The HEAL, Phase II Project: Enhancing Features of an Electronic Medical Record System to Improve Adherence to Asthma Guidelines
This article describes the implementation of an enhanced electronic medical record (EMR) system in three community health care centers in the Greater New Orleans area of Louisiana. This report may aid efforts directed at the implementation of enriched tools, such as decision support, in an EMR with the goal of improving pediatric asthma outcomes.
Asthma, electronic medical records, asthma guidelines adherence, community health center. [End Page 20]
Asthma is a chronic inflammatory airway disorder that continues to be a national health concern, particularly among minority patients. In 2009, approximately 24.6 million people in the United States had asthma, with a disproportionate burden on non-Hispanic Blacks, Puerto Rican Hispanics, and children.1 In Louisiana, disparities exist in asthma prevalence, mortality, emergency department visits, and hospitalizations by race and age.2 African Americans in Louisiana have a higher asthma mortality rate than Whites;2 African Americans in Louisiana are also four times more likely than Whites to have at least one emergency room visit due to asthma.3 Children aged 10 years and younger constitute over 50% of Louisiana’s Medicaid recipients with asthma and half of the state’s asthma expenses; Louisiana children under the age of five continue to lead all age groups in asthma-related hospital discharge rates.2
There are multiple factors that may contribute to the disproportionate burden of asthma in certain populations. Exposure to environmental triggers can contribute to health disparities in asthma. Studies show that urban households contain higher levels of environmental allergens (possible triggers of asthma symptoms) than suburban and rural households.3,4 Caretaker attitudes and beliefs may contribute greatly to health disparities in asthma as well.5 The National Cooperative Inner-City Asthma Study showed that though many caretakers were knowledgeable about asthma, factors such as problem-solving skills, multiple asthma managers, and high stress contributed to poor asthma management.5 Quality of and access to health care also plays a role in the disproportionate burden of asthma in African Americans and Hispanics.6 McDermott et al. showed that African Americans with asthma were less likely to use controller medications, have an asthma action plan, or have access to specialty care.6 Disparities in quality of care may also occur at the process level of a health system.7 Without some form of quality assurance within a system, providers may not consistently give all patients guideline-based care, thus also contributing to the disparities.7
The Head-off Environmental Asthma in Louisiana (HEAL), Phase II Project, a collaboration between Xavier University of Louisiana’s Center for Minority Health and Health Disparities Research and Education, the Merck Childhood Asthma Network, and Daughters of Charity Services New Orleans aims to improve pediatric asthma management in community health centers in the Greater New Orleans area via a multi-component approach. One major objective of the HEAL, Phase II Project is to promote delivery of universally applied evidence-based care for all pediatric asthma patients within the Daughters of Charity Services New Orleans (DCSNO) health system. The DCSNO is a non-profit organization that serves as a medical home for many of the medically underserved in the Greater New Orleans area, including a large African American population of both adults and children. The DCSNO provides primary and preventative services for approximately 17,200 patients annually. Most patients have incomes below the federal poverty level, have Medicaid, or are uninsured.
Four major components of the project have been identified: health care provider training, embedding of asthma educators into the health care system, community out-reach, and electronic medical record (EMR) enhancements to improve asthma care. This paper will describe the implementation of an enhanced feature of an EMR system at three DCSNO clinics to promote system wide adoption of, and provider adherence [End Page 21] to, the current asthma guidelines—with the overall goal of improving pediatric asthma outcomes.
Electronic Medical Records
EMRs have been shown to improve quality of patient care, enhance productivity of providers, and facilitate transfer of information between settings across the continuum of care.8 Enhancements of EMRs have also been shown to improve compliance with National Asthma Education Prevention Program (NAEPP) guidelines.9,10 Bell et al. implemented asthma management tools in an EMR, including a pediatric asthma control data-entry tool for capturing asthma symptom frequency, documentation templates to facilitate severity classification, and order sets to facilitate controller medication prescribing.9 The support tools embedded in the EMR improved clinician compliance with the 2007 NAEPP guidelines.9
Though EMRs impart many benefits, there are challenges to successful implementation that include cost, lack of knowledge of system operation, and disruption of patient care during implementation and upgrades.12 Thus, it is important to incorporate adequate technical support and trainings for staff and physicians when adopting an EMR system. The development of new processes and workflow procedures and recognition of resistance to change may also aid in a successful transition to utilization of an EMR.13,14 Successful EMR implementation can proceed in several phases. These phases incorporate a detailed planning process, communicating with staff, conducting training, making appropriate changes as necessary, and continued evaluation.13
The HEAL, Phase II Project has worked with its partners to utilize several of these phases to implement changes in an existing EMR. These enhancements may increase guideline-based documentation and pediatric asthma management at three clinic sites.
