Keywords
asthma - pediatric hospital - informatics - electronic medical record
Background and Significance
Background and Significance
Asthma is a common childhood illness affecting approximately 10% of all Australian
children,[1] with recent data demonstrating that it is the leading cause of disease amongst Australian
children aged 5 to 14 years.[2] While asthma in Australia is primarily managed in a primary health care setting,
many children require hospital care for acute or long-term management of moderate
to severe disease.[1]
In the hospital setting, childhood asthma is managed in the outpatient, inpatient,
and emergency settings. Across these encounters, routinely addressing key aspects
of asthma management has been shown to improve clinical outcomes.[3]
[4]
[5]
[6] These include assessment of asthma triggers, evaluation of severity and control
(including use of age-appropriate standardized asthma severity scores – Asthma Control
Test [ACT], Asthma Control Questionnaire [ACQ] or the Test of Respiratory and Asthma
Control in Kids [TRACK]), inhaler technique, appropriate medication dosing and adherence,
asthma education and the provision of an asthma action plan, which forms the foundation
of the Australian National Asthma Guidelines.[3]
[4]
[5]
[7]
Although these core aspects of asthma care are well established and widely accepted,
they are often either missed or duplicated during hospital-based patient consultations.
An example of these gaps in routine asthma care is poor assessment and recognition
of asthma control, which results in the under-recognition of suboptimal control.[8]
[9]
[10] Furthermore, a recent Australian survey showed that one in three children with asthma
(aged between 0 and 14) did not have an up-to-date asthma action plan,[11] despite it being shown to be associated with both reduction in asthma-related acute
presentations to hospital and overall risk of asthma-related morbidity.[6]
[7]
Many hospitals have adopted targeted clinical decision support initiatives to address
some of these gaps, which have been shown to improve the delivery of asthma care.[12]
[13]
[14]
[15] However, there remains ongoing gaps in care affecting the accuracy of patient information
collected as well as the efficiency of clinical workflow, which in turn can have a
detrimental impact on clinical decision making and outcomes. This is primarily due
to the bespoke nature of previously developed electronic tools, without the integration
with a wider electronic medical record (EMR), which therefore does not allow the possibility
of harnessing efficiency savings.
Our institution, The Royal Children's Hospital Melbourne (RCH), has an organization
wide EMR system (Epic Systems, Verona, WI) which was introduced in 2016. However,
like many EMR systems there was no dedicated asthma-related EMR tool or decision support
system to aid clinicians, with most asthma documentation and care decisions completed
without templates in an ad hoc manner as per clinician preference.
To address this, an integrated EMR-based asthma “hub” tool was developed for initial
use in the outpatient clinic setting.
Objectives
The objective of this study was to measure year-on-year improvement in asthma-related
documentation and provide a key gold-standard aspects of asthma management after the
introduction of an EMR asthma “hub” tool in the outpatient setting. Specific focus
was on key aspects of asthma management that have been demonstrated to improve clinical
outcomes, such as documentation of asthma triggers, including smoke exposure, use
of asthma severity scores, and provision of a new or updated asthma action plan.
Methods
Setting and Inclusion Criteria
RCH is a tertiary pediatric institution that has approximately 45,000 outpatient appointments
per year. The complex asthma ambulatory care clinic is specifically for patients with
moderate to severe asthma, who have multiple complex risk factors making them prone
to high risk for repeat asthma exacerbations, failure of treatment, or admission to
hospital. The clinic sees approximately 480 patients per year. This cohort was selected
for evaluation as they are the group who would benefit the most from a pilot intervention
that addressed routine provision of care for asthma.
A single-center retrospective chart review was conducted at RCH and included all patients
who attended the outpatient Complex Asthma Clinic between January to April 2020 and
January to April 2021 following the introduction of the asthma “hub” in November 2020.
The same timeframe was compared between 2020 and 2021 to account for potential seasonal
variation.
Asthma Hub Design
While the asthma “hub” has a bespoke design customized to suit organization-specific
workflows, it harnesses native EMR functionality and tools for build. It has been
designed to sit within the clinic visit workflow for clinicians, with content terminology
that suits the Australian clinical context ([Figs. 1] and [2]).
