SummaryCambridge Health Alliance’s Childhood Asthma Program uses a Web-based registry to assist primary care physicians, pediatricians, and school nurses in managing childhood asthma. Linked to the child’s electronic medical record and based on widely accepted National Heart, Lung, and Blood Institute guidelines, the registry provides vital information to providers as they see children with asthma, and generates monthly physician-specific reports that highlight care gaps in individual patients that can then be proactively addressed by office staff. A separate part of the program allows physicians to order home visits designed to identify and address environmental factors that may be exacerbating asthma-related symptoms. The program has significantly reduced asthma-related inpatient admissions and emergency department visits among pediatric patients.Moderate: The evidence consists of trends in pediatric asthma-related inpatient admissions and emergency department (ED) visits among enrollees since implementation of the program.
Developing OrganizationsCambridge Health Alliance
Date First Implemented2002
Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Age > Preschooler (2-5 years); Vulnerable Populations > Urban populations
Problem AddressedPediatric asthma is a common condition that frequently leads to diminished quality of life and costly hospitalizations and ED visits, especially among low-income children. Asthmatic children who receive care in accordance with established guidelines often avoid acute problems, but many primary care physicians and other community-based providers fail to adhere to those guidelines, often because they lack critical information and the support necessary to provide guideline-based care consistently.
- A common, growing problem: Asthma affects approximately 22 million Americans, with roughly one-third being children.1 The prevalence of childhood asthma, the most common cause of childhood disability, has increased 232 percent since 1969, well above the 113-percent rise in disability due to all other childhood chronic conditions.2
- Leading to costly hospitalizations and ED visits, especially in low-income children: Asthma is the leading cause of inpatient admissions among children, responsible for nearly 500,000 hospitalizations and many ED visits each year.3 Asthma-related mortality and severity tend to be higher among low-income, minority children.4,5
- Unrealized potential of guideline-based care: Widely accepted National Heart, Lung, and Blood Institute (NHLBI) guidelines lay out the key elements of effective ongoing management of asthma in children stratified by severity. However, many primary care physicians, pediatricians, and other community-based providers (e.g., school nurses) lack the necessary information or resources to adhere to these guidelines on a consistent basis, as outlined below:
- Inadequate diagnosis and treatment: Health care providers often underestimate the severity of asthma in patients and consequently fail to treat it appropriately, increasing the risk of hospitalizations and ED visits. Physicians often need to be reminded about guideline-based diagnosis, monitoring, and treatment, particularly as they relate to a specific patient.6
- Failure to provide action plans: National guidelines recommend that providers teach asthma patients (and parents of children with asthma) to self-monitor and manage the disease through a written action plan. However, busy primary care providers generally lack the time or resources to do so consistently.7
Description of the Innovative ActivityA Web-based registry assists primary care physicians, pediatricians, and school nurses in managing childhood asthma. Linked to the child’s electronic medical record (EMR) and based on widely accepted guidelines, the registry provides vital information to providers as they see children with asthma and generates monthly physician-specific reports that highlight care gaps in individual patients that can then be addressed by office staff. A separate part of the program allows physicians to order home visits to identify and address environmental factors that may be exacerbating asthma-related symptoms. More details on these key elements appear below:
- Web-based registry linked to EMR: A secure, Web-based registry captures patient-specific information on approximately 2,300 Cambridge Health Alliance pediatric patients with asthma. The registry incorporates widely accepted guidelines developed by NHLBI. Linked to the child’s EMR, the registry can upload information from the medical record and compare actual care received (including asthma-related inpatient admissions or ED visits) to the guidelines, thus identifying gaps that need to be addressed. With parental approval (which is almost always given), the registry can link to local pharmacy databases, thus identifying prescriptions (e.g., controller medications) that have not been filled or refilled.
- Use by physicians and school nurses during patient visits: The registry assists pediatricians, primary care physicians, and school nurses during visits by children with asthma, as outlined below:
- Pediatricians and primary care physicians: During office visits, Cambridge Health Alliance pediatricians and primary care physicians have access to the registry, which highlights recommended care and identifies care gaps based on information from the linked EMR. Once asthma is listed as a diagnosis/problem in the EMR, the asthma registry is populated. As a result, physicians are engaged in following standardized treatment based on the guidelines, including classifying the severity of the condition, developing an action plan, and prescribing appropriate controller or rescue medications. Specifically, the registry requires classification of asthma as intermittent or persistent and designation of the severity of the condition (mild, moderate, or severe). Once classified, children with persistent asthma have their controller medications listed (in addition to standard acute treatment medications) and receive followup visits.
- School nurses: With permission from parents, school nurses have access to the child’s information in the registry. If a student comes to the school clinic with symptoms, the nurse can see what medications have been prescribed and administer them as appropriate. Physicians often prescribe two sets of medications for children with asthma, one for use at home and one to be given to the school nurse. In some cases, asymptomatic children who play sports come to the school clinic before practice, so the nurse can administer controller medications that help the child participate without problems.
