JuniperCDS

JuniperCDS (Juniper Clinical Decision Support) transforms clinical guidelines into actionable person-centric care plans that are quickly deployable at point of care, enabling clinicians to implement them in their workflow. The SMART App Guideline Editor (SAGE) has been developed to allow public health organizations to quickly and easily digitize their guidelines. JuniperCDS is designed to integrate with existing clinical workflows and communicate bi-directionally with EMRs so clinicians can easily create care plans for their patients based on the best practice guidelines. These apps will bridge existing gaps in patient care and help reduce communication breakdowns. 

Currently, one of the biggest challenges The World Health Organization (WHO) faces is delivering quality person-centred health services and delivering maximum care per dollar in LMICs. As found in the WHO’s report, Global expenditure on health:  Public spending on the rise?  (https://www.who.int/publications/i/item/9789240041219) LICs prioritize PHC as they spend 65% of their total healthcare spending compared to 42% in HICs. By having accurate, timely, and actionable data, we can improve patient care quality by improving guideline adherence. At the same time we can create structured data, which can be reused for analytics rather than collecting the same data repeatedly. A process commonly referred to as “duplicate data entry.”  

JuniperCDS can create accurate, structured, and actionable data, which can improve the quality of data available for data analytics to measure quality and guideline effectiveness. By creating structured, and actionable data we can reduce the burden of clinics to collect data. In our teams’ work in LMICs we have heard stories of health facilities with 8 computers for sending data to different donors, and none for managing patient care. Our software can create usable data based on the current clinical guidelines, and measure their effectiveness in a continuous improvement cycle, something impossible to do at scale with today’s current tools. 

The WHO is spearheading the development of quality of care measurement frameworks, indicators and reporting on progress, including Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable (SMART) Guidelines (https://www.who.int/teams/digital-health-and-innovation/smart-guidelines), which aims to operationalize precision health across the world. Our team actively participates in this initiative and worked on developing the SMART Immunization guideline (https://www.youtube.com/watch?v=bu9bOqGVqgc) as part of a consortium led by the CREATE team at Hamilton Health Sciences, an innovation arm of a local hospital. JuniperCDS is capable of using this SMART Guidelines, and building them into person-centric care plans. 

The SMART guidelines offer a holistic approach to decision support and measurement. One example of how JuniperCDS could help is by leveraging the measurement information referenced in the SMART guidelines. The decision support guidance and measurement guidance use the same minimum data set produced in a computable fashion, therefore as JuniperCDS executes decision support and captures data those can be used for accurate measurement following a collect once, reuse principle. 

JuniperCDS is a standards-conformant “front end” that can operate standalone, or as a façade on top of existing digital health products (such as Epic, Cerner, Allscripts, OpenMRS, etc.) that adhere to the widely-adopted SMART-on-FHIR standard. JuniperCDS’s software façade augments the functionality of the underlying product. It adds computable care guideline-processing and care planning capabilities, including the data entry screens needed to operationalize a guideline-driven care encounter. 

The commutable care guideline-processing and care planning involves reading a digitized guideline into JuniperCDS, likely produced using our FHIR digital guideline authoring tool SAGE, and then reading data directly from the patient record and captured at point of care by the clinician in order to make a recommendation on the next best practice step. JuniperCDS is capable of reading across digitized guidelines, catching duplicate events, and processing multiple guidelines into a customized care plan for the patient. 

Our organization’s aim is to provide much of our software for free or at low cost to improve care quality in Low and Middle Income Countries (LMICs), or any low resource environments delivering healthcare. Our products have the capacity to operationalize guideline-based care anywhere in the world. 

Our team has specific training in human centered design, and has been using that approach to fulfill the needs of our stakeholders (detailed in question Who does your solution serve, and in what ways will the solution impact their lives?). We have conducted interviews with many of our stakeholder groups, asked specific questions and iterated on our requirements and designed based on their feedback. As we get closer to a more developed solution, we aim to do more interviews to solicit feedback from those stakeholders.

While our current solution is a web application, it is capable of operating with some functionality offline. As we further develop our prototype into a Minimum Viable Product (MVP), we are adding more offline capability. Our future direction also includes potentially creating an Android application, capable of operating offline, which community health workers can use in the field to deliver care. An offline capable, mobile application, could help community health workers follow a checklist of actions they need to take. Our solution offers scalability to that checklist of actions, as guideline authoring organizations like the WHO can edit and change their guidelines and easily push them to a mobile application. We will build this solution using Google’s FHIR Android SDK (https://github.com/google/android-fhir), which is being supported as a developer toolkit to deploy healthcare applications in LMICs. The Android SDK is also supported by the WHO. Currently, existing solutions often need to build one application per disease/condition, which is costly and requires multiple tools to measure effectiveness.

