Approach
As a clinician and researcher, Fontil said he understood the concept of “clinical inertia,” in which doctors busy with the problem in front of them often miss opportunities to treat for hypertension, diabetes and other diseases.
EngageRx was born out of Fontil’s frustration with those missed opportunities.
“The challenge with primary care doctors is, they already know how to treat hypertension. They don’t seek that kind of help,” Fontil said. “We often forget or neglect to provide treatment when needed.”
His idea was to put the issue front and center, so when a patient—who was likely seeing the doctor for another issue—presented with high blood pressure, the doctor could easily recommend a course of action.
“It should serve ideally as a nudge, as a prompt,” Fontil said.
Fontil started trying to develop this technology for the medical team to make decisions for hypertension or other diseases. He knew they collect data from office visits that goes into the electronic health record. He thought they could also get data from patient surveys and wearable devices and connect it all together so that the medical team and even the patients themselves could make better decisions about their care.
He started searching for programmers, designers, and people with expertise in electronic health record integration. Fontil has a background in implementation science, which he said has some overlap with human-centered design, a key process that SOM Tech brings to the table.
Two of Fontil’s mentors separately told him about SOM Tech so he scheduled a meeting. He admired their expertise, and was happy to keep the project in-house at UCSF, rather than hiring an outside consultant.
“Going with SOM Tech wasn’t just the right call,” Fontil said. “Any other call would have been the wrong call. The alternative would have been hopelessly wrong.”
SOM Tech not only had programmers who could build the brains of Fontil’s app and designers who could make it user-friendly, but it had valuable expertise in working with Epic, the system that controls UCSF’s electronic health records.
“Strategically speaking, if you’re trying to integrate with the electronic medical record, there’s a lot of regulatory and policy issues around safety and privacy,” Fontil said. “If you’re using an outside vendor, it would end up being very long and hard to do. Whereas SOM Tech has relationships within UCSF, deals with the clinical side, and has a process to get these things approved.”
Solution
Fontil had produced an algorithm that would take data—about the patient’s health from clinical visits, lifestyle reports, any home tests or blood pressure monitoring the patient had done—and generate a recommendation. He named it EngageRx. SOM Tech began designing an application and together they kept tinkering with it.
“We went through 11 iterations,” said Beth Berrean, SOM Tech’s deputy director. “We just kept iterating with different user groups to get it to be something people felt like they could use.”
Fontil said the “rapid prototyping to get you to your minimum viable product was a pleasant surprise.”
The application “is supposed to take it to a level where it helps the doctor more quickly think through a prescribed medication,” said Cynthia Milionis, a SOM Tech designer who worked on the project. Milionis worked on the design—how the product would look—while SOM Tech’s Jory Purvis and Lana Milter, systems architects, worked on the software code that powered the product.
Primary care doctors balked at initial efforts to give them one more thing to look at in a patient visit. The team came up with the idea that, when patients check into a clinic and their blood pressure is high, a tab would pop up on the screen when a doctor is looking at the patient’s electronic health record, among about eight other tabs. “That’s the balance. You want to do it in a way that it’s still a suggestion. You have to,” Fontil said. “It’s suggestive. It’s not disruptive.”
“You do not want a pop-up so they have to click it away to get to the next screen. It has to be at the right place, at the right time, when a doctor would want to see something.”
During testing, Milionis said, users insisted: “Simplify, simplify.”
Primary care doctors aren’t the only people who’d use the tool, and they may not even be the main audience. Many nurses, nurse practitioners and physician assistants see patients and might be more apt to use it, Fontil said. Specialists, from gynecologists to psychologists, might catch a high blood pressure reading. “They’re the people who the patient is seeing,” Fontil said. “And they’re the ones who don’t remember how to treat hypertension. It’s not that hard to manage, but they just haven’t done it in a while.”
Fontil is still working on EngageRx. “We’re looking to disseminate it across different institutions,” he said. “We’re building it in a way that we can attach it to different health systems, both inside and outside UCSF.”
Epic, which UCSF uses, is the biggest vendor of electronic health records in the country, and Fontil dreams that EngageRx can become an app that can be used at any institution that uses Epic. He’s also thinking about spinning it out as a commercial product.
And he imagines versions of EngageRx that are not limited to hypertension, but can recommend treatment protocols for any other ailment that might turn up in routine clinical examination.
As Fontil works on new iterations, SOM Tech continues to work with him. Milionis said SOM Tech helped Fontil on a PowerPoint pitch deck, a service it offers many of its partners.
Written by Dan Fost for SOM Tech (2022)
