- Email: [email protected]
Development of an electronic pictorial asthma action plan and its use in primary care
Patient Education and Counseling 80 (2010) 141–146
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
Development of an electronic pictorial asthma action plan and its use in primary care Nicola J. Roberts a, Gareth Evans b, Paul Blenkhorn c, Martyn R. Partridge a,* a
Department of Respiratory Medicine, NHLI at Charing Cross Hospital, Imperial College London, Hammersmith, London, UK NCC Education Ltd, The Towers, Towers Business Park, Manchester, UK c School of Informatics, University of Manchester, Manchester, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 June 2009 Received in revised form 5 August 2009 Accepted 16 September 2009
Objective: Self-management education and the issuing of a written action plan improve outcomes for asthma. Many do not receive a plan and some cannot use the written word. We have developed an electronic pictorial asthma action plan (E-PAAP). Methods: A pictorial action plan was incorporated into a software package. 21 general practices were offered this tool and the software was loaded onto 63 desktop computers (46 GPs and 17 nurses). Usage was assessed and health care professionals questioned as to its use. Results: 190 plans had been printed in a 4-month period (17 for test purposes). The individual usage rate ranged from 0 to 28 plans. Doctors printed 73% (139/190) a mean of 3 per doctor and nurses printed 27% a mean of 2 per nurse (37/190). Excluding the test copies, 116/173(67%) were printed as picture and text together. Conclusion: Nearly half of all healthcare professionals used the E-PAAP software. Usage was skewed with some individuals using the software significantly more than others. The software package should help overcome problems of access to paper templates, by calculating peak flow action thresholds and by prompting correct completion. Barriers to the use of asthma action plans, such as perceived time constraints, persist. Practice implications: The development of an electronic asthma action plan facilitates health professional access to a basic template and prompts the user as to correct usage. It is to be hoped that such facilitation enhances the number of action plans issued and in this study GPs were greater users than the nurses. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Self-management Asthma Pictorial Health literacy Electronic plans Primary care
1. Introduction Healthcare for those with long-term medical conditions requires a patient-centred approach with an emphasis upon supporting self-care. Both national [1,2] and international asthma guidelines [3] and systematic reviews [4], have demonstrated how self-management education can improve outcomes [5]. However only a minority of those with asthma are offered such plans [6–8]. Two-thirds wish to receive such advice [8] and this is probably also true for ethnic minorities [9]. If plans are an important part of such education they must be usable by all [10]. Published data suggests that impaired literacy is common and frequently overlooked [10–13]. Such patients can nevertheless benefit from tailored asthma self-management education [14]. Pictorial representations have been shown to
* Corresponding author at: Department of Respiratory Medicine, NHLI at Charing Cross Hospital, Imperial College London, St Dunstans Road, Hammersmith, London W6 8RP, UK. Tel.: +44 0208 846 7181; fax: +44 0208 846 7999. E-mail address: [email protected] (M.R. Partridge). 0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.09.040
improve recall of medical instructions in a clinical setting [15] and pictograms have been shown to be an effective tool, enhancing consultations and aiding understanding [16]. We have previously ‘‘translated’’ a standard written action plan into pictures and confirmed their understanding amongst a diverse population of patients with asthma [17]. However to issue plans, doctors and nurses need to have available suitable templates, know how to complete them, and where appropriate to be able to calculate peak flow thresholds and have time to explain such advice to patients. To improve this process we have developed our pictorial plans into an electronic software package for clinical use. 2. Methods 2.1. Production of the pictorial asthma action plans Written asthma action plans in common usage e.g. the Be In Control materials produced by Asthma UK [18] and those recommended in national and international guidelines [2,3] usually include four zones. With the help of a medical artist we devised pictorial representations of clinical scenarios and of
142
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
commonly used inhalers devices. These initial images were developed, designed and reviewed in consultation with medical and nursing respiratory members of staff before trialling with patients [17]. 2.2. The electronic action plan (E-AAP) A computerised software package was then developed which enabled construction of a personalised asthma action plan during a consultation. Following a series of sequential screens the user identifies appropriate images and scenarios to build a plan. The package automatically checks dosages used, and maximises inhaled therapy in Zone 2 (Fig. 1). For those self-monitoring their
peak flow, the program calculates the personalised action levels based upon the reported best peak flow. Users can print out a picture only plan, a words only version or a plan containing pictures and words (Fig. 2). 21 general practices were approached by letter to participate. 10/ 21 practices (47%) responded positively to the invitation for a demonstration of the use of the electronic asthma action plan (EAAP). The E-AAP software was installed in the 10 practices on all computers used by practice doctors and nurses for consultations. Limited training and instructions were given to all staff individually. The software was designed to monitor usage recording data to an xml file. After 4 months, the usage data was collected from each computer. Not all computer data could be obtained due to either staff changes or lack
Fig. 1. Examples of some of the electronic screens utilised in the E-AAP and by means of which a personalised plan is constructed by the health care professional and patient. Final printing produces a complete 4 zone plan.
