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

需求：每天有2200名美国人死于心血管疾病（CVD），而9210万人患有心血管疾病

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”.