EMGuidanceScript - antimicrobial stewardship at the point of scripting

EMGuidance Script is a SAAS prescription platform available to doctors in any sector of healthcare in South Africa. It is powered by EMGuidance, the leading independent digital platform empowering the frontline of healthcare delivery. EMGuidance Script is developing an AMR module to incorporate stewardship principles at point of scripting.

Kerry-Louise Scott, BPharm (Rhodes), MPharm (Pharmacoeconomics) (UKZN)

Lead pharmacist EMGuidance Script

EMGuidance has over 60 000 registered healthcare workers on its platform and sees over 1.5 million searches per month. EMGuidance has an in-house clinical content team producing high quality medicine monographs (over 1400 active ingredient monographs) and a current South African medicine pricing database.  EMGuidance partners with Afritox, the fourth largest poisons database in the world to display toxicology information. In partnership with the creators, EMGuidance houses a library of local guidelines, including the South African National Department of Health Standard Treatment Guidelines, which are all available for download within the app for offline use. This content is free for healthcare workers in South Africa. The EMGuidance reference information is used as the foundation for our SAAS product, EMGuidance Script, which aims to be the smartest digital script in the world. 

Antimicrobial stewardship strategies operate in silos with some areas of collaboration and information sharing (in-hospital versus out-of-hospital; private sector versus public sector; facility or hospital group interventions). This complicates decision-making for the prescriber which may result in poor treatment decisions. At point of scripting a prescriber needs to be empowered with access to localised information and behavioural nudges to make the most appropriate treatment selection and provide the most relevant patient education. 

Our target audience includes outpatient prescribers and hospital groups or individual treatment facilities. Our current reference platform has over 60 000 registered health care workers and our recently launched e-scripting solution is growing at a rate of one new prescriber every 2 days. 

Our primary aim at EMGuidance is to empower the frontline of healthcare delivery. We regularly conduct interviews with current or potential users to understand their needs and we identify pilot testers who are encouraged to give feedback in interview and survey form. 

Furthermore, we have strong connections with academic institutions and clinical societies and have already engaged to identify areas where our solution may assist with antimicrobial stewardship. We would regularly engage with these key stakeholders in the development of any solution. 

Our solution will provide support to healthcare professionals to improve stewardship practices, including reporting specific to the prescriber or facility to further identify areas for improvement. 

Aggregated reporting can be used for peer-review publication submissions and to partner with local societies and research organisations to support research data requirements.

Our B2B hospital partner serves low to middle income patients in the private sector. Current antimicrobial stewardship data capturing is manual and is not reported on. Simply by streamlining this data capture and reporting we aim to support providers with useful data to identify threats and implement changes. This same challenge affects many small an independent hospital groups who are potential B2B customers. 

Anecdotally from our interviews with experts and users, antimicrobial stewardship practices in the outpatient/community setting in the private sector are not structured as prescribers are not bound by the Dept. of Health Standard Treatment Guidelines, have access to a greater list of products and are frequently visited by pharmaceutical reps. The opportunity for small behavioural nudges developed through collaboration with local experts (bearing in mind that this will require local expert collaboration on regional level) is an opportunity to support GPs in the community with information to make the best treatment decision possible. 

Furthermore, with the sending of scripts digitally to patients we can leverage this mechanism for information on use of antibiotics and patient education. 

The scale of the solution is directly tied to the scale of our B2C and B2B business growth plans. We aim to exceed 1000 B2C users by the end of 2024 and ultimately aim to have 10 000 EMGuidance Script users by the end of the next 3 years. 

At EMGuidance Script we currently measure subscription rate, churn rate and signed scripts as a measure of adoption of the service. We can also measure switching decisions of doctors based on the options we present (e.g switching to a less costly generic on the script). 

We will be able to measure antibiotic selection based on diagnosis, area, setting, prescriber and the rate of dispensing of that product. 

We could also measure click rate on educational information sent to patients and completion of micro surveys by patients when antibiotics are sent to them. 

The South African regulations stipulate the requirements of an electronic prescription, including the level of digital certificate that must be used to sign the script (advanced electronic signature). Although our solution complies with the legislation, this legislation has not been enforced by regulators, therefore doctors opt to use non-compliant e-scripting mechanisms (word processors and email, non-compliant e-scripting modules) as they are less costly. This is impacting the rate of adoption of our solution but we will continue to lobby for the adherence to the legislation which is aimed at reducing fraud risk and protecting all parties. 

Secondly, we want to integrate with as many partners as possible (e.g EHRs, dispensing systems), but we are dependent on their system capabilities for integration and their development prioritisation. 

The balance between developing enhancements requires constant assessment because it is easy to spend resources on developing enhancements that do not necessarily increase adoption. Our current product is being adopted and major enhancements like an AMR module will add value to the healthcare system but require allocation of funds and resources and may not necessarily draw a significant financial return for the business, but will provide public good. 

Willingness to pay for an antimicrobial stewardship solution has not been convincing in the current local economic climate where it may be regarded as a nice to have but not an essential expense.  Allocation of key resources to a project with potentially limited revenue generation is a challenge.  

However, we do understand that we are in the perfect position from a platform and audience engagement perspective to develop a very impactful solution to drive positive antimicrobial stewardship practices for the greater good. 

Our main barrier is the financial support to allocate the required resources to the project development and engage key collaborators. 

Local and international infectious disease and other relevant societies.

Private laboratory services (e.g Lancet, Pathcare, Ampath) and the South African National Health Laboratory Service

Academic institutions for:

• Infectious disease experts and clinical microbiology experts. 
• Experts in behavioural psychology. 
• Translators who can assist with translating information into the national languages of South Africa (of which there are 11) and patient education experts who can support compilation of information for low levels of literacy.