Fig. 1 RCH EMR Asthma “Hub” – initial navigator. EMR, electronic medical record; RCH, Royal
Children's Hospital Melbourne.
Fig. 2 RCH EMR Asthma “Hub” – assessment and orders. EMR, electronic medical record; RCH,
Royal Children's Hospital Melbourne.
The hub has three main features ([Table 1]):
-
Collating relevant asthma-related clinical information from across a patient's chart
into a single location for ease of review and evaluation.
-
Provision of a standardized template to document key asthma-related information that
can either carry across all patient encounters (e.g., asthma triggers) or are specific
to that patient visit (e.g., asthma assessment score).
-
Provision for clinicians to act on this information via various mechanisms within
the same workflow (e.g., develop/print asthma action plan or order community-based
education follow-up visits).
Table 1
Elements of the Asthma “Hub”
|
Elements requiring manual entry
|
Elements auto-displayed from chart information
|
Elements that clinician could act on, document or order
|
|
• Date of initial diagnosis
• Asthma triggers
• Smoke exposure in household
• Asthma-related medications
|
• Co-morbidities
• Asthma-related investigations
• Asthma-related hospital visits.
|
• Asthma severity scores: the Asthma Control Test (ACT), Asthma Control Questionnaire
(ACQ) or the Test of Respiratory and Asthma Control in Kids (TRACK)
• Medication dosing and adherence
• Review and/or update current asthma action plan
• Review spacer and inhaler technique
• Provide online/print based asthma education resources
• Influenza vaccination status
• Referral to community-based asthma education program
|
The hub was collaboratively developed over a 3 month period by a “hub working group”
comprising clinicians working in the complex asthma clinic and health informaticians.
Content development was established using clinical practice guidelines and stakeholder
inputs and consensus from the broader organizational asthma working group. This was
then translated into an informatics tool by informaticians. Three rounds of user acceptance
testing (UAT) were conducted by the hub working group to ensure that the content matched
organizational workflow and practice, and the tool was as efficient as it could be
with user experience as streamlined as possible ([Fig. 3]).
Fig. 3 RCH EMR Asthma “Hub” design flowchart. EMR, electronic medical record; RCH, Royal
Children's Hospital Melbourne.
Statistical Consideration
Presence of documentation of each aspect of asthma care was reviewed and described
in percentages. Fisher's exact test was used to compare pre and post intervention
data, with p <0.05 considered statistically significant.
Results
A total of 161 cases were reviewed, with 80 and 81 patients in the pre- and post-asthma
“hub” groups, respectively.
After the introduction of the asthma “hub” there was a significant increase in the
documentation of asthma triggers (e.g., smoking/smoker exposure), (47.5–92.6%, p <0.001), current asthma action plans (70.4–86.3%, p = 0.02), and severity scores (46.3–81%, p < 0.001). There was no significant difference in the documentation of reliever (as
required) or regular preventer medications (93.8–95.1%, p = 0.75).
Evaluation of patients' post-introduction of the asthma “hub” demonstrated documentation
of inhaler and spacer technique assessments in 37.5% of patients, and documentation
of the provision of asthma education via online links and videos in 25.0%. There was
no documentation of these metrics in any cases prior to the introduction of asthma
“hub.”
Discussion
This study demonstrated that an EMR-based asthma “hub” is effective at increasing
the provision of key aspects of routine asthma management and documentation in a systematic
manner. This supports previous studies demonstrating the utility of EMR-based asthma
tools in influencing the provision of and improving the quality of asthma care.[12]
[13]
[14]
[15]
[16]
[17]
Increasing evaluation of core aspects of asthma management and documentation directly
improves clinical outcomes.[4] The recognition of asthma triggers, including allergens and tobacco smoke exposure
can reduce disease severity and specifically avoiding tobacco smoke has been demonstrated
to reduce early lung function decline.[18]
[19] Further to this, the use of severity scores and asthma action plans have been shown
to reduce associated morbidity and the use of acute and specialist health care services.[8]
[9]
[10]
The implementation of the asthma “hub” significantly increased these key elements
– namely recognition and documentation of asthma triggers, including smoke exposure,
use of asthma severity scores, and provision of a new or updated asthma action plan.
