ESCAVO is a company that develops digital health content and mobile health applications, which range from point-of-care medical reference guides to clinical decision support tools. The ESCAVO team comprises physicians, experienced software developers, and graphic designers committed to the improvement of healthcare quality and delivery through mobile technology.
Can you tell us the story behind your mobile apps? Where did the idea for your apps come from? What served as your inspiration?
Sepsis Clinical Guide: My mother died from sepsis in 2009 and during her ordeal, I was by her bedside and witnessed significant lapses in medical care. Although a significant effort was put into her care, recognition and treatment of her sepsis were significantly delayed which unfortunately contributed to her death. The hospital where she was treated had no sepsis protocols in place and staff did not seem to follow sepsis management guidelines available at the time, which emphasized the importance of prompt treatment, and especially prompt antibiotic administration. Being an MD, an editor for a medical education publisher, and having experience in tech, I decided to author and develop the Sepsis Clinical Guide app to put major sepsis guidelines in the hands of clinicians in a practical, concise, simple to digest format that can be used as a reference at the bedside. The app was developed with the help of Boxador, an LA-based technology incubator, and has also been translated into Spanish.
Sepsis Timer: In 2015, US CMS instituted a new core measure called SEP-1 that tracks hospital performance on sepsis treatment and potentially penalizes hospitals that don't do well. This measure essentially implements treatment recommendations provided by the Surviving Sepsis Campaign guidelines, specifically their Sepsis Bundles, which call for certain initial treatment steps to occur within 3 and 6 hours. Sepsis Timer app was inspired by the need of hospital staff to carefully track sepsis treatment steps and times to comply with this CMS measure. The idea for the app was actually given to us by a sepsis coordinator at a US hospital who thought it would be very helpful to have a simple reminder and alerting tool that house staff can use on their mobile devices.
The Chief Complaint: The Chief Complaint app was authored by Dr. Chris Feier MD, PharmD, a practicing emergency room physician and assistant professor of emergency medicine the Keck School of Medicine of the University of Southern California. The app is based on a popular EM reference book he wrote by the same name which has been widely praised by readers on Amazon and elsewhere. The book started as an effort by Dr. Feier to create concise notes and treatment algorithms during his residency on flashcards to help him remember how to best treat patients for common conditions in the ER. He eventually further developed these cards and aggregated them into a nicely formatted book that became The Chief Complaint print version and later the app. Incidentally, Dr. Feier did a lot of the layout and front-end design programming of the app himself using the ESCAVO content management platform, so he also has a knack for tech and software development too.
How did you build the content that's contained in the apps? Does the information in your apps come from evidence-based resources, such as scientific literature, peer-reviewed articles and case studies?
The content of the Sepsis Clinical Guide app is based on evidence-based guidelines from leading organizations such as the Surviving Sepsis Campaign, Infectious Diseases Society of America and many others, as well as numerous studies and peer-reviewed papers. All content is carefully referenced, the app currently has nearly 160 citations.
The treatment steps and timing intervals used in Sepsis Timer are based on the Surviving Sepsis Campaign Sepsis Bundles and CMS SEP-1 guidelines. Some of the information in the help sections of the app is taken from our Sepsis Clinical Guide app which is based on numerous guidelines and studies.
The Chief Complaint app's content is based on the book by the same name by Dr. Chris Feier, as mentioned above. The app's content is exhaustively referenced with over 450 citations, more than any medical reference app that I'm aware of. In addition, the app emphasizes evidence-based medicine throughout with features such as Journal Club (discussions of key studies on certain topics) and links to relevant articles on popular evidence-based sites such as Essentials of Emergency Medicine, theNNT, and EM:RAP podcasts (these require separate subscriptions on those services). In my opinion, The Chief Complaint is one of the best apps for emergency medicine out there, every EM clinician should have a copy.
An Interview With Daniel Nichita, MD, the President of ESCAVO
What impact have your apps had on clinical practice so far? We'd appreciate it if you could share some stats on how frequently your app is used worldwide.
