COPD action plans are a cornerstone of effective COPD self-management, but there is currently no standard accepted format for patients or providers. This review of existing COPD action plans found large variability in action plan development methods, content, and usability, with most plans lacking rigorous evaluation or user involvement in development. These findings are directly relevant to the design of the action plans we included in the EAPOC system. In order to maximize the clinical impact of our action plans, we developed them with transparent methodology, involved patients and clinicians in co-creation, and rigorously tested them for usability.
Mobile health (mHealth) tools such as the patient portal in EAPOC hold promise for expanding patient engagement and enabling guideline-based care. This scoping review examined whether people aged 65 years and older have been meaningfully included in asthma and COPD mHealth research and found that, although older adults are often recruited to these studies, their specific needs are rarely integrated into study design, analysis, or tool development. The findings underscore the importance of co-design and age-inclusive evaluation when building such technology, to ensure real-world effectiveness and equitable uptake across age groups. Accordingly, we have integrated this principle throughout the EAPOC system development.
This qualitative study captured older adults’ perspectives on mobile health tools for asthma and COPD, revealing a nuanced balance between enthusiasm for technologies that support autonomy and concerns about disruption to established care routines. For the EAPOC system, which engages patients through pre-visit questionnaires and integrates evidence-based recommendations into clinical workflow, understanding these lived experiences is vital. Older adults valued tools that enhanced patient-provider collaboration and affirmed their existing care, rather than replacing it. These insights provided actionable guidance for designing and adapting EAPOC in order to ensure that it augmented rather than replaced care and improved patient trust and confidence.
Climate change has evolved into the leading public health crisis, and disproportionately affects patients with respiratory disease. Paradoxically, patients with asthma and/or COPD take metered-dose inhalers which use potent greenhouse gases as propellants, contributing to the climate crisis. However, the same medications can be delivered through dry powder inhalers, which have a much lower carbon footprint. Here, we explore how to safely and effectively consider if and when patients can be started and/or switched to a dry powder inhaler to reduce the carbon footprint of their care. This work informed the process of developing the conversation aid integrated into the EAPOC system, to inform discussions around inhaler selection at the point of care.
Large gaps exist in the management of asthma and COPD, which contribute not only to suboptimal patient outcomes, but also to a higher carbon footprint of care. These gaps include misdiagnosis, inadequate inhaler therapy, and use of inhaler strategies with a high carbon footprint over medically equivalent lower carbon footprint alternatives. In this analysis, we explored the environmental impact of addressing these care gaps. This work provides an important basis for the core functions of the EAPOC system, including the conversation aid which informs inhaler device selection at the point-of-care.
Computerized clinical decision support systems (CDSSs) such as the
Electronic Asthma Management System (eAMS) can improve care by bridging
knowledge to practice gaps. However, the real-world uptake of such systems
in health care settings has been suboptimal. We sought to use a proven model (
called the Theoretical Domains Framework - TDF) to identify barriers and
enablers to usage of the eAMS by primary care providers. We then complimented
that analysis by matching its findings to the elements in the Guideline
Implementation with Decision Support (GUIDES) Checklist - a checklist designed
to optimize the success of CDSSs. Through this work, we identified multiple
unique barriers and enablers to uptake of the eAMS CDSS and successfully mapped
these to GUIDES domains and factors to determine required changes to eAMS
context,
content,
and system
features. This work will also further inform
the types of behaviour change techniques that will be needed to further drive
uptake of the eAMS in real-world settings.
Clinical decision support systems often fail to achieve their goals because of poor uptake by providers. To better understand this problem, we systematically searched all published studies of clinical decision support systems since 2000 (which included the eAMS), and identified that only 12.4% even reported provider uptake. Of those that did, uptake was overall low at 34.2%. When we looked at factors associated with higher uptake of clinical decision support systems, we found that features related to the context in which the system was rolled out and the associated implementation strategy best predicted uptake. The results of this study provide guidance for improving the platform upon which the eAMS is built, and will also help others to design decision support tools that providers are more likely to use.
The eAMS makes treatment recommendations but does not address some of the patient-level barriers to adherence to asthma treatment. In addition, with the introduction of "as-needed" budesonide-formoterol as an alternative option to daily low-dose inhaled corticosteroids for mild asthma (in the 2021 Canadian Thoracic Society Asthma Guideline), there is an urgent need to help both patients and providers to make the best individualized choice between these mild asthma treatment options. To address these issues, we worked with patients, respiratory educators, asthma experts, and primary care providers to develop and optimize a decision aid (for patients) and conversation aid (for providers). The tools are integrated into the eAMS and also available at: https://asthmadecisionaid.com
Clinical decision support systems often fail due to poor user uptake. This study analyzes the real-world clinician uptake of the eAMS, presenting novel modelling strategies to identify factors that influenced this uptake. Authors also used the GUIDES checklist for clinical decision support systems to identify areas where the tool could be improved according to best evidence, to further improve uptake.
The eAMS features a patient-facing electronic questionnaire that requires completion before each visit. This qualitative study used a rapid-cycle design process to identify and operationalize patient preferences for usability-related features (questionnaire design features such as visual characteristics and navigation) for this electronic questionnaire. The outcome was a highly usable questionnaire, across age groups and touch-device familiarity.
The eAMS features a patient-facing electronic questionnaire that requires completion before each visit. This quantitative study describes the real-world patient uptake of the eAMS patient questionnaire in primary care settings, and applies modelling strategies to identify patient-level factors that influenced its uptake.
