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Research ArticleOriginal Research

Planning for Action: The Impact of an Asthma Action Plan Decision Support Tool Integrated into an Electronic Health Record (EHR) at a Large Health Care System

Lindsay Kuhn, Kelly Reeves, Yhenneko Taylor, Hazel Tapp, Andrew McWilliams, Andrew Gunter, Jeffrey Cleveland and Michael Dulin
The Journal of the American Board of Family Medicine May 2015, 28 (3) 382-393; DOI: https://doi.org/10.3122/jabfm.2015.03.140248
Lindsay Kuhn
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
MHS, PA-C
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Kelly Reeves
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
BSN, RN
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Yhenneko Taylor
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
PhD
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Hazel Tapp
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
PhD
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Andrew McWilliams
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
MD, MPH
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Andrew Gunter
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
MD
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Jeffrey Cleveland
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
MD
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Michael Dulin
From the Department of Family Medicine (LK, KR, HT, AM, MD), Dickson Advanced Analytics (YT, MD), and Department of Pediatrics (AG, JC), Carolinas HealthCare System, Charlotte, NC.
MD, PhD
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Article Figures & Data

Figures

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  • Figure 1.
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    Figure 1.

    Electronic asthma action plan decision support tool (eAAP) development phases. EHR, electronic health record.

  • Figure 2.
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    Figure 2.

    Screenshot of the electronic asthma action plan decision support tool (eAAP) in the electronic health record.

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    Figure 3.

    Screenshot of the electronic asthma action plan decision support tool (eAAP) patient handout for self-management.

  • Figure 4.
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    Figure 4.

    Electronic asthma action plan decision support tool (eAAP) usage per month across the health care system's primary care outpatient network. From December 2012 through September 2014, a total of 6484 eAAPs were completed. The tool was used at 30 to 40 outpatient practices each month by October 2013.

Tables

  • Figures
    • View popup
    Table 1. Ambulatory Asthma Action Plan Committee Team Members and Role Descriptions
    Team Members (n)Credentials/Type (n)Role Descriptions
    Physician leader (1)MD, PhD (1)Oversaw the development and implementation of the eAAP; principal investigator of research project that partially funded the work
    Project manager (2)MBA, PT (1)Coordinated team to meet goals and keep the project on track
    MHS, PA-C (1)
    Content experts (2)MHS, PA-C (1)Incorporated the 2007 NHLBI asthma guidelines into the eAAP's recommended stepwise treatment options
    BSN, RN (1)
    Clinical advisors (8)MD (6)Provided feedback regarding usability, functionality, and accessibility with regard to patient care and work flow
    RRT (1)
    MSN, RN (1)
    Programmers (5)RN (1)Built the platform of the program into the EHR
    BA/BS (5)
    Information services (5)BBA, RRT (1)Handled technical challenges blending clinical and application areas
    BSN, RN (3)
    BS (1)
    Quality specialists (5)MHS, PA-C (1)Ensured the integration of appropriate care measures into the tool; team of nurses supported its use in the field
    BSN, RN (2)
    MHA, CPHQ (1)
    BS, RRT (1)
    Administrators (2)MSN, RN (1)Supported system-wide expansion
    BSN, RN (1)
    Evaluation support (3)PhD (2)Provided research and data analysis for outcomes measures
    MSPH (1)
    Pilot sites (5)Pediatrics (2)Provided initial feedback during the experimental phase before the system-wide launch
    Family medicine (2)
    Teen specialty (1)
    • eAAP, electronic asthma action plan decision support tool; EHR, electronic health record; NHLBI, National Heart, Lung, and Blood Institute.

    • View popup
    Table 2. Demographic Characteristics for the Sample of Patients Receiving the Electronic Asthma Action Plan Decision Support Tool (N = 5174)
    Children (0–17 Years) (n = 4259; 82%)Adults (≥18 Years) (n = 915; 18%)
    Mean age (years)9.340.0
    Gender (%)
        Female37.769.6
        Male62.330.4
    Race/ethnicity (%)
        African American34.042.3
        Caucasian34.041.4
        Hispanic/Latino8.43.9
        Asian1.30.2
        Native American0.10.3
        Multiracial1.50.1
        Other race3.41.9
        Missing17.39.9
    Insurance (%)
        Commercial56.053.4
        MedicareN/A15.5
        Medicaid41.122.2
        Self-pay/charity0.00.3
        Other/unknown2.98.5
    • N/A, not applicable.