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
Fig. 2. An example of a pictorial asthma action plan.
Fig. 3. Usage of the E-AAP in general practice.
143
144
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
Table 1 Primary care health care professional (HCP) usage of the E-AAP. General practice
Patient list size
Number of weeks software was installed on practice computers
1 2 3 4 5 6 7 8 9 10
9,429 12,598 8,178 4,588 5,146 5,467 11,137 6,000 3,561 6,500
20.1 19.4 17.1 21.0 19.9 19.7 17.1 19.6 18.3 20.1
Total
19.24 (mean)
Total number of computers usage data was collected from (per practice)
Number of doctors from whom usage data was collected (per practice)
Number of nurses from who usage data was collected (per practice)
Number of plans doctors printed
Number of plans nurses printed
Total
4 1 5 3 7 4 8 5 3 3
3 1 3 3 5 3 8 3 1 2
1 0 2 0 2 1 0 2 2 1
12 2 5 14 1 0 78 5 0 27
1 0 6 0 2 22 0 0 12 3
13 2 11 14 3 22 78 5 12 30
43
32
11
144
46
190
of computer access on the day of retrieval. A short questionnaire was also given to the doctors and nurses who had access to the software to assess their views regarding the program. 3. Ethical approval This study was approved by Riverside Research Ethics Committee. 4. Results 4.1. Use of the electronic asthma action plan (E-AAP) 10 practices participated and the software was installed on 63 computers, 46 used by doctors and 17 used by practice nurses. A
total of 190 plans had been printed with doctors printing 73% (139/ 190) and nurses 27% (37/190) (Table 1, Fig. 3). Amongst those that used the software the number of plans issued varied with a range of 1–28 plans printed by individual staff. The software was used 17/190 (9%), times for test or demonstration purposes. Excluding this data, most of the plans were printed in the format of symbols and text together 116/173 (67%), with a smaller proportion printing pictures alone (31/173, 18%) or text alone (26/173, 15%). 32 health care professionals (HCPs) (21 doctors and 11 nurses) completed the questionnaire. 4/32 (12.5%) reported that they had no access to the software in their consulting room. 18/32 (56%) stated that they had not used the software at all, and 14/32 (44%) reported using it between 1 and 5 times. 12/30 (40%) see between 3 and 5 asthma patients (adult) per week; only 6/30 (20%) seeing more than that. Reasons (Table 2) for non-usage included seeing
Table 2 Why was the software not used (32 doctors/HCP completed the questionnaire). 1. Inappropriate patients ‘‘Patients attending opportunistically not for annual review’’ ‘‘Not clinically indicated’’ ‘‘Used software [only] at annual asthma reviews’’ ‘‘I tend to see diabetic patients and the other nurse deals with asthma/COPD’’ ‘‘Most adults with well controlled or perceived well controlled asthma present with other issues and ‘‘while I’m here Doctor can I have an inhaler’’—few attend for ‘‘asthma check’’ with GP more with nurses’’ ‘‘Most patients seen by nurse’’ ‘‘If I did use it I would usually ask the patient to return for a longer appointment, I suppose they don’t always come back. Sometimes I was unable to proceed with the software. (1) When the patient had not used peak flow meters. (2) When their medication did not lend itself to changes in dosages i.e. seretide (they might need a completely different device to step up/down treatment levels’’ ‘‘It looks very useful, I do not see patients with asthma so was not shown how to use it when it was installed’’ ‘‘I did use the software when the patient did not already have a plan, sometimes there was a time constraint because the patient had an acute exacerbation—routine follow-ups are done by nurse’’ ‘‘Unaware software was to be used, unaware of setup, no guidelines for use, no information provided’’ 2. Lack of motivation ‘‘Inertia’’ ‘‘Too lazy to learn to use something new, sorry!’’ ‘‘Time, habit, not suitable for current presentation, felt patient not suitable, patient expressed wish not to have when offered’’ ‘‘Insufficient time to do the annual review and go through management plan, however appointment times now increased’’ 3. Time constraints ‘‘Generally because I forgot to use it. Some patients have multiple complaints so did not have time to go through the software’’ ‘‘Did not do any asthma reviews and time limited otherwise’’ ‘‘Time, some difficulties finding options, initial problems saving plan’’ ‘‘Too busy!’’ ‘‘Comfortable in current practice, time pressures during consultations often over-running surgery sessions can mean it may not be possible’’ ‘‘I was concerned about the length of consultations as patients come in with a long agenda’’ 4. Other (including technical issues) ‘‘Only just had it installed, looks very useful and have already used it once’’ ‘‘Couldn’t get it to run on my terminal a file in the initialisation folder was missing’’ ‘‘Really thought the software was good. However did not get myself organised enough to use it. Did not realise it was 3-month trial’’ ‘‘It was not installed on my computer and I was not aware a disc had been sent’’ ‘‘[I was] late finding out about it but it looks good’’
