Integrating Patient-Reported Outcomes into Routine Primary Care: Monitoring Asthma Between Visits (California)

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A Simple Mobile Application is Key to Patient Engagement in Reporting and Monitoring of Asthma Symptoms

Key Finding and Impact:

A simple app, designed with input from patients, resulted in 92 percent of patients continuing to report their asthma outcomes at the end of the study. A tool like this simple app may help patients better control their asthma and prevent emergency care.

Seeing value in using PROs data for research purposes, Dr. Robert S. Rudin from the RAND Corporation recognized that PROs data could also be used to improve patient care. People with asthma have better outcomes and fewer flareups when their symptoms are routinely monitored and managed by clinicians. Using mobile applications to report asthma symptoms to clinicians would allow for more timely management of asthma systems.

Dr. Rudin and his research team designed a patient-facing mobile phone app for people with asthma using user-centered design principles and an iterative process that engaged patients and providers. Patients received a weekly prompt to answer five standardized questions about their current asthma symptoms. A care manager, such as a nurse or medical assistant, received notifications if patient-reported symptoms met specific conditions of worsening severity.

User feedback is important to the development of mobile health apps.

Keeping patients engaged is often a challenge in healthcare; therefore, the research team knew they had to develop an app that would be of value to patients so that they would continue to use it. Dr. Rudin commented, “Using a user-centered design process, the patients reveal to you what they want for the design. I’ve yet to have an interaction with a user where I didn’t learn something.” The user-centered design process informed the development of the app and the practice model for the intervention. For instance, physicians invited their patients to use the mobile app, because the researchers found during the formative research that patients are more likely to adhere to recommendations made by their physicians.

The importance of keeping it simple “Too often we try to load up interventions with bells and whistles, and then you don’t know exactly why it works or doesn't work. For this intervention, we discovered that asking patients five simple questions once a week, with the option to call the provider, kept patients engaged in asthma management and made them feel more connected with their physicians.”
- Dr. Robert S. Rudin

A simple solution to engage patients.

Dr. Rudin and his team conducted a 6-month feasibility study in two subspecialty care clinics, analyzing app usage logs and data from interviews conducted with patients and clinical staff. At the end of 6 months, they were surprised and pleased to find high patient engagement: 92 percent of patients were still completing weekly PRO questionnaires. Over 80 percent of patients received at least one call based on their weekly PRO responses. Patients reported that the app was simple and easy to use, increased awareness of their asthma symptoms and flares, made them feel more connected to their provider, and avoided emergency care. Providers reported minimal workflow burden.

Scale and spread of this successful application and model.

Dr. Rudin has been funded for future work by AHRQ to scale and spread this successful app and practice model. For this current research, Dr. Rudin and his team are applying user-centered design processes to enhance and adapt the app in a primary care setting, where much of asthma disease management occurs. The enhancements will include recording peak flows and details on recent symptoms and triggers, which were suggested by patients and providers during the original research project. The enhanced app and model will be rigorously evaluated with a randomized controlled trial to understand the impact of the app on quality of life and asthma-related healthcare utilization.

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Enhancing and scaling a previously piloted mobile health application that incorporates the collection of asthma-related patient-reported outcomes into routine primary care will assist clinicians in better managing their patients with asthma and improve their quality of care. Incorporating functionality relevant to the COVID-19 pandemic may provide insight into how health systems can efficiently and effectively identify and recruit high-risk patients for digital home monitoring to reduce utilization of pandemic-related limited emergency and hospital resources.


Uncontrolled asthma impairs quality of life and is associated with utilization of high-cost healthcare services. Current clinical guidelines recommend frequent monitoring of asthma symptoms in the ambulatory setting to avoid clinical deterioration and the need for emergency care. However, adherence to guidelines is poor, and tools and practice models for intensive symptom monitoring are needed. The research team previously developed and successfully pilot-tested a simple mobile health (mHealth) application (app) that tracks patients’ self-reported asthma symptoms, and a practice model to monitor the symptoms as part of routine care.

This followup research is adapting and scaling the app-enabled practice model to the primary care setting, the setting where most asthma patients are treated, at an accountable care organization that serves a large and diverse population of patients with asthma. The Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which emphasizes the importance of simplicity in designing and scaling technology, is guiding the study. A rigorous evaluation will be conducted to understand the impact on quality of life and asthma-related healthcare utilization.

The specific aims of this research are as follows:

  • Adapt the existing health information technology (IT)-enabled practice model for asthma symptom monitoring using patient-reported outcomes (PROs) to a primary care population that includes Spanish-speaking and low-health-literacy patients. 
  • Implement the adapted health IT-enabled practice model in four primary care community clinics, identify a cohort of eligible asthma patients to participate, and train clinicians and clinical staff. 
  • Rigorously evaluate the impact of this new health IT-enabled practice model using a randomized controlled trial. 

The COVID-19 pandemic presents an unprecedented risk for the 25 million individuals in the United States who have asthma, and an AHRQ-funded supplemental grant will allow the team to make three enhancements in response to the current pandemic. First, they will enhance the mHealth app with a COVID-19 symptom screener and relevant educational materials. Second, they will identify best practices, barriers, and facilitators for recruiting patients to use this intervention during an historic time. Finally, they will develop and validate a predictive model to identify asthma patients who may benefit the most from the intervention, using data available from the electronic health record.

The findings of this research will demonstrate how healthcare systems can use data-driven approaches to identify patients at risk for poor outcomes who would benefit from routine and remote monitoring of PROs via clinically integrated digital interventions. The knowledge gained from this research will provide a clearer understanding of how health systems might use health IT to improve outcomes of patients with chronic conditions, such as asthma, by improving compliance with guidelines. Doing so will not only mitigate the impact of the pandemic on this population, but also minimize the strain on acute and critical care capacity in future surges.