Use of the Chronic Disease Electronic Management System to Improve

the Care of Patients with Asthma in West Virginia

 

Heidi Putman-Casdorph RN, DNSc, Adam Baus, BS, MA, MPH and

Michael J. Romano MD, MBA

 

Citation:

Putman, H., Baus, A. & Romano, M. (2007). Use of the Chronic Disease Electronic Management System to Improve the Care of Patients with Asthma in West Virginia. Online Journal of Nursing Informatics (OJNI), 11, (2) [Online]. Available at http://ojni.org/11_2/putman.htm

 

 

 

Abstract

 

C-bAMP, or Clinic-based Asthma Management Program, is designed to improve the capacity to track and treat patients with asthma in West Virginia. C-bAMP combines clinical expertise in asthma management and education with the use of the Chronic Disease Electronic Management System (CDEMS) electronic patient registry to track the care provided to patients with asthma and target education to providers in Federally Qualified Health Centers, which provide primary health care for the underserved. Nursing responsibility is multifaceted in achieving the expected patient care endpoints in the C-bAMP project. CDEMS is an information technology tool that provides an avenue to assist practitioners in the translation of current National Institutes of Health (NIH) asthma care guidelines into practice.

 

Key words: asthma, electronic patient registry, information technology, multidisciplinary health care, rural


Use of the Chronic Disease Electronic Management System to Improve     

the Care of Patients with Asthma in West Virginia

 

The West Virginia Asthma Education and Prevention Program (WV-AEPP), developed by the West Virginia Department of Health and Human Resources through a grant from the Centers for Disease Control and Prevention, is a part of the West Virginia Bureau for Public Health’s Division of Health Promotion and Chronic Disease.1 The WV-AEPP is a statewide program designed to reduce the health and economic consequences of asthma in West Virginia.

            C-bAMP, or Clinic-based Asthma Management Program, is designed to improve the capacity to track and treat patients with asthma.  C-bAMP was developed by the WV-AEPP in cooperation with the West Virginia University (WVU) School of Medicine’s Department of Pediatrics (WVU PEDS), the WVU Office of Health Services Research (WVU OHSR), and the West Virginia Asthma Coalition (WVAC). C-bAMP combines clinical expertise in asthma management and education with the use of the Chronic Disease Electronic Management System (CDEMS) electronic patient registry to track the care provided to patients with asthma and target education to providers.  CDEMS, which is public domain software, was originally developed by the Washington State Department of Health Diabetes Prevention and Control Program (Washington State Dept. of Health, 2007) and has been modified by the WVU OHSR.

CDEMS assists nurses and primary care providers in tracking patient care indicators longitudinally; offering decision-support to providers, for example, in identifying needed and/or overdue treatments and services, prescribing appropriate medications, and recognizing possible patient deterioration. CDEMS prompts providers through use of a tickler system, which highlights overdue services and laboratory results that are outside recommended guidelines. CDEMS also generates specific guidelines and personalized graphed laboratory results, which providers can use to formulate patient self-management goals and patient education.

The educational curriculum for C-bAMP is drawn from the National Heart Lung and Blood Institute Expert Panel Report for the Diagnosis and Management of Asthma (1997) and the Update on Selected Topics (2002).

C-bAMP focuses on six areas of treatment for patients with asthma:

  1. use of written asthma action plans,
  2. documentation of flu vaccinations,
  3. assignment of asthma severity classification,
  4. use of spirometry assessment,
  5. prescription of inhaled corticosteroids as a first line of therapy in patients with mild, moderate, or severe asthma,
  6. monitoring of albuterol inhaler prescriptions and refill requests.

The goal of the program is to guide primary care clinics using medical information as data to guide patient care, while overcoming common barriers to the use of health information technology such as CDEMS, and to help in the using of medical information as data to guide patient care. C-bAMP also assists clinics in the development of customized queries and reports.

Practice settings

            CDEMS is currently being used to track the care of patients with asthma within five community health centers in West Virginia. C-bAMP sites are located in Greenbrier,  Hardy,  Monongalia, and Summers counties. All counties are rural, with total populations between 13, 209 and 84, 386 (US Census Bureau, 2004). The clinics are designated as Federally Qualified Health Centers, which provide primary health care for the underserved.