The eAMS features a patient-facing electronic questionnaire that requires completion before each visit. This qualitative study applies the theoretical domains framework (TDF) to identify the determinants (barriers and enablers) of patient uptake and completion of the eAMS questionnaire on a mobile device before the appointment. These determinants were then addressed in order to optimize user uptake.
The eAMS targets the three care gaps that are major contributors to poor asthma control: control level assessment, medication optimization, and asthma action plan (AAP) delivery. This interrupted time series analysis of the eAMS in three large family health teams in Ontario demonstrates that the tool successfully bridges each of these three major gaps, in real-world practice.
The eAMS features a patient-facing electronic questionnaire that requires completion before each visit. This qualitative study used a rapid-cycle design process to identify and operationalize asthma patient preferences for content (e.g. language, descriptors, images) in this electronic questionnaire. The outcome was a patient-relevant and patient-designed questionnaire with low required literacy.
Asthma action plans (AAPs) improve asthma outcomes, but uptake is limited due to lack of clinician training and experience in completing AAPs, and particularly in completing instructions for dose intensification in the AAP yellow zone (acute loss of asthma control zone). This paper discusses a bedside tool to facilitate completion of the AAP yellow zone in daily practice. This tool was developed for and integrated into the eAMS.
There are large evidence-to-practice gaps in asthma care that contribute to significant ongoing morbidity from this chronic disease. This retrospective review sought to characterize the nature and quality of asthma care in three large real-world family health teams in Ontario. Identified gaps were later used to target the eAMS intervention.
A key feature of the eAMS is its asthma action plan (AAP), for which there is strong evidence to suggest improvements in patient outcomes. Current studies suggest that a four-fold increase in inhaled corticosteroid dose should occur in the yellow zone (acute loss of asthma control zone) of the AAP. This paper suggests that although more research is needed to best define the optimal dose increase in the yellow zone, AAPs remain a cornerstone of asthma management, supported by very strong evidence.
Asthma action plans (AAPs) improve asthma outcomes, but uptake is limited due to lack of clinician training and experience in completing AAPs, and particularly in completing instructions for dose intensification in the AAP yellow zone. This paper discusses recently developed strategies to empower real-world clinicians to complete the AAP yellow zone, including electronic approaches such as the eAMS.
Clinicians often confuse acute loss of asthma control requiring a transient escalation in therapy (often with the help of an asthma action plan) and chronically poor asthma control requiring a change to baseline therapy. This paper clarifies differences between these concepts and the importance of asthma action plans, facilitated by tools such as the eAMS, in operationalizing a therapeutic approach to acute loss of asthma control.
Asthma action plan uptake is limited by lack of effective guidance for what recommendations clinicians should make regarding intensifying therapy for acute loss of asthma control as part of the asthma action plan (AAP). This systematic review identifies best evidence-based practices for dose intensification for acute loss of asthma control and strategies for effective implementation of these dose changes. Knowledge derived from this review was then integrated into the eAMS clinical decision support system.
Evidence suggests that both the formatting and the language used in clinical practice guidelines influence the extent to which they are accepted and implemented. This paper operationalizes an evidence-based framework for optimizing the language and format used in guidelines. This work informed the language use and formatting elements in the eAMS clinical decision support system.
Several international groups develop asthma guidelines. As a key part of the development of clinical decision support within the eAMS, this study analyses contemporaneous asthma guidelines from three major organizations to identify similarities, differences, and possible reasons for differences in guidance across guideline documents.
The eAMS is an electronic medical record (EMR) system-based decision support tool. To practically implement the eAMS in clinical settings, it is important to accurately identify target patients with asthma in EMR databases. This study proposes and tests a series of EMR search algorithms to identify asthma patients in real-world primary care EMRs and recommends a set of validated search approaches with corresponding operating characteristics. These search strategies are now used in the eAMS and can be implemented to identify asthma patients for other quality measurement and improvement initiatives.
Usability testing can ensure that stakeholder preferences for design and content are adequately represented in healthcare tools. This case study analyzed the multi-stakeholder user preference-based AAP developed by our group (and later incorporated into the eAMS) and used both reverse-engineering and traditional task-based methods to identify usability issues.
Given that existing asthma action plans (AAPs) were largely developed by experts, without inclusion of key stakeholders such as primary care clinicians, asthma educators, and patients, this study presents the outcome of a multi-stakeholder co-development process for a user preference-based AAP. This evidence-based AAP was then endorsed and adopted by several organizations, and is the AAP used in the eAMS.
Existing poor uptake of asthma action plans (AAP) is partly driven by suboptimal approaches to AAP design and a fragmented landscape of multiple existing AAPs across jurisdictions. This is a systematic analysis of 69 AAPs from around the world, seeking to identify conformity with best evidence for development process, visual design and usability, and content. This work was used as a foundation for development of the AAP used in the eAMS.
Patient communication tools such as asthma action plans (AAPs) are often developed without sufficient patient input, and without consideration for usability and visual design optimization. This study presents the outcomes of the development and use of a novel technology to enable online collaboration and co-development of an asthma action plan (AAP), while mitigating inter-stakeholder hierarchies and enabling feedback on visual elements and format as well as content, through a novel wiki-based method ("WikiBuild"). This dynamic action plan rendering technology was later used in the eAMS.