One of the key factors in successful implementation of the enhanced EMR is a detailed and deliberate planning process. Strategic planning, project goal-setting, and collection of pertinent information are significant during this stage.11,12 The DCSNO utilizes a medical record system named Electronic Health System. This system allows for disease-specific information to be collected directly from patients and embedded in their electronic charts. The Asthma Severity Index, a unique component of the EMR system, captures asthma-specific information from patients including day symptoms, night symptoms, and peak flow measurements. Though this information is asthma-specific, it does not reflect a focus of the updated guidelines13 regarding classification of both asthma severity and control.
The 2007 NAEPP guidelines highlight the concepts of severity and control for patient assessment and monitoring. Severity, the intensity of the disease, is emphasized when initiating asthma medications. Control, the degree to which signs and symptoms of asthma are minimized, is emphasized after therapy has been initiated. These concepts [End Page 22] help guide clinical decisions on medication therapy in the management of asthma. There are four classes of asthma severity: intermittent, mild—persistent, moderate—persistent, and severe—persistent. There are three levels of asthma control: well-controlled, not well-controlled, and very poorly controlled.13
The NAEPP guidelines also acknowledges the Asthma Control Test (ACT)14 as an assessment tool. The ACT is a five item validated tool that assesses symptoms, nighttime awakenings, rescue inhaler use, and interference with normal activities. This tool is utilized in patients ages 12 and up. The updated asthma guidelines relates ACT scores to level of control. A score above 19 indicates that the patient is well controlled; 15–19, not well controlled; and less than 15, very poorly controlled.13 The Childhood Asthma Control test (C-ACT) is validated for children ages 4 to 11; the scores and corresponding levels of control are the same as the ACT.
Though the Asthma Severity Index allowed collection of asthma-specific information, it did not permit providers to classify severity and control, which are key areas in updated guidelines. Without collecting information about asthma severity and control, it is difficult for health care providers using the system to comply with current national asthma guidelines.
. Stages of EMR Enhancements
|Stage 1: Planning Period||Stage 2: Pilot Testing||Stage 3: Institutionalization of EMR Enhancements|
EMR = Electronic Medical Records
In order to move towards an enhanced EMR by improving the Asthma Severity Index, weekly meetings were held with key clinical personnel. A pediatrician, EMR expert, nurse manager, and member of clinic administration met with the HEAL, Phase II team weekly to develop enhancements that would be both meaningful to the Daughters of Charity System, as well as the HEAL, Phase II Project. All members [End Page 23] involved were essential to developing an enhanced system that would be sustained within the organization. The pediatrician and nurse manager gave feedback from a user perspective. These team members were also critical in assessing current clinic workflow for pediatric asthma patients. The medical assistants and pediatricians are the personnel that actually use the enhanced system by entering the information. Input from these key staff members was critical for successful implementation. The presence of DCSNO’s EMR expert was also vital to successful implementation of the enhanced Asthma Severity Index. This expert was responsible for recommending realistic modifications that could be made in the EMR and implementing those changes. This feedback enabled the group to work more efficiently when discussing possible developments. Administration participation was vital during this process. Without the approval of the medical director, no changes could be made to the system. The administrator who participated in the weekly meetings was able to keep upper-level personnel abreast of discussions and desired enhancements.
It took approximately one year of dialogue to reach a consensus on the final enhancements of the Asthma Severity Index. The Asthma Severity Index was expanded to include asthma severity, control, and the ACT14 score to align with the updated guidelines. All pediatric asthma patients now receive the ACT or the cACT from the medical assistant before seeing the pediatrician. The pediatrician then enters the score of the ACT into the Asthma Severity Index. When evaluating the patient, the pediatrician assesses asthma severity and/or control and inputs this information into the enhanced Asthma Severity Index. Figure 1 outlines adopted changes in the DCSNO EMR that align the system with NAEPP guidelines; Figure 2 provides a screenshot of the enhanced Asthma Severity Index.
With these additions to the Asthma Severity Index within the EMR, an evidence-based asthma tracking system that can identify potential problems can be implemented. For example, one can search for asthmatic patients who are very poorly controlled or have an ACT score of 15 or less. Additionally, a patient’s profile may be flagged by incorporating certain parameters utilizing data collected from the augmented Asthma [End Page 24] Severity Index. This will help facilitate asthma management both during and outside of clinic visits. Furthermore, patients who are not well-controlled or very poorly controlled could be identified and controller medications added or the dosage increased. Having access to critical information regarding patients’ level of control could aid in management of patient’s symptoms and the providers’ and overall health system’s improved compliance with guidelines.
After the planning phase ended, a three-month pilot phase was implemented to review and refine enhancements and clinic workflow. Meetings were held bi-weekly to discuss methods to improve and sustain EMR changes. During these meetings, staff members provided valuable feedback about successes and challenges of implementation.