    • View popup
    Table 3. Data Frequencies in the Matched Sample of Patients Receiving the Electronic Asthma Action Plan Decision Support Tool
    ChildrenAdults
    eAAP (n = 2783)Control (n = 2783)eAAP (n = 892)Control (n = 892)
    Mean age, years (SD)9.3 (4.3)9.3 (4.6)40.1 (17.1)40.2 (16.6)
    Race/ethnicity, n (%)
        African American1,044 (37.5)1,063 (38.2)377 (42.3)373 (41.8)
        American Indian or Alaska Native15 (0.5)11 (0.4)8 (0.9)8 (0.9)
        Asian35 (1.3)33 (1.2)2 (0.2)0
        Caucasian1,220 (43.8)1,219 (43.8)377 (42.3)404 (45.3)
        Hispanic20 (0.7)21 (0.8)2 (0.2)1 (0.1)
        Other187 (6.7)184 (6.6)39 (4.4)36 (4.0)
        Unknown262 (9.4)252 (9.1)87 (9.8)70 (7.8)
    Insurance category, n (%)
        Charity2 (0.1)1 (0)2 (0.2)2 (0.2)
        Commercial1,452 (52.2)1,432 (51.5)488 (54.7)513 (57.5)
        Medicare
        Medicaid1,247 (44.8)1,260 (45.3)202 (22.6)180 (20.2)
        Other38 (1.4)41 (1.5)8 (0.9)10 (1.1)
        Self-pay1 (0.1)1 (0.1)1 (0.1)
        Unknown44 (1.6)49 (1.8)49 (5.5)48 (5.4)
    Gender, n (%)
        Female1,091 (39.2)1,111 (39.9)620 (69.5)622 (69.7)
        Male1,692 (60.8)1,672 (60.1)272 (30.5)270 (30.3)
    ED visit in prior 12 months, n (%)132 (4.7)127 (4.6)40 (4.5)41 (4.6)
    Hospitalization in prior 12 months, n (%)40 (1.4)45 (1.6)4 (0.4)3 (0.3)
    Outpatient oral steroid in prior 12 months, n (%)716 (25.7)803 (28.9)181 (20.3)159 (17.8)
    Follow-up time, n (%)
        3 months184 (20.6)226 (25.3)373 (13.4)494 (17.8)
        6 months392 (43.9)374 (41.9)931 (33.5)780 (28.0)
        12 months316 (35.4)292 (32.7)1,479 (53.1)1,509 (54.2)
    • eAAP, electronic asthma action plan decision support tool; ED, emergency department; SD, standard deviation.

    • View popup
    Table 4. Acute Asthma Outcome Frequencies in the Matched Sample of Patients Receiving the Electronic Asthma Action Plan Decision Support Tool
    Outcomes by Follow-up TimeChildrenAdults
    eAAP (n = 2783)Control (n = 2783)eAAP (n = 892)Control (n = 892)
    ED visit, n (%)
        3 months after31 (1.1)26 (0.9)14 (1.6)10 (1.1)
        6 months after56 (2.0)53 (1.9)20 (2.2)18 (2.0)
        12 months after89 (3.2)84 (3.0)29 (3.3)23 (2.6)
    Hospitalization, n (%)
        3 months after6 (0.2)11 (0.4)2 (0.2)1 (0.1)
        6 months after12 (0.4)15 (0.5)3 (0.3)4 (0.4)
        12 months after16 (0.6)18 (0.6)6 (0.7)4 (0.4)
    Outpatient oral steroid, n (%)
        3 months after162 (5.8)223 (8.0)62 (7.0)76 (8.5)
        6 months after237 (8.5)297 (10.7)88 (9.9)93 (10.4)
        12 months after219 (7.9)311 (11.2)60 (6.7)60 (6.7)
    Any exacerbation, n (%)
        3 months after194 (7.0)250 (9.0)76 (8.5)84 (9.4)
        6 months after282 (10.1)329 (11.8)105 (11.8)107 (12.0)
        12 months after261 (9.4)344 (12.4)76 (8.5)70 (7.8)*
    • ↵* Counts for outcomes 3, 6, and 12 months after the intervention include only patients with enough follow-up to capture those outcomes.

    • eAAP, electronic asthma action plan decision support tool; ED, emergency department.

