M. Diane Lougheed

Background: Asthma care gaps between best practice and clinical practice contribute to the burden of asthma on individuals and society. Electronic medical records (EMRs) provide a unique opportunity to integrate novel e-tools at the point of care. Objective: The purpose of this study was to evaluate the perceived utility, health care practitioner satisfaction, and barriers and enablers associated with the implementation of the Provider Asthma Assessment Form (PAAF), a novel e-tool integrated into the primary care EMR. Methods: Health care practitioners (n=80) at a family health team were invited by email to participate in a voluntary survey regarding their use of the PAAF in their role within the family health team. Respondents who had used the PAAF were asked to assess its perceived utility, their satisfaction with it, and any associated barriers and enablers. Responses were analyzed using descriptive quantitative analysis and qualitative analysis to identify major themes. Results: In total, 18 responses were included, including 4 (22.2%) from practitioners who had used the form and 12 (66.7%) from practitioners who had not. Overall, most practitioners who used the form were satisfied with the PAAF and reported that it was helpful in clinical practice, aided decision-making, and was user-friendly. Enablers such as detailed documentation, decision support, and multidisciplinary involvement were identified. Several barriers were also identified, including time constraints, lack of knowledge and training regarding the use of the form, limited opportunity to use it, and limited availability of necessary data elements to complete the PAAF. Conclusions: The PAAF was perceived to be a useful and largely satisfactory e-tool by responding practitioners. However, several barriers limited user uptake and sustained use. Future directions for PAAF implementation include increased tailoring to the needs of primary care teams and leveraging technological advancements. Lessons learned from the PAAF can inform the development and implementation of novel e-tools in primary care EMRs.

Background: Despite national asthma care guidelines, care gaps persist between best-practice and clinical practice, contributing to poor health outcomes. The Provider Asthma Assessment Form (PAAF) is an electronic asthma management and Knowledge Translation tool with an embedded decision support algorithm for severe and/or uncontrolled asthma, designed to support evidence-based asthma management. Objective: In this study, we aimed to document baseline asthma practice patterns and determine whether the broader intervention of PAAF integration into a primary care electronic medical record (EMR) improves evidence-based asthma diagnosis and management. Methods: We performed a single-center pre- and postobservational study at an academic Family Health Team in Kingston, Ontario, Canada. Retrospective baseline data were collected for 2 years prior to PAAF implementation from January 2018 to December 2019. Prospective postintervention data were collected from October 2022 to July 2024. A validated adult asthma EMR case definition was applied to EMR data to identify suspected or objectively confirmed asthma cases for both datasets, on which detailed manual chart abstractions were performed. A data extraction was performed for completed PAAFs. Results: There were 230 patients in the retrospective baseline and 143 patients in the postimplementation cohort. Overall, 31.3% (n=72) of patients at baseline versus 23.8% (n=34) at postimplementation had confirmed asthma. There were significantly more pulmonary function tests requested after the implementation of the PAAF (postimplementation: n=70, 49%; baseline: n=71, 30.9%; P<.001). A significantly higher percent of postimplementation patients were on single inhaler controller and reliever therapy (postimplementation: n=31, 21.7%; baseline: n=2, 0.9%; P<.001), inhaled corticosteroid/long-acting β-2 agonist therapy (postimplementation: n=36, 25.2%; baseline: n=34, 14.8%; P=.01), and inhaled corticosteroid if their asthma was uncontrolled (postimplementation: n=69, 62.2%; baseline: n=100, 43.5%; P=.002). Barriers were significantly more commonly addressed after implementation (postimplementation: n=24, 16.8%; baseline: n=11, 4.8%; P<.001). A significantly higher average number of asthma control parameters was documented when the PAAF was used (PAAF: mean 5.4, SD 1.9; manual chart abstraction: mean 2.3, SD 1.2; P<.001). Care as assessed by key Primary Care—Asthma Performance Indicators showed improvement in the postimplementation cohort, which did not reach statistical significance. Conclusions: The multifaceted intervention of implementing the PAAF in this primary care practice was associated with improved documentation of diagnosis status and asthma control parameters and improved adherence with evidence-based recommendations for care, such as the use of pulmonary function tests and addressing barriers to effective asthma management. However, uptake was low, and key asthma care gaps were still common. Future directions should involve evaluating the impact of the PAAF on care and outcomes after widespread implementation in primary care settings and investigating methods to increase user uptake of the PAAF.

