An Asthma Action Plan Decision Support Tool in an EHR
An Asthma Action Plan Decision Support Tool in an EHR
Introduction Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes.
Methods eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls.
Results Between December 2012 and September 2014, 5174 patients with asthma (~10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pediatric asthma exacerbations, including 33% lower odds of requiring oral steroids (P < .001), compared with controls. Equivalent adult measures were not statistically significant.
Conclusions This study supports existing evidence that patient self-management plays an important role in reducing asthma exacerbations. We show the feasibility of leveraging technology to provide guideline-based decision support through an eAAP, addressing known challenges of implementation into routine practice.
Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. According to 2012 data from the Centers for Disease Control and Prevention, the prevalence of asthma is increasing and is estimated to affect 8.3% of the US population. More than 25.5 million people are affected, of whom over 6.8 million are children. Unfortunately, many patients with asthma lack adequate control of their symptoms, which negatively affects their overall quality of life and leads to increased use of expensive acute care services. The burden of asthma is exceedingly high. Each year, 2 million emergency department (ED) visits, 439,000 hospitalizations, and 3,000 deaths are a result of poorly controlled asthma.
An asthma action plan (AAP) is a tool designed to assist patients with self-management of their chronic disease. In fact, guidelines from the National Heart, Lung, and Blood Institute (NHLBI) recommend that all patients with asthma be provided with a plan that includes instructions for daily management and how to recognize and handle worsening symptoms. AAPs are particularly helpful for patients with moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma. While the content of each AAP may vary to some extent, typical plans outline which medications and what actions to take in the following 3 zones: (1) the "green zone," which includes medications taken every day to achieve and maintain good control; (2) the "yellow zone," which includes which rescue medications to add when asthma gets worse and when to see their provider for follow-up; and (3) the "red zone," which details what medications to take and how to seek care in the event of an asthma emergency. Previous studies demonstrate that patients receiving an AAP as part of their self-management education have higher satisfaction with their care, increased medication adherence, and fewer acute care visits compared with patients with no AAP. A Cochrane review of 36 studies showed significant reductions in both ED visits (relative risk, 0.82; 95% confidence interval [CI], 0.73–0.94) and hospitalizations (relative risk, 0.64; 95% CI, 0.50–0.82) among patients with an AAP as part of optimal self-management compared with usual care.
Although provision of an AAP to every patient with asthma is considered to be the standard of care, provider compliance with this recommendation has been limited. Barriers to provider compliance include lack of time, inexperience, and insufficient confidence in generating appropriate recommendations, as well as perceptions that patients may be nonadherent to AAPs or unable to self-manage. Providers also underutilize other recommendations in the NHLBI's guidelines, including assessments of asthma severity and control and the stepwise approach to managing asthma when choosing medication options for their patients. Adherence to the asthma guidelines is poor in part because of their complexity. The most recent version of the NHLBI's asthma guidelines is 440 pages long and requires providers to recall variations in the recommendations that are dependent on patient age, severity or level of control, and therapy step to tailor medication selection.
The complexities and intricacies of asthma management require innovative approaches to improve quality gaps and patient outcomes. Technology can be leveraged to link and filter the guidelines to providers at the point of care, resulting in increased adherence and reduced exacerbations. By incorporating technology into providers' asthma workflow, these solutions may increase the likelihood of patients receiving guideline-based recommendations and an AAP, thus facilitating their active involvement in their own care.
The goal of this project was to develop an electronic AAP decision support tool (eAAP) within the electronic health record (EHR) that could streamline the evidence-based NHLBI guidelines for providers, while also creating an individualized instructional handout for patients to use as their self-management plan. An additional aim was to prospectively evaluate the effectiveness of the eAAP's integration across the outpatient network of this large health care system. We hypothesized that patients with asthma receiving an eAAP would have fewer exacerbations after 3, 6, and 12 months compared with patients not receiving an eAAP.
Abstract and Introduction
Abstract
Introduction Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes.
Methods eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls.
Results Between December 2012 and September 2014, 5174 patients with asthma (~10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pediatric asthma exacerbations, including 33% lower odds of requiring oral steroids (P < .001), compared with controls. Equivalent adult measures were not statistically significant.
Conclusions This study supports existing evidence that patient self-management plays an important role in reducing asthma exacerbations. We show the feasibility of leveraging technology to provide guideline-based decision support through an eAAP, addressing known challenges of implementation into routine practice.
Introduction
Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. According to 2012 data from the Centers for Disease Control and Prevention, the prevalence of asthma is increasing and is estimated to affect 8.3% of the US population. More than 25.5 million people are affected, of whom over 6.8 million are children. Unfortunately, many patients with asthma lack adequate control of their symptoms, which negatively affects their overall quality of life and leads to increased use of expensive acute care services. The burden of asthma is exceedingly high. Each year, 2 million emergency department (ED) visits, 439,000 hospitalizations, and 3,000 deaths are a result of poorly controlled asthma.
An asthma action plan (AAP) is a tool designed to assist patients with self-management of their chronic disease. In fact, guidelines from the National Heart, Lung, and Blood Institute (NHLBI) recommend that all patients with asthma be provided with a plan that includes instructions for daily management and how to recognize and handle worsening symptoms. AAPs are particularly helpful for patients with moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma. While the content of each AAP may vary to some extent, typical plans outline which medications and what actions to take in the following 3 zones: (1) the "green zone," which includes medications taken every day to achieve and maintain good control; (2) the "yellow zone," which includes which rescue medications to add when asthma gets worse and when to see their provider for follow-up; and (3) the "red zone," which details what medications to take and how to seek care in the event of an asthma emergency. Previous studies demonstrate that patients receiving an AAP as part of their self-management education have higher satisfaction with their care, increased medication adherence, and fewer acute care visits compared with patients with no AAP. A Cochrane review of 36 studies showed significant reductions in both ED visits (relative risk, 0.82; 95% confidence interval [CI], 0.73–0.94) and hospitalizations (relative risk, 0.64; 95% CI, 0.50–0.82) among patients with an AAP as part of optimal self-management compared with usual care.
Although provision of an AAP to every patient with asthma is considered to be the standard of care, provider compliance with this recommendation has been limited. Barriers to provider compliance include lack of time, inexperience, and insufficient confidence in generating appropriate recommendations, as well as perceptions that patients may be nonadherent to AAPs or unable to self-manage. Providers also underutilize other recommendations in the NHLBI's guidelines, including assessments of asthma severity and control and the stepwise approach to managing asthma when choosing medication options for their patients. Adherence to the asthma guidelines is poor in part because of their complexity. The most recent version of the NHLBI's asthma guidelines is 440 pages long and requires providers to recall variations in the recommendations that are dependent on patient age, severity or level of control, and therapy step to tailor medication selection.
The complexities and intricacies of asthma management require innovative approaches to improve quality gaps and patient outcomes. Technology can be leveraged to link and filter the guidelines to providers at the point of care, resulting in increased adherence and reduced exacerbations. By incorporating technology into providers' asthma workflow, these solutions may increase the likelihood of patients receiving guideline-based recommendations and an AAP, thus facilitating their active involvement in their own care.
The goal of this project was to develop an electronic AAP decision support tool (eAAP) within the electronic health record (EHR) that could streamline the evidence-based NHLBI guidelines for providers, while also creating an individualized instructional handout for patients to use as their self-management plan. An additional aim was to prospectively evaluate the effectiveness of the eAAP's integration across the outpatient network of this large health care system. We hypothesized that patients with asthma receiving an eAAP would have fewer exacerbations after 3, 6, and 12 months compared with patients not receiving an eAAP.