In low and middle income countries it is essential to maximize care per dollar. JuniperCDS can be an important digital health tool to help maximize that dollar by improving guideline adherence, creating person-centric health, and automating data collection. Due to the holistic nature of our solution, there are 5 target groups: Clinicians, Patients, Payors/Donors, Guideline Authoring organizations, and Care delivery Networks. Addressing the problems of only one of these groups would be insufficient to meaningfully address patient care and data capture needs. Below are some ways in we will address the needs of each stakeholder group:

Clinicians:

• JuniperCDS automates and streamlines clinician's data entry tasks so that they can spend more time with the patient and deliver better care.

• JuniperCDS consolidates new guidelines and their implementation into one application.

• JuniperCDS enables clinicians to stay up to date with current practice guidelines and build person-centric care plans to accurately track their patient's history, while planning their future care

Patients:

• JuniperCDS assists clinicians to always recommend the tests you need so that unnecessary follow-ups are never a thing.

• JuniperCDS ensures that your clinician has the most up to date scientifically backed information to treat you with, to ensure you're getting the highest quality of care.

Payors/Donors: 

• JuniperCDS produces high quality structured data that can be automatically sent from the clinician to the payor for reporting purposes.

Guidelines Authoring Organizations (ie: WHO and Ministries of Health):

• SAGE allows guidelines to be communicated automatically in a digital format so that clinicians can focus on creating the most accurate person-centric care plans. 

• JuniperCDS provides structured data which can be used to measure guideline effectiveness.

• SAGE creates guidelines which can be embedded at point of care using tools like JuniperCDS

• JuniperCDS can integrate into most modern EMRs, including many open source ones commonly used in LMICs like OpenMRS 

• SAGE provides a repository of clinical guidelines so that clinicians of any level of clinical or technical expertise can provide consistent care.

Care Delivery Networks:

• JuniperCDS allows clinicians to automatically create person-centric care plans based on the latest clinical guidelines, from the most authoritative sources, all at point of care.

• JuniperCDS ensures that there is high quality, structured data, reaching the EMR so that it can be extracted for data analytics to measure quality, guideline effectiveness and automate billing.

• JuniperCDS can automate and streamline structured data capture to ensure that clinical data is reusable in a variety of contexts.

• JuniperCDS encourages guideline adherence which can improve test and procedure appropriateness, helping reduce costs.

JuniperCDS possesses a team of experts in software development, policy, and digital health. These members have years of qualified experience to deliver such a necessary product to make healthcare become more equitable, safe, and consistent.

In particular, our founder, Alexander Goel, has recently worked on projects in Cambodia and Sri Lanka to provide training on implementation of digital health solutions using current health standards. 

JuniperCDS is a solution designed to put clinical guidelines in the hands of clinicians in a meaningful and actionable way, which is impossible today. Measurement and process improvement are an integral part of our mission, though we aim to solve that problem by focusing on putting useful tools in the hands of clinicians and producing structured data at point of care which can be used for measurement. 

There is currently a financial and human effort barrier to obtaining high quality data, by automating that process we can improve data quality and get healthcare workers spending more time with patients, and less time on reporting. 

Clinical workflows have become bulky, time consuming, and work intensive to use, because applications have siloed data and have not translated clinical practice guidelines (CPGs) effectively across stakeholders. It can take up to 15 years for the latest guidelines to be widely adopted as common practice. Such slow adoption often leads to guideline compliance as low as 30-50%. Additionally, clinicians allocate 16 minutes for a 10-minute patient visit, which leaves little time for guideline and patient data review.

Most of our competitors digitize clinical practice guidelines in a proprietary manner, which is not auditable or testable. These products pose an inherent risk to patients as users must rely on the vendor to keep the product up to date with the latest guidelines, and they may provide advice which goes against current best evidence, with minimal auditing or tracking on why that decision was made. By putting SAGE directly in the hands of guideline authors, app developers will no longer be required to interpret and create the digital representation of the guidelines, making it significantly faster to test and deploy clinical practice guidelines at point of care. 

Only two of our competitors, LogicNets and Trisotech, offer authoring platforms. However, only Trisotech is capable of representing clinical practice guidelines in the latest digital health standards. Even so, Trisotech’s platform requires knowledge of Business Process Modelling Notation (BPMN) to digitize clinical practice guidelines, which requires a unique level of expertise. SAGE is designed with the guideline author or clinician in mind as digitized clinical practice guideline authors and without a significant amount of training or additional knowledge required. 