Implementation of C-bAMP

C-bAMP is initiated at each site by approaching health center administrators, providers, and medical staff for their participation, demonstrating the CDEMS electronic patient registry, and informing them about the additional resources C-bAMP affords to the patients with asthma. Once an agreement is reached to use C-bAMP, a phone interview is conducted with the clinic’s Medical Director to identify current practice patterns and perceived needs to enhance asthma care.  Baseline data for each site’s  patient  population with asthma is added to CDEMS, and this baseline data is then used by the physician and nurse asthma experts with C-bAMP to develop a focused asthma education plan to improve compliance with the six goals for treatment of asthma patients. Additionally, the visiting physician and nurse assess each health center’s knowledge of current NIH guidelines, provide customized electronic asthma action plan forms, assessment forms, and patient call charts, and provide equipment such as stadiometers.  Follow-up site visits and telephone follow-ups are periodically made by WVU PEDS and the WVU OHSR to assess progress.

Addressing Challenges in Introducing C-bAMP

The diffusion of innovations in the use of various types of health information technology, such as CDEMS, is a social process in which new technologies are communicated among and become accepted by users.  The diffusion process provides a useful framework for examining the dynamics involved in adopting CDEMS and ways in which challenges to adoption can be anticipated and overcome. Innovative technology  should improve upon prior practice, require little capital expenditure and training, and allow the users to observe the benefits versus risks of adoption as the technology is integrated into practice (California Healthcare Foundation, 2002).

            Challenges in guiding each health center in adopting CDEMS are eased by demonstrating the long-term benefits of enhanced patient data, enhanced population-level reporting capabilities, and automated registry maintenance whenever possible (for example, in interfacing with laboratory companies and importing data from health center billing systems). Once integrated, use of the CDEMS Progress Note (Figure1) during the patient encounter can save time by collating medical information generally scattered throughout the patient chart. The process of integration differs according to site, and depends upon the site analyzing the work-flow and determining the most efficient way in which the registry can function. Continual training and support in the use of CDEMS are provided throughout the process to ensure successful integration. Those providing support for registry use provide specialized technical assistance, while also recognizing the uniqueness of each practice and the differences in the speed with which practices can adopt CDEMS (Baron, Fabens, Schiffman, & Wolf, 2005; Baum, 2006; Goldschmidt, 2005; Koo, 2004; Miller & Sim, 2004; Satinsky, 2004). 

Figure1.  Sample CDEMS progress note for asthma

i 

Modified from the Washington State Diabetes Prevention/Control Program

 Results

Baseline data for each health center taking part in C-bAMP suggest that before the introduction of this program, documentation of patient services and care measures for asthma were not meeting national standards of care (Table 1).

Table 1.  Health center baseline statistics

Key Measure

Health Center A (Year 01 Site)

Health Center B (Year 01 Site)

Health Center C (Year 02 Site)

Health Center D (Year 02 Site)

Health Center E (Year 02 Site)

Documented

Flu Vaccine

(% Registry)

10.0%

5.9%

10.2%

5.8%

10.0%

Documented Written Asthma Action Plan

(% Visits)

0.0%

0.0%

0.0%

0.0%

0.5%

Documented Spirometry

(% Registry)

0.0%

5.9%

0.0%

9.8%

16.3%

Documented Asthma Severity Level (% Visits)

34.9%

2.9%

0.0%

5.8%

18.0%

Documented

ICS Rx

(% Visits)

0.0%

3.4%

3.8%

0.5%

1.4%

Documentation of Albuterol Use

(% Visits)

5.0%

0.9%

6.2%

17.8%

5.2%

 

However, marked improvements in patient care have been demonstrated at one of the first-year C-bAMP sites to fully implement CDEMS.  Figure 2 displays intervention-specific data at baseline, relative to each successive quarter. As evidenced, there have been overall improvements in adherence to NHLBI guidelines. Improvements include increases in the percent of patients with documented asthma severity levels, percent of patients receiving spirometry tests, percent of patients with documentation of written asthma action plans, and percent of patients with prescriptions for inhaled corticosteroids as a first-line defense.

Figure 2. Year 01 Health Center data graphed by quarter

2

 

Implications for clinical nursing and medicine

Nursing responsibility is multifaceted in achieving the expected patient care endpoints in the C-bAMP project. Nurses need to administer spirometry tests at  designated times and explain to patients why the test is important for tracking patient care.  Nurses also need to assist primary care providers by reminding them when the test is due to be administered to the patient. This process can be aided by “flags” on the CDEMS progress note which help to remind primary care providers to address gaps in patient care.  Nurses also need to understand the asthma severity classification scheme when taking patient histories in order to obtain data that helps the provider correctly diagnose the asthma severity level for each patient and plan treatment accordingly.

A written asthma action plan based on symptoms needs to be reviewed by the nurse with each patient with asthma in order to foster patient self-management techniques. In addition, short acting bronchodilator use must be closely tracked by the nurse in terms of number and frequency of refills, since frequent refills may indicate poor asthma control and the need for the primary care provider to re-evaluate the current plan of care.  Nurses are in an excellent position to stress to patients the need to consistently take maintenance inhaled corticosteroids and point to the benefits this has on long-term asthma control. Also, nurses should document flu shot administration as part of a well rounded asthma care strategy.

