Updated: Aug 5, 2022
"Match-making Digital Health and Pharmacist Clinicians in the delivery of Post AMI Care"
Did our previous multi-disciplinary features result in all your hearts yearning for more? We guarantee you that this week's feature will definitely capture your attention! ❤️
This week, we would like to showcase our pharmacists playing leading roles in promoting better post-acute myocardial infarction (AMI) care through the use of technology!
Why is Post AMI Care important?
More commonly known as heart attack, AMI (acute myocardial infarction) is a phenomenon where the coronary artery is obstructed, resulting in insufficient blood supply to the heart muscles. This is a medical emergency and often require rapid interventions.
AMI afflicts 10,000 Singaporeans annually, and the incidence is expected to increase by 59% by 2030. Among the high-income OECD countries, Singapore has also one of the highest 30-day AMI all-cause mortality rates. Hence, there is great importance for quality care after an episode of AMI.
Some of the key gaps in the current AMI care model include:
What is the AMI-HOPE programme about?
With the gaps identified, several healthcare professionals in Singapore gathered to form the AMI-HOPE (Acute Myocardial Infarction allied Health-Oriented Patient-centred digitally-Enabled care) team, which aims to cultivate a learning healthcare system that:
empowers allied health professionals (pharmacist clinicians) to delivery high quality care using digital interfaces,
values quality of patient care and patient outcomes over the quantity of service delivery, and
delivers the above at an affordable price.
AMI-HOPE is a step-wedge pragmatic study in partnership with the Ministry of Health (MOH), MOH Office for Healthcare Transformation (MOHT), Health Promotion Board (HPB), and Integrated Health Information System (IHiS), to deliver a remote care model for AMI patients across Singapore’s healthcare clusters (NUHS, SingHealth & NHG). It aims to improve post AMI quality of care, person-centred outcomes and reduced cost through a greater involvement of pharmacist clinicians in patient care.
Overview of a patient journey under the AMI-HOPE program
Let us hear some inspiration from the AMI-HOPE team!
"The team was very honoured when Health Discovery+ was chosen by MOHT and NUHS as the platform to build the AMI-HOPE protocols with the intent to care for AMI patients. The objective is really about harnessing technology to empower these post-MI patients in healthy living, and facilitating timely interventions by clinicians. The big picture of the project is about saving more lives in this space. Working with MOHT and NUHS team has been gratifying and hopefully vital sign monitoring (VSM) can path the way of future healthcare in Singapore.”
– Mr Torres Oey, Deputy Director, IHIS –
“AMI HOPE has indeed been an eye opening! It was humbling to witness and participate in the partnerships between MOHT health technologists and fellow pharmacist clinicians across the island. It is exciting to see how these partnerships have birthed novel remote health monitoring and education technologies to better care provision for our post AMI patients!”
– Mr Samuel Ho, Lead, Educational Strategy, AMI-HOPE & Cardiac Pharmacist Clinic, Khoo Teck Puat Hospital –
"As a technologist, I found that being involved in this project was fascinating, I learned a lot about cardiology and the role of pharmacists. As we exchanged with other teams around the world, it became clear that, for patients, just the idea that “someone is looking out for you”, and in a non-intrusive way, is quite a valuable lifeline and an encouragement for adherence and healthy living. As we get more experience, and introduce new gentle nudges this idea could become even more transformative."
– Prof Robert Morris, Chief Technology Strategist, MOHT –
How do Pharmacist Clinicians contribute in AMI-HOPE?
The AMI-HOPE care model is divided into 3 phases:
Prior to discharge from the hospital, pharmacist clinicians will have a meet-and-greet session with patients to build rapport so that the patient is acquainted with the pharmacist who will walk with him in his journey of care. Medication review will also be performed to ensure all the medications are evidence-based and initiated appropriately.
To ensure early post discharge care, all patients will receive a phone call within 5 days of discharge. Our pharmacist clinicians will then assess the patient’s general condition, and manage any complaints which could be related to the condition, adverse reactions or otherwise. Furthermore, the pharmacist will determine the patient's adherence to prescribed medicines, assess the level of physical activity, offer smoking cessation and dietary advice. Naturally, the pharmacist may also adjust or add important medications, and address the patient's queries on the disease or prescribed medications.
Digital technologies such as the HD+ (Health Discovery+) mobile app were also deployed during the sessions, which aid pharmacist clinicians to perform vital sign monitoring (VSM) through the use of a dashboard, laboratory results monitoring, and medications titration remotely. This is to ensure better compliance to follow-up and less physical waiting time at the clinic.
Vital Signs interface in Health Discovery + mobile app
As for the patient-facing application, thresholds and rules were set by a cardiologist-pharmacist working group. These rules, coupled with a chatbot, not only ensures patient safety, but also assist pharmacists in patient prioritisation. This streamlined workflow reduces administrative work, enabling pharmacist clinicians to focus on patient engagement activities. In addition, pharmacist clinicians will explore patients’ values and beliefs through shared-decision making to establish personalized treatment goals. Patients can be more empowered and motivated to achieve results.
To ensure smooth transition to primary care (e.g. polyclinics and general practitioners), pharmacist clinicians perform tele-collaboration with their team when patients are ready to be discharged from tertiary care. The essence of this telecollaboration is that all information (eg. person-centred values and beliefs, medication intolerances and adverse reactions) are well-documented and handed over appropriately.
Pharmacist clinicians in primary care will thus be able to seamlessly take over the baton in delivering digital-based, dashboard-enabled care for these MI patients. Should the primary care require clarification or assistance, a point-of-contact in the tertiary care is also readily available. Furthermore, this long runway is critical for patients with hard-to-control type 2 diabetes mellitus, hypertension or hypotension.