The Sepsis Clinical Guide app has consistently ranked as the #1 app on the topic of sepsis in both the iTunes and Google Play stores, at least in the US stores, but likely in others as well. The app has high ratings (4.4-5.0) in both stores from a good number of users (over 700 in Google Play and over 40 in iTunes) as well as many positive review comments, especially in Google Play. The app has had over 150k downloads and is regularly used by thousands of clinicians throughout the world every month.
Although we don't track user occupations, based on user feedback, most are physicians and nurses specializing in critical care medicine, emergency medicine, and other hospital-based specialties. Some users have communicated that their entire ICUs regularly use the app, and some hospitals have installed it on their mobile device fleets to encourage its use by house staff.
Recently, Beckman Coulter, one of the world's largest medical diagnostics companies has sponsored the app. Their generous support has allowed major improvements and continued maintenance of the app for which we are very grateful. It is hard to gauge the app's impact on clinical practice, but based on user comments from Google Play store and communications with users over the years, it is significant.
The Sepsis Timer app has a very niche application and was only recently released on iOS only so its user base is still quite small. We don't directly track internal app events for this app, but according to limited app store data, it gets several hundred sessions per month primarily in the US, probably due to its relevance to US sepsis treatment regulations.
We do not directly track events for the Chief Complaint app, but it gets several thousand sessions per month according to app store data. The app is highly rated in both iOS iTunes store (5 stars) and Android Google Play (4.7 stars). According to the positive comments in the app stores as well as on Amazon in reference to the print version of the app, The Chief Complaint has probably helped a good number of clinicians practice better medicine in emergency rooms throughout the US and elsewhere.
What are the tools and technologies used to build your mobile apps (both cloud- and client-side)? Was it a native or cross-platform development? Did you consider other technologies?
The app is developed in Axway Appcelerator, a Javascript-based cross-platform development toolkit. Appcelerator is very robust and well supported, is well integrated with native SDKs, and produces apps that approach native performance.
What were the main challenges you had to overcome when developing your apps? Could you please single out the biggest technical challenges, product challenges, marketing challenges, and support challenges?
On the technical end, it can be difficult to find good mobile developers, especially for specialized non-native platforms. Content development is highly technical and time consuming given that the app addresses very a specialized medical topic. The app has a niche professional audience so finding the right marketing channels can also be a challenge - wide-scale social media marketing doesn't work.
Could you single out the three biggest mistakes you made when developing your apps?
Waiting a year to develop an Android version, otherwise happy with our choices.
When it comes to medical apps, sooner or later the issue of data protection and security always comes up. How do you make sure that user data is secure?
We do not collect personal user data other than basic analytics — number of page views, downloads, locale, etc.
What's next for your apps? Are there any new features, functionalities, or upgrades planned for future updates?
We are constantly updating the app's content to stay up to date with changes in clinical practice guidelines. In terms of new features, more diagnostic tools may be coming.
We are excited about the technologies and what they might hold for the healthcare and the future of medicine. What do you think this technology-driven, human-centered future holds for mobile health and how do your apps plan to contribute?
We believe AI holds great promise for medicine and are investigating ways of leveraging this technology in future products.
Could you share a word of advice with other mobile app developers? What steps they should follow in order to make a successful app?
With the exception of big apps like Medscape, which is fantastic, many medical mobile apps out there are very poor, in my opinion. Many provide little information (e.g. an app that has one medical calculator), are not evidence-based, and have unattractive poorly designed UIs and poor usability.
My recommendations for a medical app developer are to:
- understand the medicine behind the app, whether its medical science or medical process workflow depending on what the app is intended for,
- base it on real science and/or a real understanding of how medicine is practically practiced in the area the app is designed for, and
- design a beautiful app with a nice modern interface with good usability/Ux.
Medical is probably one of the most unattractive app categories in the app stores — but just because it's medical it doesn't mean it should be ugly!
Sources & Links
- Photo courtesy of ESCAVO