            CDEMS can positively impact clinical practice and patient care not only for patients with asthma, but also patients with other chronic illnesses such as diabetes and cardiovascular health conditions. Trends in patient condition can be easily tracked. Gaps in patient care may also be more easily recognized and corrected thus ensuring that current patient care standards in all the applicable chronic diseases are being met for each patient. The quality of care is enhanced through readily available data, improved patient and population-level tracking, prompts identifying needed care, and educational interventions based on patient data.  C-bAMP also enhances collaboration between nurses and direct care providers, while enhancing the organization and structure of patient care.   

CDEMS is an information technology tool that provides an avenue to assist practitioners in the translation of current NIH asthma care guidelines into practice. C-bAMP is an ongoing and successful project that helps both nursing and medicine to deliver the best asthma care possible.

 

1. This work is supported by a grant from the Centers for Disease Control and Prevention (Grant number  CDC U59/CCU324180-03)

References

Baron, R., Fabens, E, Schiffman, M., & Wolf, E. (2005). Electronic health records: Just around the corner? Or over the cliff? Annals of Internal Medicine, 143,

            222-226.

Baum, N. (2005). Choosing an EMR: how to determine what’s best for you. Urology Times, 32, 13.

California HealthCare Foundation (2002). Diffusion of innovation in health care. San Francisco: Institute for the Future.

Goldschmidt, P. (2005). HIT and MIS: implications of health information technology and medical information systems. Communication of the ACM, 48, 69-74.

Guidelines for the Diagnosis and Management of Asthma (1997). National Institutes of Health, National Heart, Lung and Blood Institute, NIH Publication No.

            97-4051.

Guidelines for the Diagnosis and Management of Asthma – Update on Selected Topics. (2002). National Institutes of Health, National Heart, Lung and Blood Institute,

            NIH Publication No. 02-5075.

Koo, C. (2004). Getting ready for an EMR: physician practices should consider several key factors before selecting an electronic record system. Health Management

            Technology, 26-28.  Retrieved  October 11, 2006 from http://www.acumentra.org/downloads/doqit/getting-ready-Koo.pdf

Miller, R., & Sim, I. (2004). Physician’s use of electronic medical records: barriers and solutions. Health Affairs, 23, 116-126.

Satinsky, M. (2004). Questions come before answers. Review of Ophthalmology, 26, 67-72.

U.S. Census Bureau- Quick Facts (2004). Retrieved October 11, 2006 from http://quickfacts.census.gov/qfd/index.html

Washington State Department of Health – Diabetes Prevention and Control Program. Retrieved February 15, 2007 from http://www.doh.wa.gov/cfh/diabetes.

 

 

Authors’ Bios

 

Heidi Putman-Casdorph RN, DNSc

 

Dr. Putman holds a BSN from St. Francis College, an MSN from Indiana University of PA, and a DNSc from Widener University. She is an Assistant Professor at the West Virginia University School of Nursing. Her area of research focus has been in pulmonary nursing, specifically in adult asthma care, and examining depression and anxiety in COPD patients. Her clinical nursing focus is in Adult Health nursing.

 

 

Adam Baus, BS, MA, MPH

 

Mr. Baus earned a BA in Sociology at Saint Vincent College in 2000, a MA in Applied Social Research at West Virginia University in 2002, and a Master of Public Health degree at West Virginia University in 2006. He began working with the West Virginia University Office of Health Services Research in 2003. Since that time has developed considerable interest in the use of electronic patient registries for use in chronic disease management, and the growing use of electronic medical records within West Virginia community health centers and primary care settings. Currently he assists the OHSR in working with state-wide community health centers and health care professionals in chronic disease management, and offers database design and development, report writing, and statistical support.

 

 

Michael J. Romano MD, MBA

 

Dr. Romano is an Associate Professor and Head, Section of Critical Care, in the Department of Pediatrics at West Virginia University School of Medicine, and Medical Director of the Pediatric Intensive Care Unit at Ruby Memorial Hospital.   He is Board Certified in Pediatric Critical Care Medicine, and has worked in multiple settings in his career including military, private, and academic medicine.  He has a long standing interest in the care of children with asthma, having founded and directed the Asthma Program in the Department of Pediatrics at Texas Tech University prior to joining WVU.  He has researched and published on the use of School Based Health Clinics and Telemedicine in the care of children with asthma.  His current outpatient research interests center on treatment delivery models for children with asthma living in rural areas.  Dr. Romano has been active in the WV Asthma Coalition, and has twice served as president of the organization.