AMI is associated with significant short-term and long-term mortality and morbidity. The journey of recovering for post-AMI patients can be challenging, frightening or even lonely as patients adapt to the new normal. With newly introduced medication regimes and lifestyle changes, patients can be easily lost and confused, especially when the medication side effects are unbearable, or they are unable to accept their reduced ability to function. Therefore in this new AMI-HOPE care model, pharmacist clinicians will walk with them closely right from the beginning of their heart attack journey, with the effective use of digital technologies and the human touch.
Wait, curious to hear from more team members behind AMI-HOPE?
"My greatest takeaway from contributing to the pilot roll out of AMI-HOPE has to be the importance of Shared Decision Making (SDM) with the patients that I care for. SDM was first introduced to us when we were trained through a weekly case discussion round with a Senior Cardiologist and Cardiology Specialist Pharmacist. Through the program, we called up patients within the first 5 days of discharge. I was not only able to pick up new-onset heart failure early, I was able to practise my new-found skills of SDM on this patient by providing information on heart failure disease and the goals of treatment to help him make informed care decisions that align with his goals and preferences."
– Ms Low Peik Ching, Senior Clinical Pharmacist, NUHS –
"The AMI-HOPE pharmacists were specially trained through didactic and hands-on case discussions. I was tremendously impressed by how thorough clinical pharmacists are in optimising post-MI care, from assessment of the patient to adjusting medicines and advising on lifestyle modifications.”
– Associate Professor Mark Chan, NUS Yong Loo Lin School of Medicine & Senior Consultant Cardiologist, NUHCS –
"As a Digital Ambassador for the pilot AMI-HOPE project, this is my first time working in such close collaboration with pharmacists Su Ching and Peik Ching. Looking back on the time working together, it was quite an enjoyable experience. Being the first point of contact for the patient when they encounter any issues can be quite a nerve-wrecking experience for someone without a medical background. For instance, I encountered a patient who developed rashes at upper body and I was worried if it was an allergic reaction to his medicines. I raised it to the team, and we worked closely to further question the patient on the history. It turned out to be a simple case of eczema. By working closely with the pharmacist, it is another source of support for me to reach out to when patients require prompt attention. The participants’ feedback was very positive feedback about the pharmacists. Many felt very reassured as the pharmacists were very patient and helpful in addressing their concerns.”
– Ms Cinthia Phua, Digital Ambassador –
"It is an honour to partake in this work with both MOHT and NUHS teams, in a bid to use technology to enable more efficient and safe clinical practice. The customised system allows patients to submit their vitals from the comfort of their home; the system has been configured to provide advice whenever the threshold of safety falls out of the range. Educational messages timed at strategic time intervals serve to guide patients on how to improve their well-being. Pharmacist Clinicians are now able to monitor patients centrally using a live dashboard, configured to increase the efficiency of patient management through priority sorting. We eagerly look forward to the deployment of Health Discovery+ into all 3 clusters’ hospitals and polyclinics in the years to come!"
– Mr Christopher Ng, Digital and Integration Services –
“Being one of the Digital Ambassadors for AMI-HOPE pilot programme, my roles involved patient screening, consent taking, patient enrolment as well as device set-up. My greatest sense of achievement and joy is to see recruited patients empower their own health by compliant in BP measurement, taking healthy diets and keeping track on their steps on daily basis. I was exceptionally thrilled to learn that majority of them wish that the program can carry on beyond a month.”
– Dr Tan Sock Hwee, Digital Ambassador –
"I work with the clinical team to determine threshold rules and educational messages which are timed at clinician-pharmacist determined milestones. In this aspect, rules have to be carefully written and tested in many scenarios to make sure the platform is safe for our heart attack patients. My personal desire is to enable the patients as true partners in their health management alongside clinicians, and telemonitoring programs such as AMI-HOPE are one of the most promising ideas to achieve that."
– Dr Praveen Deorani, Data scientist, MOH Office for Healthcare Transformation –
“I truly did not know what I was getting myself into when I agreed to take on the role of pharmacist clinician lead for the nation’s inaugural large-scale project of this nature and scale. It has been an amazing journey from the writing of the grant application, the inception of the first logic model, right down to the writing of clinical guidance documents, customising patient educational material and training the first 36 pharmacist clinicians across the country in their phase 1 training. I am privileged to have been a part of an important milestone in clinical cardiology practice in Singapore. Though the preparation and set up was tremendously challenging and tedious for the most part, I would not have it any other way. The journey of the man-machine interface has just begun. Watch this space for the updates from the AMI-HOPE team!”
– Associate Professor Doreen Tan, NUS Dept of Pharmacy & Visiting Cardiology Specialist Pharmacist, NUHCS –
Ms Low Peik Ching (Senior Clinical Pharmacist, NUHS), and Associate Professor Doreen Tan (NUS Dept of Pharmacy & Visiting Cardiology Specialist Pharmacist, NUHCS)
We would like to thank the AMI-HOPE team members for their contributions:
Associate Professor Mark Chan, NUS Yong Loo Lin School of Medicine & Senior Consultant Cardiologist, NUHCS
Mr Samuel Ho, Lead, Educational Strategy, AMI-HOPE, Khoo Teck Puat Hospital
Dr Tan Sock Hwee, Digital Ambassador, NUHS
Did you enjoy reading our latest article? Wish to find out what more can be done to empower a healthier you?
Our Pharmacy Week 2022 health carnival will be happening live on 24 September 2022 (Saturday). There will be an exciting lineup of health talks, fitness and cooking activities, and interactive booths! This event is FREE and suitable for all ages. Register with us to reserve a slot today!