- Monthly reports that identify care gaps: Each month, the registry generates physician- and site-specific reports that highlight individual patients with asthma who have identified care gaps, including those in need of an office visit, severity classification, action plan, or specific medications (e.g., controller medications for persistent asthma). Although the report covers all patients, those with identified gaps appear in red at the top.
- Proactive outreach to address gaps: Based on information in the reports, practice sites take the necessary actions to address the identified gaps, such as setting up an appointment, prescribing a medication, or contacting the patient/parent about the need to refill a prescription. Typically a nurse performs this function, although practices vary in how they handle it. (All Cambridge Health Alliance pediatricians have a nurse partner.)
- Home visits: As necessary based on information provided during office visits, physicians can request that an inspector from the Cambridge Department of Public Health visit the home to identify and address suspected environmental issues that may be causing asthma-related problems. For example, the inspector might provide a mattress cover or lend parents a special vacuum cleaner to reduce the child’s contact with contaminants. Originally, grant funding allowed for Cambridge Health Alliance staff to perform these visits. Since funding ran out, the program has relied on the health department inspectors to play this role. These inspectors regularly visit homes as part of their job responsibilities, with most visits being for reasons other than looking for environmental triggers of asthma.
References/Related ArticlesBielaszka-DuVernay C. Taking public health approaches to care in Massachusetts. Health Aff. 2011;30(3):435-8. [PubMed]
Contact the InnovatorDavid Link, MD
Chief of Pediatrics, Cambridge Health Alliance
Associate Professor of Pediatrics, Harvard Medical School
1493 Cambridge Street
Cambridge, MA 02139
Innovator DisclosuresDr. Link reported having no financial interests or business/professional affiliations relevant to the work described in this profile, other than the funders listed in the Funding Sources section.
ResultsThe program has significantly reduced asthma-related inpatient admissions and ED visits among pediatric patients, leading to significant cost savings.
Moderate: The evidence consists of trends in pediatric asthma-related inpatient admissions and emergency department (ED) visits among enrollees since implementation of the program.
- Fewer inpatient admissions: Pediatric asthma-related inpatient admissions among those enrolled in the program fell by more than 50 percent during the first 2 years of the program (from 4.8 to 2.3 admissions per 100 child years). Since that time, pediatric asthma-related inpatient admissions have continued to fall. The drop in admissions has been even more significant in sites that performed poorly before creation of the registry. For example, in 2 such sites, the proportion of patients with 1 or more asthma-related admissions per year fell by roughly 80 percent, from just below 10 percent in early 2002 to less than 2 percent 5 years later.8
- Fewer ED visits: Since 2002, asthma-related pediatric ED visits have been cut by one-half for those enrolled in the program. As with inpatient admissions, the decline has been even greater in 2 poor-performing sites, with the proportion of children with 1 or more asthma-related ED visits per year falling by roughly 60 percent, from approximately 20 percent in early 2002 to 8 percent 5 years later.8
- Significant cost savings: The reductions in inpatient admissions and ED visits have led to substantial overall cost savings. For example, each inpatient admission costs between $1,000 and $7,000 at local hospitals, with wide variations between community and tertiary facilities. As discussed in the Adoption Considerations section, much of these savings accrue to third-party payers for those children who have insurance.
Context of the InnovationCambridge Health Alliance is an integrated health system with 3 hospitals and more than 30 primary and specialty care practices that serve a diverse population in and around Cambridge, Massachusetts. David Link, MD, Chief of Pediatrics, spearheaded the program based on his previous experience in developing and using patient registries to address significant public health problems. His first effort focused on improving immunization rates through development of a five-city registry. After seeing significant positive benefits from this effort, Dr. Link decided to tackle the more complex issue of pediatric asthma, a major public health problem in most urban areas. Using principles from a previous immunization effort, he began working with colleagues to develop the registry based on widely accepted NHLBI guidelines.
Planning and Development ProcessKey steps included the following:
- Developing registry: Over a period of roughly 6 months, a pediatric ambulatory nurse manager, pediatrician (Dr. Link), and experienced information technology (IT) programmer developed the registry based on their experience building an immunization registry (although creating the asthma registry ended up being substantially more complex). The process required intensive effort from the IT person, along with periodic meetings with the three individuals to determine relevant data fields and develop a reporting function that provided the appropriate information. Cambridge Health Alliance’s EMR did not have built-in software to develop an integrated registry.
- Designing related program elements: The three-person team made various decisions related to program components, including whether to make home visits a core element (which they decided to do initially based on the availability of grant funding) and how to format the monthly reports to make them as easy for physicians and nurses to use.
- Coordinating with schools: Dr. Link had established relationships with the school superintendent and many local school principals during the time he served on Cambridge’s Healthy Children’s Task Force. Consequently, school leaders enthusiastically supported making the registry available to school nurses, seeing it as a way to keep children with asthma in class. The school leaders directed their staff to work with Cambridge Health Alliance to develop the relevant protocols and parental release form.
