1. Asthma Care Program EMR Update & Next Steps Janice Minard, RN MSc Project Manager, Asthma Care Program EMR Project Asthma Research Unit, Kingston General Hospital, Queen’s University M.D. Lougheed, MD, MSc, FRCP(C), Professor Departments of Medicine, Physiology and Community Health and Epidemiology Adjunct Scientist, ICES-Queen’s, Queen’s University, Kingston ON

2. Learning Objectives  To identify successes, challenges and next steps to address gaps between asthma care and guidelines in primary care in Ontario.

3. Initiatives to Address Gaps ‘Successes’  Asthma Plan of Action (APA)  Primary Care Asthma Project Pilot (PCAPP)  Integrative literature review  e-Record Pilot Jan-Jun 2008  Validation of 3 electronic AQLQs 2009-10  Report on asthma indicators (RESPONSE Study)  Data Standards  CRG Committee of the CTS endorsed need to develop strategy for respiratory standards for EHR

4. Primary Care, Chronic Disease and Asthma EMRs  309 articles identified; 76 met the inclusion criteria  17 (22%) specific to asthma  59 (78%) pertained to other chronic diseases and/or the overall status of an EMR in primary care.  76 articles in English literature Categories Themes Total ToolsStatusUtility Primary Care EMRs0201333 Chronic Disease EMRs132226 Asthma Primary Care EMRs301417 TOTAL4234976 Minard J, Turcotte S, and Lougheed MD. J Asthma 2010; 47(8) 895-12 Utility: predict mortality, assess severity and timeliness of diagnosis

5. e-Record Pilot Results  2 primary care sites incorporated asthma care map elements into asthma EMR (standalones)  Data transmitted in real time to central server for analysis and report generation  Able to begin to monitor, benchmark, surveillance Minard J et al. Am J Respir Crit Care Med 2009; 179: A4071

6. Administrative Reporting: Patient Characteristics (n=130) Site Site 1 Site 2 Overall n%n%n% Age Child (< 18) 718.94447.35139.2* Adult 3081.14952.77960.2 SexMale 1129.73941.95038.5 Smoking Status Never Smoked 1643.28187.19774.6 * Ex- Smoker 924.344.31310.0 Current Smoker 513.588.61310.0 * Not Classified 4 18.90075.4 Drug Plan Y 821.67580.78363.9 * Missing 410.8004 3.1 Total 3710093100130100 * P value <0.05, difference between sites Minard J et al. Am J Respir Crit Care Med 2009; 179: A4071

7. Benchmarking: Asthma Diagnosis Confirmed Minard J et al. Am J Respir Crit Care Med 2009; 179: A4071

8. Surveillance: Work-Related Asthma Occupational n=11 n=11 Patient states he/she has suspected asthma occupational exposure Y/N Occupationtext Work exposure(s) type text Relationship between asthma symptoms and work Y/N Started at work *1 Started within days of accidental spill or fire *2 Worsened at work *3 Chest symptoms less on days off *4 Chest symptoms less on holidays *5 Gender (F) 8 Age (years) 15-85 Median Median51 Work exposure type Acid anhydrides Acid anhydrides1 Carpeting, Dust Carpeting, Dust1 Dust, Humidity, PA Dust, Humidity, PA1 Dust, Molds Dust, Molds1 Other/missing Other/missing7 Relationship symptoms-work 10 Started at work Started at work2 Within days of accidental spill-fire Within days of accidental spill-fire0 Worsened at work Worsened at work8 Chest symptoms less on days off Chest symptoms less on days off4 Chest symptoms less on holidays Chest symptoms less on holidays3 * Minard J et al. Am J Respir Crit Care Med 2009; 179:A4071

9. Asthma Quality of Life Questionnaires (AQLQ) Asthma Quality of Life Questionnaires (AQLQ) Validated electronic versions of Juniper’s  Mini AQLQ (2009)*  Mini Pediatric AQLQ (2010)  Caregiver AQLQ (2010) Permission to use AQLQs in acute care, primary care and research in Ontario Olajos-Clow J et al. Respir Med 2010; 104(5) 658-67

10. Mini AQLQ Olajos-Clow J et al. Respir Med 2010; 104(5) 658-67

11. Data Standards  Networked with OntarioMD, OHISC, CHI, CIHI, SNOMED experts  Data standards  definitions for asthma care map elements  Data schema  format, precision, definitions  Standardized nomenclature  cross referenced care map with SNOMED ® and LOINC ®

12. Results  21 major sections in PCAP care map tool  163 elements mapped  47.8% perfect match  17.8% related concept found  34.4% no match Thomas N et al. Am J Respir Crit Care Med 181;2010:A4294

13. SNOMED-CT SNOMED-CT ® Results Thomas N et al. Am J Respir Crit Care Med 181;2010:A4294

14. Challenges Ontario   Implementation of the e-health strategy has been delayed   Finding a custodian a very difficult task   ‘Who will house the data?’   New Privacy Regulations   Is it quality assurance or research?   Sending data beyond circle of care   Lack of interoperability   No connectivity across vendors, primary care, acute care, emergency care etc.

15. Challenges Primary Care   Incremental adoption of EMRs   Primary Care Renewal Initiatives   Asthma a lower priority than other diseases   Multiple vendors (15 fully certified)   Process for minimum specifications in progress   Standardized nomenclature not incorporated   Timely, meaningful data extraction not a priority

16. Challenges PCAP   Electronic asthma care map available in few locations   ACM completed most often by CRE, CAE   Gaps in standardized definitions (asthma control)   Gaps in SNOMED-CT   Individual approach to complete ACM   ACM has limited endorsement as a standard

17. Next Steps National Approach   Task force to develop a strategy for respiratory standards for EHR   April-May 2011 environmental scan (international)   June 2011 Task Force Meeting ● ● Introduction to status of EHR in Canada and benefits of standardized terminology ● ● Multi-phase project, requiring funding

18. Next Steps Ontario   Test feasibility of AQLQs in 2-3 p.c. sites   Meet requirements (Dec 2011) to have page 1 & 2 of ACM endorsed as minimum specifications?   Plans for Human Factors Project?   Other?