    • View popup
    Table 5. Odds Ratios Comparing the Odds of Acute Asthma Outcome Events Among Recipients of the Electronic Asthma Action Plan Decision Support Tool Versus Controls
    Outcomes by Follow-up TimeChildrenAdults
    Odds Ratio (95% CI)P ValueOdds Ratio (95% CI)P Value
    ED visit
        3 months after1.19 (0.17–2.00).5011.41 (0.62–3.20).416
        6 months after1.03 (0.69–1.55).8691.14 (0.57–2.30).709
        12 months after1.00 (0.67–1.49).9981.53 (0.79–2.94).207
    Hospitalization
        3 months after0.54 (0.20–1.48).2322.00 (0.18–22.16).571
        6 months after1.05 (0.43–2.60).9080.23 (0.03–2.11).195
        12 months after1.17 (0.42–3.23).7650.61 (0.10–3.71).594
    Outpatient oral steroid
        3 months after0.71 (0.58–0.87).0010.80 (0.57–1.13).209
        6 months after0.73 (0.61–0.88)<.0010.88 (0.64–1.20).402
        12 months after0.67 (0.56–0.81)<.0010.91 (0.62–1.35).652
    Any exacerbation
        3 months after0.76 (0.63–0.92).0050.90 (0.65–1.24).502
        6 months after0.79 (0.67–0.94).0060.91 (0.68–1.22).592
        12 months after0.73 (0.61–0.87)<.0011.02 (0.71–1.45).923
    • CI, confidence interval; ED, emergency department.

    • View popup
    Table 6. Acute Asthma Outcomes Among Patients Receiving the Electronic Asthma Action Plan Decision Support Tool by Time Since First Use of the Tool
    OutcomesFollow-up Time
    3 Months before3 Months after6 Months before6 Months after12 Months before12 Months after
    Children, n (%)3 Months (n = 4,259)6 Months (n = 3,358)12 Months (n = 1,925)
        ED visit72 (1.7)44 (1.0)*85 (2.5)57 (1.7)*93 (4.8)55 (2.9)†
        Hospitalization16 (0.4)8 (0.2)‡21 (0.6)12 (0.4)18 (0.9)9 (0.5)‡
        Outpatient oral steroid467 (11.0)232 (5.4)†510 (15.2)303 (9.0)†413 (21.5)273 (14.2)†
        Any exacerbation537 (12.6)277 (6.5)†585 (17.4)357 (10.6)†484 (25.1)319 (16.6)†
    Adults, n (%)3 Months (n = 915)6 Months (n = 717)12 Months (n = 316)
        ED visit17 (1.9)15 (1.6)19 (2.7)17 (2.4)19 (6.0)19 (6.0)
        Hospitalization1 (0.1)2 (0.2)1 (0.1)1 (0.1)3 (1.0)2 (0.6)
        Outpatient oral steroid106 (11.6)63 (6.9)†98 (13.7)89 (12.4)56 (17.7)60 (19.0)
        Any exacerbation117 (12.8)78 (8.5)*112 (15.6)106 (14.8)70 (22.2)76 (24.1)
    • Change from prior period determined using the McNemar test:,

    • ↵* P< .05,

    • ↵† P < .001,

    • ↵‡ P < .10.

    • ED, emergency department.

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The Journal of the American Board of Family     Medicine: 28 (3)
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Planning for Action: The Impact of an Asthma Action Plan Decision Support Tool Integrated into an Electronic Health Record (EHR) at a Large Health Care System
Lindsay Kuhn, Kelly Reeves, Yhenneko Taylor, Hazel Tapp, Andrew McWilliams, Andrew Gunter, Jeffrey Cleveland, Michael Dulin
The Journal of the American Board of Family Medicine May 2015, 28 (3) 382-393; DOI: 10.3122/jabfm.2015.03.140248

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Planning for Action: The Impact of an Asthma Action Plan Decision Support Tool Integrated into an Electronic Health Record (EHR) at a Large Health Care System
Lindsay Kuhn, Kelly Reeves, Yhenneko Taylor, Hazel Tapp, Andrew McWilliams, Andrew Gunter, Jeffrey Cleveland, Michael Dulin
The Journal of the American Board of Family Medicine May 2015, 28 (3) 382-393; DOI: 10.3122/jabfm.2015.03.140248
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