact that the app is much more than a risk estimator or calculator; it is a self-enclosed tool to help make informed decisions about cholesterol management therapy.

Given your roles in developing the digital strategy efforts for the College, have you both always been interested in technology?

Dr. Kovacs: Ty and I are maybe a generation-and-a-half apart, so keep that in mind. I actually attended an ACC course in the early 1980s that aimed to teach cardiologists how to use personal computers! My specific interest involves tools that will seamlessly integrate into our clinical workflow. Like many physicians I spend a huge proportion of my time dealing with electronic records, reading test results and managing patients. Working on apps such as the ASCVD Estimator is an opportunity for me to guide the development of tools that will augment, not inhibit, our workflow.

Dr. Gluckman: I am a medium-stage adopter of new technology. My primary interest was in building out the clinical content of the app and making sure it was usable, so that clinicians and patients alike would find value. This may be the first of several interviews with the BPQI committee going forward since everyone on the committee has specific areas of interest, be it heart failure or atrial fibrillation, and I expect we'll be developing apps for these guidelines as well. I hope we will see many more digital tools moving forward, so that people both within and outside the College will benefit.

There are thousands of medical apps available in the iTunes and Google Play stores. How do you tell a good app from a bad app?

Dr. Kovacs: Similar to comparing quality of articles you read, I think the imprimatur of the ACC/AHA on this particular app is one marker of quality of the app. That is an important role the College can play in the wide world of apps. We did everything internally so we knew we were accurately recreating the risk estimator, and that experts vetted the content. We have a unique constellation of people who can put these kinds of things together. We are also working on the development of a risk pictograph, since it's very hard for patients and providers to understand what risk actually means. Displaying that concept visually is much more understandable.

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Shiv Gaglani is an MD/MBA candidate at the Johns Hopkins School of Medicine and Harvard Business School. He writes about trends in medicine and technology and has had his work published in Medgadget, The Atlantic, and Emergency Physicians Monthly.

Keywords: Quality Improvement, Risk, Atherosclerosis, Decision Making, Committee Membership, Workflow, Mobile Applications, CardioSource WorldNews, ACC Publications

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