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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.

Yamada J, Kouri A, Simard SN, Lam Shin Cheung J, Segovia S, Gupta S. Improving computerized decision support system interventions: a qualitative study combining the theoretical domains framework with the GUIDES Checklist. BMC Med Inform Decis Mak. 2023 Oct 18;23(1):226. doi: 10.1186/s12911-023-02273-6. PMID: 37853386; PMCID: PMC10585867.

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.

Kouri A, Yamada J, Lam Shin Cheung J, Van de Velde S, Gupta S. Do providers use computerized clinical decision support systems? A systematic review and meta-regression of clinical decision support uptake. Implementation Science. 2022;17(21). doi:10.1186/s13012-022-01199-3

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

Gagné M, Lam Shin Cheung J, Kouri A, Fitzgerald JM, O'Byrne PM, Boulet LP, Grill A, Gupta S. A patient decision aid for mild asthma: Navigating a new asthma treatment paradigm. Respiratory Medicine. 2021. https://doi.org/10.1016/j.rmed.2021.106568

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.

Lam Shin Cheung J, Paolucci N, Price C, Sykes J, Gupta S: For the Canadian Respiratory Research Network. A system uptake analysis and GUIDES checklist evaluation of the Electronic Asthma Management System: A point-of-care computerized clinical decision support system. Journal of the American Medical Informatics Association.2020;27(5):726-737.doi:10.1093/jamia/ocaa019.

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.

Lam Shin Cheung V, Kastner M, Sale JE, Straus S, Kaplan A, Boulet LP, Gupta S: Development process and patient usability preferences for a touch screen tablet-based questionnaire. Health Informatics Journal. 2020;26(1):233-247. doi:10.1177/1460458218824749.

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.

Kouri A, Yamada J, Sale JEM, Straus SE, Gupta S: Primary Care Pre-Visit Electronic Patient Questionnaire for Asthma: Uptake Analysis and Predictor Modeling. J Med Internet Res 2020;22(9):e19358. doi: 10.2196/19358.

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.

Yamada J, Kouri A, Simard SN, Segovia SA, Gupta S: Barriers and Enablers to Using a Patient-Facing Electronic Questionnaire: A Qualitative Theoretical Domains Framework Analysis. J Med Internet Res. 2020;22(10):e19474. doi: 10.2196/19474.

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.

Gupta S, Price C, Agarwal G, Chan D, Goel S, Boulet LP, Kaplan AG, Lebovic G, Mamdani M, Straus SE: The Electronic Asthma Management System (eAMS) improves primary care asthma management. European Respiratory Journal. 2019;53(4):1802241. Published 2019 Apr 25.doi:10.1183/13993003.02241-2018.

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.

Gupta S, Lam Shin Cheung V, Kastner M, Straus S, Kaplan A, Boulet LP, Sale JE: Patient preferences for a touch screen tablet-based asthma questionnaire. Journal of Asthma: Official Journal of the Association for the Care of Asthma. 2019;56(7):771-781.doi:10.1080/02770903.2018.1490750.

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.

Kouri A, Kaplan A, Boulet LP, Gupta S: New evidence-based tool to guide the creation of asthma action plans for adults. Canadian Family Physician. 2019;65(2):103-106.

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.

Price C, Agarwal G, Chan D, Goel S, Kaplan AG, Boulet LP, Mamdani MM, Straus SE, Lebovic G, Gupta S: Large care gaps in primary care management of asthma: a longitudinal practice audit. BMJ Open. 2019;9(1):e022506. Published 2019 Jan 29. doi:10.1136/bmjopen-2018-022506.

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.

Kouri A, Kaplan A, Gupta S: Quadrupling inhaled corticosteroid doses. Canadian Family Physician. 2019;65(7):456-457.

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.

Gupta S, Kaplan A: Solving the mystery of the yellow zone of the asthma action plan. NPJ Primary Care Respiratory Medicine. 2018;28(1):1. Published 2018 Jan 11.doi:10.1038/s41533-017-0067-1.

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.

Kouri A, Boulet LP, Kaplan A, Gupta S: Asthma control and action plans. European Respiratory Journal. 2017;50(6):1701883. Published 2017 Dec 7. doi:10.1183/13993003.01883-2017.

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.

Kouri A, Boulet LP, Kaplan A, Gupta S: An evidence-based, point-of-care tool to guide completion of asthma action plans in practice. European Respiratory Journal. 2017;49(5):1602238. Published 2017 May 1. doi:10.1183/13993003.02238-2016.

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.

Gupta S, Rai N, Bhattacharrya O, Cheng AYY, Connelly KA, Boulet LP, Kaplan A, Kastner M: Optimizing the language and format of guidelines to improve guideline uptake. Canadian Medical Association Journal. 2016;188(14):E362-E368. doi:10.1503/cmaj.151102.

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.

Gupta S, Paolucci E, Kaplan A, Boulet LP: Contemporaneous International Asthma Guidelines Present Differing Recommendations: An Analysis. Canadian Respiratory Journal. 2016;2016:3085065. doi:10.1155/2016/3085065.

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.

Xi N, Wallace R, Agarwal G, Chan D, Gershon A, Gupta S. Identifying patients with asthma in primary care electronic medical record systems Chart analysis-based electronic algorithm validation study. Canadian Family Physician. 2015;61(10):e474-e483.

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.

Ghajar-Khosravi S, Wan FT, Gupta S, Chignell M: Reverse Engineering of Content to Find Usability Problems: A Healthcare Case Study. Journal of Usability Studies. 2012;8(1):16-28.

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.

Gupta S, Wan FT, Hall SE, Straus SE. An asthma action plan created by physician, educator and patient online collaboration with usability and visual design optimization. Respiration. 2012;84(5):406-15. doi: 10.1159/000338112. Epub 2012 Jul 10. PMID: 22797144.

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.

Gupta S, Wan FT, Ducharme FM, Chignell MH, Lougheed MD, Straus SE: Asthma Action Plans Are Highly Variable And Do Not Conform To Best Visual Design Practices. Annals of Allergy, Asthma, and Immunology. 2012;108(4):260-5.e2. doi:10.1016/j.anai.2012.01.018.

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.

Gupta S, Wan FT, Newton D, Bhattacharyya OK, Chignell MH, Straus SE: WikiBuild: a new online collaboration process for multistakeholder tool development and consensus building. Journal of Medical Internet Research. 2011;13(4):e108. Published 2011 Dec 8. doi:10.2196/jmir.1833.