Additionally, based on our research, the majority of our competitors have chosen to go direct to hospital rather than through a larger channel partner to deliver their product to end users. This strategy could be a significant differentiator for the go-to-market scalability. We believe that our solution can fundamentally change how healthcare systems practice digital health and implement software solutions for guidelines at point of care.

Our 4 impact goals are to improve: 

1. adoption of guidelines

2. delivery of person-centric care 

3. implementation of value-based care

4. patient outcomes 

Our impact goals all center around being able to improve patient outcomes. We fundamentally believe that increased adherence to scientifically backed best practices guidelines will improve patient outcomes. That said, our solution allows for clinicians to customize and define per patient what their care plan should be according to the recommendations from those guidelines. By engaging guideline authoring organizations and improving their communication capabilities to implement guidelines at point of care with our SAGE and JuniperCDS products, we strongly believe that we can achieve all 4 of our goals. Achieving these goals will produce better health and well-being and the structured data collected from the implementation of our products, or similar products, will allow care delivery networks, guideline authoring organizations and other stakeholders in the healthcare system to better understand where clinical practice can be improved in a more timely manner than is currently possible. 

All of our indicators are related to improving health by increasing guideline adherence and the speed of guideline implementation. Our key indicators are:

• How often are guidelines updated?

• What is the cost of implementing a given guideline?

• What is the cost of measuring guideline effectiveness? 

• How long does it take to measure guideline effectiveness?

• What is the turnaround time for submitting data to a donor/authority? 

• How much effort/time/money is spent on capturing and formatting data for various reports?

Our theory of change is centered around our core belief that our technology can meaningfully contribute to improving guideline adherence, which will in turn improve patient outcomes, and that our application will produce the structured data required to measure how healthcare delivery can be improved. This cycle is what some refer to as the “learning health system,” which the WHO aims to achieve at Level 5 of their SMART guidelines. 

Activities: digitize clinical guidelines in a standardized format, implement those clinical guidelines at point of care.

Outputs: measurable outcomes on which guidelines are most effective, guidelines are reasonably improved by their authoring organizations. 

Short term outcomes: clinicians demonstrate higher levels of guideline adherence. 

Long term outcomes: scale guideline adherence across large care delivery networks allowing for more equitable delivery of care and better information on how clinical guidelines can be improved. 

JuniperCDS uses conditional “if-then” processing in order to capture conditions on how to deliver guideline-adherent care. The recommendation engine relies on a digitized version of existing expert-created healthcare guidelines. For example, the American Society of Clinical Oncology (ASCO) could use our SAGE tool to digitize their recommendations for clinicians performing cancer screenings. Those guidelines are created by an expert panel  who review all of the current literature and recommendations from the latest clinical trials. There is no black-box of Artificial Intelligence or Machine Learning, so the clinic/clinician can always see why and how the JuniperCDS system produced a recommendation, and decide if they want to act on it or adjust their course of treatment. The guidelines may also be customized at the local level, using our SAGE tool.

As JuniperCDS is a clinical solution, primary healthcare data for our solution is collected by us and structured in a standardized HL7 FHIR format (based on the latest international digital health standards). We follow the same guidance as recommended by the WHO’s SMART guidelines. Any applications JuniperCDS interfaces with will also collect primary health data. 

Ultimately, the only way to solve data capture quality is to collect better data at point of care with a holistic approach, like JuniperCDS.

At JuniperCDS, our team is committed to promoting diversity, equity and inclusion. Currently, our team has a large diversity of races and religions and we are aiming to further diversify across sex and gender in our next round of hiring. 

In our product, we aim for our software to equitably implement guidelines so that patients receive the care they need based on the guideline author’s recommended practice.

JuniperCDS will generate revenue by helping providers and care delivery network operators capture value from the improved patient and population health outcomes that arise from stronger adherence to evidence-based care, at scale. This revenue will come from software licenses and related professional services. 

The increasing push for CDS adoption in Global health markets makes JuniperCDS an attractive candidate for business-to-business and partnership sales models because of its ease of integration and comprehensive breadth of coverage. As the JuniperCDS organization scales, employing a B2B model will provide the opportunity to increase JuniperCDS market exposure and decrease the cost and effort associated with direct sales and support activities. 

A partnership approach is also a promising sales model as Electronic Medical Record (EMR) and Computerized Provider Order Entry (CPOE) software vendors are continually scanning the emerging technology market for offerings as they seek to expand their product portfolios with value-added features and services. Flexible and robust CDS solutions like JuniperCDS will be a valuable offering for these vendors as value-based care models become more popular. 

Pricing will ideally be vetted and adapted by a channel partner to the market. JuniperCDS expects to make money on the “long tail” by charging the whitelabelling B2B client a licensing fee for use of our app, ideally on a per-transaction basis. 