- Training physicians and school nurses: Primary care physicians and pediatricians affiliated with Cambridge Health Alliance received brief training on the registry and registry-based reports. The chief school nurse in the area trained school nurses on use of the registry. The chair of the Cambridge Health Alliance Department of Pediatrics oversaw all training.
- Expanding to other conditions: Based on the success of the registry with pediatric asthma and immunizations, Cambridge Health Alliance developed a registry for children with attention deficit hyperactivity disorder (ADHD), which has already yielded improvements in how clinicians manage ADHD. Other registries may be developed in the future.
Resources Used and Skills Needed
- Staffing: As noted, upfront development of the program required approximately 6 months of intensive work by an experienced IT professional, supported by a pediatrician and nurse manager. A program champion also played an important role in securing leadership support and getting the program up and running. Once implemented, the program requires no new staff, as physicians and office- and school-based nurses incorporate it into their daily routines.
- Costs: Data on upfront development costs are not available, but they consisted largely of salary and benefits for those involved in developing the program. The required level of effort will vary significantly depending on whether a would-be adopter has an EMR and an in-house IT department with experience building registries. For those that do, the incremental costs of developing the program will likely be relatively moderate, particularly if the EMR has a built-in registry function. For organizations without an EMR and experienced IT staff, the costs could be significant.
Funding SourcesInstitute for Healthcare Improvement; Harvard Catalyst Grant Program
The Institute for Healthcare Improvement and the Harvard Catalyst Grant Program funded initial development and implementation of the registry.
Tools and Other ResourcesNational Guideline Clearinghouse. National Heart, Lung, and Blood Institute. Clinical Practice Guidelines. Available at: http://www.guideline.gov/browse/by-organization.aspx?orgid=451&term=asthma%20clinical%20practice%20guideline.
National Heart, Lung, and Blood Institute. Asthma Action Plan template. Available at: http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.htm.
Getting Started with This Innovation
- Identify program champion: A successful launch requires continuous work over a period of time by a respected individual who is passionate about improving the management of pediatric asthma. This individual will play a critical role in securing administrative and clinical leadership support and funding.
- Clearly document magnitude of problem: Before implementation of this program, many Cambridge Health Alliance patients with pediatric asthma did not receive effective care. Yet many providers were unaware of this fact, blaming the parents or children for suboptimal outcomes (e.g., not picking up prescriptions or taking medications as directed). Providers will be more likely to support the program once they see data documenting their poor adherence to accepted guidelines.
- Sell quality and business case: In addition to documenting the magnitude of the problem, the program champion needs to demonstrate the program’s potential to improve quality and reduce costs. The cost savings potential may be particularly important to organizations that face capacity constraints, that care for many uninsured children with asthma, or that care for children covered by at-risk contracts with payers. For these organizations, the reductions in inpatient admissions and ED visits generated by the program will tend to yield financial benefits. Provider organizations without capacity constraints that care for many children covered by fee-for-service (FFS) contracts may not benefit financially as discussed in the Sustaining the Innovation section below.
- Build program to leverage IT: Before implementation of this program, Cambridge Health Alliance leaders did not fully appreciate the wide-ranging potential of EMR-integrated electronic registries to facilitate quality improvement. Now they plan to leverage these capabilities to improve the management of other chronic conditions that affect many children and adults.
Sustaining This Innovation
- Monitor impact over time: To maintain enthusiasm for the program, continue to monitor and share information documenting its impact on inpatient admissions and ED visits.
- Consider approaching payers about sharing savings: As noted, this program generates savings by reducing costly inpatient admissions and ED visits. Under traditional FFS-based payment systems, such savings accrue to the payer, leaving hospitals and affiliated specialists with lower revenues. Consequently, depending on the payer mix of the population served, some providers may be worse off financially as a result of the program, thus threatening the sustainability of any provider-led registry program. To address this issue, consider approaching payers about modifying payment structures so that both parties benefit financially. These conversations may prove to be difficult—thus far, Cambridge Health Alliance has not been successful in negotiating such arrangements with payers.
Newacheck PW, Halfon N. Prevalence, impact, and trends in childhood disability due to asthma. Arch Pediatr Adolesc Med. 2000;154(3):287-93. [PubMed]
Moorman JE, Rudd RA, Johnson CA, et al. National surveillance for asthma—United States, 1980-2004. MMWR Surveill Summ. 2007;56(8):1-54. [PubMed]
Shapiro GG, Stout JW. Childhood asthma in the United States: urban issues. Pediatr Pulmonol. 2002;33(1):47-55. [PubMed]
Wolfenden L, Diette G, Krishnan J, et al. Lower physician estimate of underlying asthma severity leads to undertreatment. Arch Intern Med. 2003;163:231-6. [PubMed]
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120:S94-138. [PubMed]
Bielaszka-DuVernay C. Taking public health approaches to care in Massachusetts. Health Aff. 2011;30(3):435-8. [PubMed]
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Service Delivery Innovation Profile
Original publication: October 09, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.