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
145
Table 3 What problems did you encounter using the software? (for example, technical problems, organisational issues such as working at other computers, forgetting that it was available, etc.) (n = 32 completed questionnaires). 1. No problems ‘‘None’’(10) ‘‘None but can be time consuming probably more appropriate to use it during dedicated annual asthma review appointment’’ ‘‘None—very good software. Patient like the plans; you can print off, easy to use’’ 2. Forgot about the software ‘‘Forgetting it was available, sorry’’ ‘‘Forgetting it was available’’ ‘‘Forgot what it is for a while after it was first installed otherwise fine’’ ‘‘Sometimes I forget that it is there, would be helpful if it came up on desktop (i.e. can minimise)’’ 3. Technical problems ‘‘I seem to have deleted my name from it, and have to type it in each time. Once I could not find it on my desktop then as if by miracle; It reappeared. I think it is a great piece of software just wish we could link it to patients’ records. At present it is only available to print off as paper record. Also currently we can not print off in colour’’ ‘‘Not easy to save, some preventor options not available (non-standard doses/preps)’’ ‘‘It looks a bit small when printed out, I am not sure how much it helps’’ ‘‘Front screen needs to be improved—confusion adding pts name, would be nice to have management plan linked to asthma template’’ ‘‘I didn’t like the addition of fluticasone on the plan’’
patients who were deemed unsuitable for a plan (n = 9), perceived time constraints (n = 4) or Dr/HCP reporting lack of motivation (n = 2). 12/25(48%) reported no problems (Table 3), 4/25 (16%) ‘‘forgot the software was available’’, and 6/25 (24%) reported other issues. The HCPs were asked to list details of any aspect they found unhelpful, and the commonest comment related to a perceived time constraint. 4/25 (16%) respondents suggested developing a link between the software and the practice systems or asthma template/register. 25/32 (78.1%) thought that similar plans for children and COPD patients 21/32 (65.6%) would be useful. 5. Discussion and conclusion 5.1. Discussion The first British Asthma Guidelines published in 1990 [19] stated that ‘‘as far as possible patients should be trained to manage their own treatment rather than be required to consult their doctor before making changes’’. Systematic reviews have shown the importance of receipt by the patient of a written asthma action plan advising when to increase their preventative therapy, when to start steroid tablets, and when to seek urgent medical attention [5]. However few patients receive such plans [6–8]. Reasons for nonreceipt may reflect poor dissemination of the content of guidelines, doctors’ lack of faith in delivering advice or a lack of suitable materials. The concept may be perceived as too complicated, and calculation of peak flow thresholds time consuming. Some might regard plans as being too complex for their patients. Simple pictorial plans may have wider appeal and applicability in minority groups and there is clear evidence that literacy is overestimated by doctors [11]. Paper-based pictorial plans have to be available in several different formats to encompass different inhaler devices and to cover those monitoring symptoms and or peak flow. Busy healthcare professionals will not always have time to seek out the correct paper template and healthcare professionals may not know how to complete an asthma action plan. Our software prompts the HCP with the action to take and ensures that correct doses and frequencies are selected. These electronic plans take only a few minutes to construct and can be printed out for the patient to take away in several formats and can be stored in the patient’s record electronically. Such software is only of value if it is used. We anticipated nurses using the tool and were encouraged that doctors did so also. However half did not issue any plans and whilst ambivalence towards this subject has been reported previously [20] our respondents were generally positive about