Providing SAGE at no cost to guideline authoring organizations is essential to our business model. Having authoritative guidelines from reputable organizations will build a library of guidelines we can draw on to implement within JuniperCDS. Therefore, we will offer SAGE free to guideline authoring organizations in order to obtain their content. 

SAGE will follow a “freemium” model, where the service will be free to use, but a premium tier will include features such as provenance, digital signing of guidelines, and analytics on how guidelines are adapted and used at point of care. The premium tier could be offered via a subscription or enterprise license. 

JuniperCDS will charge on a per transaction basis, where the user will be charged when they apply a guideline to a patient, however if it is more appropriate we may use a subscription model or combined pricing model. 

Since our value proposition mostly greatly benefits larger health systems looking to build consistency and operationalize clinical guidelines, we believe our best fit is to build partners with larger organizations in the Health IT space. Through our networks, we aim to build partnerships which would allow us to make a business to business sale in order to establish a foothold in the market. This approach will likely be more effective than trying to make direct sales since the incumbents in the healthcare industry hold a significant amount of clout with their clients. 

The goals listed below highlight key milestones for when we hope to generate traction and/or revenue in order to demonstrate viability. With appropriate investment in the Funding Rounds, we can potentially accelerate this timeline. Our goals take into account that healthcare has a “low sales cycle” meaning that we may only make sales every 4-6 months. The slow cycle will impact our testing and feedback on our MVP.

SAGE Beta client testing Jan. 2023

We aim to have a SAGE Beta ready for Jan 2023. It will have a limited feature-set, but have some core capabilities including the creation of basic SMART Guidelines, library and sharing functions, and the ability to copy and edit SMART Guidelines, as well as upload them to our SAGE testing platform. 

SAGE First Sale Jun. 2023

Our first Sale of SAGE should come in mid 2023. This sale will likely be to some kind of professional organization interested in creating interoperable FHIR versions of their clinical practice guidelines. We have traction with the WHO and ASCO, both of whom could become potential paying customers when we achieve an MVP. 

JuniperCDS Channel Partner Integration and Testing Sep. 2023

We aim to be testing and integrating with a channel partner by Sep. 2023. Achieving this goal will be essential for us to test and determine if our JuniperCDS app can be applied at point of care and be deployed as part of a larger solution. We have already taken many steps to mitigate risks in testing within existing vendor sandboxes, but there is still development of necessary MVP features required.

JuniperCDS Clinical Trial Jan. 2024

JuniperCDS must undergo a clinical trial before we can achieve a Software as a Medical Device License. We have plans to start this clinical trial within Canada, but are also exploring doing a US-based pilot for FDA approval. We aim to start this clinical trial in Jan. 2024, by which time we should have added the automated features, which will significantly increase the clinical value of JuniperCDS. Our team has already engaged Eastern Health Authority in Newfoundland and Hamilton Health Sciences as potential pilot sites. We are currently looking for a potential US-based pilot site.

Sales Forecast Assumptions

JuniperCDS requires a significant amount of time to achieve a market-ready product, since it makes recommendations to the clinicians themselves. Due to the nature of the product, it requires a Software as a Medical Device License from any jurisdiction in which we wish to do business. Given our focus in North America, we have plans to undergo an ISO13485 audit and seek a Food and Drug Administration Class II Medical Device, in addition to Health Canada approval. 

Given the long runway to a sale for JuniperCDS, the team is focusing on producing an MVP of SAGE which could result in a sale. We are targeting June 2023 as our first major sale of SAGE, likely to a Guideline Authoring organization who wishes to create, edit or modify FHIR CPGs. Additionally, we will engage in professional services to begin generating revenue to mitigate the slow sales-cycle risk.

Despite not having sales or being production ready yet, several large organizations such as the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) and Agency for Health Research and Quality (AHRQ) have made significant investments in the HL7 FHIR clinical practice guidelines which can be run on our JuniperCDS application. 

While these are all being pushed as top-down initiatives from large agencies, we believe that there is room for us to sell directly to clinical practitioners, however, there is more proven value for JuniperCDS at the system level, than at the practitioner level.

Our first main point of interest when bringing our products to the market is to create channel partnerships. The increasing push for CDS adoption in Global health markets makes JuniperCDS an attractive candidate for business-to-business and partnership sales models because of its ease of integration and comprehensive breadth of coverage. As the JuniperCDS organization scales, employing a B2B model will provide the opportunity to increase JuniperCDS market exposure and decrease the cost and effort associated with direct sales and support activities. Globally we will seek opportunities surrounding implementations of the WHO SMART Guidelines in order to expand and provide value.