Improving Asthma Care in an Integrated Safety Net through a Commercially Available Electronic Medical Record

The electronic asthma action plan (e-AAP) application is a computerized decision support tool developed with funding from the Agency for Healthcare Research and Quality (AHRQ) that integrates the 2007 National Asthma Education Prevention and Promotion (NAEPP) Guidelines for the Diagnosis and Treatment of Asthma into an electronic health record (EHR).

The e-AAP is launched at the point of care with an order that is entered by the primary care physician (PCP) during a patient encounter. The e-AAP screens systematically walk the PCP through patient-focused questions, as recommended by the Guidelines, that result in assessment of asthma severity or control, provide choices of Guideline-recommended treatment plans and the corresponding medications, and incorporates that information into a written asthma action plan (available in English and Spanish) for the patient to have as their chronic care document.

The primary objectives of the project were to:

• Develop the electronic decision support tool, with content based on the recommendations presented in the National Asthma Education and Prevention Program 2007 Guidelines for the Diagnosis and Management of Asthma. (For more information, please see: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf (PDF, 3.87 MB.)
• Create a mechanism that enables a user to launch and complete the e-AAP while working in a patient's EHR.
• Introduce the e-AAP to providers at eight Hennepin County Medical Center (HCMC) primary care clinics, a safety net teaching hospital located in Minneapolis, Minnesota, emphasizing how the e-AAP supports quality asthma care.
• Create an asthma registry populated by data generated by the e-AAP and merged with asthma-relevant data generated by patient EHRs, and use the registry as the data source for regular reports showing clinic-by-clinic measures of asthma care quality.

The project succeeded in establishing an EMR-supported mechanism through which clinicians could invoke the asthma electronic decision support tool while engaging in a patient encounter. However the project did run into a number of challenges including difficulty in operationalizing evidence-based guidelines during the delivery of medical care. It was noted that guidelines often fail to provide the kind of support clinicians need while they are performing clinical work. As such, the project team recommends developing new criteria for guideline quality that includes the ability to operationalize recommendations.

The team also noted that software remains useful only to the extent that it is maintained. For clinical decision support software, clinical content must be kept current with emerging guidelines. In addition, technical maintenance needs to occur, including modifying the software in response to user feedback regarding usability, functioning, and screen displays. When providing clinical decision support, underlying content must reflect current clinical conditions or it will be less than useful at best, and harmful at worst. Resources must be allocated to perform these ongoing maintenance activities.

The final products, listed below in the news and publications section, include a report on the evaluation of clinician acceptance of the application, using as evidence the rates with which patients seen for asthma had completed asthma action plans generated by the application.