Background: An evidence-based standardized ED asthma care pathway (EDACP) was developed and implemented in Ontario, Canada. Objective: To determine the impact of EDACP implementation and access to ED asthma management resources and specialists on return ED visits. Methods: All 173 Ontario hospitals were surveyed regarding their access to community and ED asthma specialists and ED asthma management resources, including EDACP implementation date and status as of August 2017. Survey data were linked to provincial health administrative data to quantify acute health services utilization. A Poisson regression interrupted time series analysis was conducted. Results: Of the 123 hospitals responding to the survey, 44 (35.8%) had approved the EDACP. Data were analyzed for the 5 years preceding (30,028 asthma visits) and 17 months following (7,916 asthma visits) implementation, with a 3-month implementation black-out period. After controlling for auto-regressive factors, EDACP implementation was associated with a 2% reduction in the absolute rate of return ED visits within 72 h (p = 0.0124), and within 7 days (p = 0.0295) at teaching hospitals. The same effect was not seen at community hospitals. Peak expiratory flow testing (available at 77% of sites) and spirometry (available at 45% of sites) were associated with 34% (p = 0.0071) and 23% (p = 0.028) reductions in the odds of return ED visits within 72 h, respectively. Conclusion: The positive results from this large-scale effort to implement an evidence-based knowledge translation initiative in diverse settings, suggests there is merit in continuing to invest time and resources to overcome barriers to adoption and implementation of this EDACP.

Background: Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices. Objective: The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance. Methods: In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis. Results: Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care. Conclusions: Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

BACKGROUND Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices. OBJECTIVE The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance. METHODS In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis. RESULTS Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care. CONCLUSIONS Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

Background: A work-related asthma (WRA) screening questionnaire is currently being validated for implementation in clinical settings. To minimize barriers to integrating tools into clinical practice, a discussion of strategies for the implementation of the questionnaire has begun.Objective: This study aimed to understand the benefits, feasibility, barriers, and limitations of implementing the Work-related Asthma Screening Questionnaire–Long version (WRASQ[L]) and asthma e-tools in clinical settings and propose dissemination and implementation strategies for the WRASQ(L).Methods: This study was conducted in Kingston, Ontario, Canada, from September 2019 to August 2021. A workshop and 2 questionnaires were used to understand the benefits of and barriers to implementing the questionnaire in clinical settings. An expert advisory committee was established to develop the implementation and dissemination strategies. Workshops were semistructured and used thematic qualitative analysis to identify themes that provided an understanding of the benefits and limitations of and barriers to using the WRASQ(L), and e-tools in general, in clinical settings. Workshop participants included patients and health care providers, including physicians, nurses, and asthma educators, who were implementation specialists and expert electronic medical record users. A questionnaire focusing on providers’ knowledge and awareness of WRA and another focusing on WRASQ(L) feedback was administered at the workshops. Advisory committee members from relevant stakeholders met 3 times to strategize implementation opportunities.Results: A total of 6 themes were identified in the workshop: involving and addressing patient needs, novel data collection, knowledge translation, time considerations, functional and practical barriers, and human limitations. Questionnaire responses yielded positive feedback on the utility of the WRASQ(L) in clinical settings. All participants agreed that it is an easy way of collecting information on occupational and exposure history and could prompt a discussion between the health care provider and patient on how the workplace and exposures could affect one’s asthma, increase awareness of WRA in patients and providers, and increase awareness of exposures in the workplace. Implementation and dissemination strategies were generated with input from the advisory committee.Conclusions: Stakeholders and workshop participants consider the WRASQ(L) to be a useful tool that satisfies many provider needs in their clinical settings. Once validated, dissemination strategies will include developing educational materials that include the WRASQ(L), linking the questionnaire to stakeholder websites or e-toolkits, translation into other languages, leveraging health care and research networks, conference presentations, and peer-reviewed publications. Implementation strategies will include integration into electronic medical records; designing multifaceted interventions; and targeting nontraditional settings such as workplaces, pharmacies, and research settings. The WRASQ(L) addresses many benefits of and barriers to implementation, as identified in the workshop themes. These themes will guide future implementation and dissemination strategies, noting that human limitations identified in providers and patients will need to be overcome for successful implementation.