This is likely due to a systematic standardized proforma which provided key information
within the clinician's workflow and acted as an aid to prompt clinicians to ask or
update key elements of asthma care.
In contrast, this study found no significant difference in documentation of reliever
(as required) or regular preventer medications despite the introduction of the asthma
“hub.” This is likely due the need of prescriptions for medications, which already
required an active ordering process within an EMR setting. Thus, the hub served to
streamline and collate a list of patient medications without the clinician needing
to find this in other parts of the patient's medical record – but the overall documentation
rates did not improve.
Importantly, the “hub” also enabled evaluation of the provision of asthma care by
facilitating aspects of management that had not previously been routinely documented.
There was minimal information or documentation of clinical items such as assessments
of spacer and inhaler technique and the provision of asthma education through online
and print resources prior to the introduction of the “hub,” which therefore made direct
clinical impact difficult to measure. Although there was improved documentation after
the “hub,” this provides an opportunity to engage other informatics solutions such
as predictive ordering or clinical decision support tools to prompt clinicians and
enhance uptake of these important asthma preventative care strategies.
Overall, the study highlights the importance and impact of the basic foundational
benefit of using the EMR to provide appropriate and relevant data within a clinician's
workflow. While additional informatics solutions and tools can assist and enhance
asthma care, they rely first on appropriate and accurate data to be available for
evaluation and analysis.
Further evaluation of impacts of this informatic solution on specific clinical outcomes
including number of exacerbations and hospital attendances, would provide more comprehensive
evaluation of its clinical utility. Evaluation of user experience will also allow
understanding of the intervention on clinic efficiency and workflow. A more comprehensive
understanding of the benefits, practicalities, and acceptability will enable planning
for potential rollout into other settings such as inpatient and emergency settings,
as well as how to synergize the “hub” with other potential interventions.
Limitations
The single center study was conducted at a tertiary level pediatric hospital and therefore
conclusions may not be applicable to different environments where there are different
resource availabilities. The study was conducted in a single asthma clinic with highly
repetitive workflows. Application in other clinics where workflows are more sporadic
may impact the effectiveness.
The tool was introduced during the COVID pandemic period which significantly affected
the mode of care – culminating in a significant shift to telehealth after March 2020
due to COVID restrictions. Although this may have affected clinician–patient interaction,
the study measures the impact of documentation rather than clinical outcomes or improvement,
which is unlikely to be significantly altered by COVID-related changes.
Conclusion
The use of an EMR-based asthma “hub” improved the documentation and provision of asthma
care in a pediatric outpatient setting, particularly in key areas which have been
shown to improve clinical outcomes. Further evaluation of potential improvement in
specific clinical outcomes, including impact on emergency attendance and admission
frequency, and user experience will influence expansion of the “hub” into inpatient
and emergency settings.
Clinical Relevance Statement
Clinical Relevance Statement
This study demonstrated that the use of an EMR tool, the asthma “hub,” in an outpatient
setting, positively impacts core aspects of asthma management by boosting clinical
provision of asthma care through improved documentation.
Multiple Choice Questions
Multiple Choice Questions
-
This study demonstrated a dedicated EMR-based asthma tool, the asthma “hub,” can support
and improve asthma management when using standardized data elements. Which of the
following elements were not included in the asthma “hub”?
-
Co-morbidities.
-
Detailed family history of asthma.
-
Asthma-related investigations.
-
Influenza vaccination status.
Correct Answer: The correct option is b. While a family history of asthma predicts an increased risk
of developing the disease, a family history of asthma has been demonstrated to have
a low positive predictive value and has a limited role in guiding asthma management.
The remainder of the options were elements included in the asthma “hub.”
-
Which of the following was the main feature of the EMR-based asthma “hub” assessed
in this current study?
-
Making available and summarizing asthma relevant clinical information for general
practitioners and community health care providers.
-
Providing asthma medication recommendations based on relevant clinical information
available.
-
Providing links to relevant clinical asthma guidelines.
-
Allowing clinicians to evaluate and act on the collated relevant asthma information
from a patient's electronic medical record.
Correct Answer: The correct option is d. The other options were not features of the current study
but are important features to consider for future development of the asthma “hub.”
