optima4heart: pharmacological intervention and transition of care in cardiovascular disease management

需求：每天有2，200名美国人死于心血管疾病（CVD），而9210万人生活在 某种形式的心血管疾病或中风不受控制的高血压（HTN）、心力衰竭（HF）、冠状动脉 心血管疾病（CAD）和心房纤颤（AFib）代表CVD "流行病"的主要驱动因素。的 美国心脏病学会（ACC）建议改善护理的两个关键方向：（1） 推动有效治疗决策的药物干预，以及（2）护理标准化 提供者之间治疗方案的交叉沟通流程。 解决方案：为响应ACC指南（如上所述），Optima Integrated Health旨在建立一个 临床医生信任的软件工具（optima4heart），建议：（1）药物干预， (2)基于团队的护理转移[初级保健提供者（PCP）<$心脏病专家]的必要变化， 管理CVD患者的临床医生。optima4heart通过患者定制的临床应用 分析智能（AI）通过电子健康中的仪表板用户界面显示增强 记录（EHR）。optima4heart直接解决了目前的进展障碍。其目的是：（1）解决 治疗管理指南的不断发展的复杂性;（1b）统一和协调隔离 患者数据集;（2a）提供临床组织整合的药理学方法 干预措施;（2b）制定一项部门间移交护理协议。optima4heart是一个多- Optima4BP的疾病扩展，这是一种为解决药物干预而开发的AI解决方案 管理临床医生治疗不受控制的HTN患者。optima4heart目的：减少 HF、卒中、心肌梗死（MI）的发生率]或死亡。 I期目标：通过构建2种疾病CVD药理学，扩展optima4BP的功能 将HF与现有HTN解决方案集成的干预和护理转移平台。 具体目标是：目标1。开发和推广药物干预。optima4BP AI 将调整框架，优先考虑药物干预变化，以解决实时 根据患者状态的变化，HF和HTN之间的动态变化。目标2.开发和调试HF传输 照顾。护理转移将确定患者是否稳定/不稳定，导致 在指定照顾方面的建议（适当时转移照顾）。目标1和目标2验证将是 使用理论上的患者测试案例进行。Optima 4心脏药物干预的裁定 由多学科临床团队进行的护理转移将确立其临床有效性。 未来工作：II期将建立4种疾病的CVD药物干预和转移护理 平台，扩展HTN + HF以包括CAD和AFib。结果：灵活的护理管理平台 它可以适应影响CVD“流行病”的主要驱动因素之一或任何组合。

Need: 2,200 Americans die of cardiovascular disease (CVD) each day, while 92.1 million live with some form of CVD or stroke. Uncontrolled hypertension (HTN), heart failure (HF), coronary artery disease (CAD), and atrial fibrillation (AFib) represent the primary drivers of the CVD “epidemic”. The American College of Cardiology (ACC) recommends two critical directions for improving care: (1) Pharmacological Interventions that drive effective treatment decisions, and (2) Standardization of Care Flows for cross-communication of treatment protocols amongst providers. Solution: In response to the ACC guidance (above), Optima Integrated Health aims to build a clinician-trusted software tool (optima4heart) that recommends: (1) a pharmacological intervention and (2) needed changes in team-based transfer of care [primary care provider (PCP) ó Cardiologist] for clinicians managing patients with CVD. optima4heart is clinically applicable through a patient-tailored analytic intelligence (AI) augmented by a dashboard user-interface display in the electronic health record (EHR). optima4heart directly addresses the current barriers to progress. It aims to: (1a) address the evolving complexity of the treatment management guidelines; (1b) unify and harmonize segregated patient datasets; (2a) provide a clinical organization-integrated approach to pharmacological interventions; (2b) establish an inter-division protocol for transfer of care. optima4heart is the multi- disease expansion of optima4BP, an AI solution developed to address pharmacological intervention management for clinicians treating patients with uncontrolled HTN. optima4heart Aim: Reduce the incidence of HF, stroke, myocardial infarction (MI)] or death. Goal of Phase I: Expand the capabilities of optima4BP by building a 2-disease CVD pharmacological intervention and transfer of care platform that integrates HF with the existing HTN solution. The Specific Aims are: Aim 1. Develop and Validate the Pharmacological Intervention. optima4BP AI framework will be adapted to prioritize pharmacological intervention changes that tackle the real-time dynamic between HF and HTN based on changing patient status. Aim 2. Develop and Validate HF Transfer of Care. The Transfer of Care will establish whether the patient is stable/unstable leading to a recommendation in assignment of care (transfer of care, when appropriate). Aim 1 & Aim 2 Validation will be performed using theoretical patient test cases. Adjudication of optima4heart pharmacological intervention and transfer of care by a multi-disciplinary clinical team will establish its clinical validity. Future Work: Phase II will establish a 4-disease CVD pharmacological intervention and transfer of care platform, expanding HTN + HF to include CAD and AFib. The result: a flexible care management platform that can adapt to one or any combination of the primary drivers impacting the CVD “epidemic”.