Training also took place during the pilot phase. A major barrier to successful implementation of an EMR is the lack of knowledge on use of the system.11 Once enhancements to the Asthma Severity Index were made in the EMR, DCSNO staff from each of the three clinics was trained on the new clinic workflow for pediatric asthma. Case managers and medical assistants were informed that all pediatric asthma patients should receive an Asthma Control Test (ages 12 and up) or Childhood Asthma Control Test (ages 4 to 11) at each clinic visit. After the patient and/or caregiver complete the control assessment tool, the score is entered by the pediatrician into the EMR via the Asthma [End Page 25] Severity Index housed within EHS. Pediatric providers were updated on the changes at a monthly provider meeting. These providers also received training regarding the updated NAEPP guidelines. During the training, the following topics were covered: asthma severity, asthma control, Asthma Control Test, and implementation of guidelines.
Institutionalization of EMR Enhancements
The literature discusses the importance of continuous updating, training, monitoring and evaluation of the implementation process.15,16 If updates occur to the EMR, users must be informed of changes; failure to do so will cause problems in EMR utilization. Evaluation of health system utilization of the EMR and continuous feedback are also extremely important.15 During the pilot phase, data was collected monthly regarding completion of the Asthma Severity Index by medical assistants and providers. One major challenge that has surfaced after implementation of the enhanced EMR is full utilization of the Asthma Severity Index. Although the organization was amenable to expanding the data collection tool, data entry remained incomplete during the pilot phase. Thirty-five percent of pediatric asthma patients had no asthma control documented. In addition, 26% of patients had no asthma severity documented. Possible barriers include resistance to change and workflow procedures. The project will continue to train and update DCSNO staff on the enhanced EMR component to assist during this transition. The project will continue to monitor staff utilization of the Asthma Severity Index by retrieving and reviewing data on the use of the tool on a monthly basis. This information will be brought back to the planning team for discussion on ways to improve the system for optimal results. Thus far, pediatricians have completed additional trainings to reinforce utilizing the enhanced Asthma Severity Index. Documentation of asthma severity and control has increased from 74.1 and 64.8% to 81.5 and 77.8%, respectively. As with other reported efforts, we anticipate that over time, the percentage of completed Asthma Severity Indexes will continue to increase.17
The impact of the enhanced Asthma Severity Index on pediatric asthma care within the DCSNO system will be evaluated using multiple measures. Key stakeholders, including providers and clinic administrators, will participate in focus groups to gain insight and feedback on the value of the enriched tool within the system. Organizational process measures, including utilization of the enhanced Asthma Severity Index will be assessed. Asthma outcome measures, such as symptom days, missed school days, emergency department visits, and hospitalizations will also be assessed. In addition patient satisfaction surveys regarding pediatric asthma care are collected after every visit to the clinic. Monthly reports are generated based on data imported from the EMR at DCSNO. [End Page 26]
Enhancements in the EMR should support pediatric asthma management at DCSNO clinics. These enhancements were designed to reinforce physician adherence to asthma guidelines and increase patient follow up. Improved asthma outcomes, including a decrease in emergency department visits, hospitalizations, and missed school days, should follow. Enhancements in the EMR will possibly lead to an increase in patient satisfaction around quality of care at DCSNO. The HEAL, Phase II Project will continue to monitor, report, and disseminate findings regarding the impact of making enhancements within the EMR on improving asthma-related pediatric care at DCSNO. We anticipate that over time, with system-wide adoption of the HEAL, Phase II Project, pediatric asthma patients will be more likely to receive the same level of evidence-based care in all three clinics.
Dr. Kristi Isaac Rapp is a Clinical Associate Professor at Xavier University (XULA) and Co-Principal Investigator of the HEAL, Phase II Project. Please address correspondence to her at Xavier University of Louisiana, College of Pharmacy, 1 Drexel Drive, New Orleans, LA 70725. Dr. Leonard Jack, Jr. is Director of the Center for Minority Health & Health Disparities and Principal Investigator of the HEAL, Phase II Project at XULA. Dr. Post is Chief Medical Officer of Daughters of Charity Services New Orleans. Dr. Flores is staff at Daughters of Charity Services New Orleans. Dr. Morris is Director of Business Development at Daughters of Charity Services New Orleans. Ms. Arnaud is Chief Nursing Officer at Daughters of Charity Services of New Orleans. Dr. Malveaux is Executive Director of the Merck Childhood Asthma Network, Inc. Dr. Woodall-Ruff is a pediatrician at Daughters of Charity Services of New Orleans. Mrs. Sanders is an asthma educator of the HEAL, Phase II Project. Ms. Denham is an asthma educator of the HEAL, Phase II Project. Mrs. Sunda-Meya is Project Manager of the HEAL, Phase II Project. Ms. Wilson is Biostatistician of the HEAL, Phase II Project.
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