plans, even if not utilising the tool. Respondents to the questionnaire pointed out the advantages of linking the E-AAP to asthma registers and as many commented on how good it was but had forgotten it was there, other reminder systems might help. Others clearly believed plans should be introduced only in a planned way during annual review of patients and not opportunistically during other consultations. 5.2. Conclusion In summary we have produced a simple desktop package to enable health professionals to provide for those with asthma, personalised asthma action plans. This real life study showed that such a package is used by approximately one half of the healthcare professionals to whom it was available. Some healthcare professionals may require additional encouragement and reminders to use new computer tools. Further modification of the software to improve communication between different systems and databases is likely to improve usage in every day clinical practice. 6. Practice implications The development of an electronic asthma action plan facilitates health professional access to a basic template and prompts the user as to correct usage. It is to be hoped that such facilitation enhances the number of action plans issued and in this study GPs were greater users than the nurses. Funding This study was funded by a Trevor Clay Memorial Grant from the British Lung Foundation Acknowledgement We acknowledge with considerable gratitude the skill of our Medical Artist colleague Mrs A Wadmore. References [1] British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guidelines on the management of asthma. Thorax 2003;58(Suppl. 1). [2] National Asthma Education and Prevention Program. Quick Reference of the NAEPP Expert Panel Report: guidelines for the diagnosis and management of asthma. Update on selected topics; 2002. [3] Global strategy for asthma management and prevention. Global initiative for asthma (GINA); 2006, http://www.ginasthma.org (accessed 18 July, 2007).
146
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
[4] Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003;CD001117. [5] Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59:94–9. [6] Price D, Wolfe S. Delivery of asthma care: patients’ use of and views on healthcare services as determined from a nation-wide interview survey. Asthma J 2000;5:141–4. [7] Pinnock H, Martin N, Walters P. Acute asthma attacks: the patient’s perspective. Asthma J 2000;5:130–2. [8] Haughney J, Barnes G, Partridge M, Cleland J. The Living and Breathing Study: a study of patients views of asthma and its treatment. Prim Care Respir J 2004;13:28–35. [9] Hussein S, Partridge M. Perceptions of asthma in South Asians and their views on educational materials and self-management plans: a qualitative study. Patient Educ Couns 2002;48:189–94. [10] U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health, 2nd ed., Washington, DC: U.S. Government Printing Office; 2000 [accessed 01 December, 2000]. [11] Kelly PA, Haidet P. Physician overestimation of patient literacy: a potential source of health care disparities. Patient Educ Couns 2007;66:119–22. [12] Gordon M, Hampson R, Capell H, Madhok R. Illteracy in rheumatoid arthritis patients as determined by the Rapid Estimate of Adult Literacy in Medicine (REALM) score. Rheumatology 2002;41:750–4.
[13] Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114:1008–15. [14] Paasche-Orlow MK, Riekert KA, Bilderback A, Chanmugam A, Hill P, Rand CS, et al. Tailored education may reduce health literacy disparities in asthma selfmanagement. Am J Respir Crit Care Med 2005;172:980–6. [15] Houts P, Bachrach R, Witmer J, Tringali C, Bucher J, Localio R. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns 1998;35:83–8. [16] Houts P, Doak C, Loscalzo M. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns 2006;61:173–90. [17] Roberts NJ, Mohamed Z, Wong PS, Johnson M, Loh LC, Partridge MR. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns 2009;74:12–8. [18] Asthma UK—Be in Control materials. http://www.asthma.org.uk/health_ professionals/ordering_materials/be_in_control_2.html [accessed July 12, 2007]. [19] British Thoracic Society, Research Unit of the Royal College of Physicians of London, Kings’ Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults. 1. Chronic persistent asthma. Br Med J 1990;301:651–3. [20] Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. Br Med J 2000;321: 1507–10.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
Development of an electronic pictorial asthma action plan and its use in primary care Nicola J. Roberts a, Gareth Evans b, Paul Blenkhorn c, Martyn R. Partridge a,* a
Department of Respiratory Medicine, NHLI at Charing Cross Hospital, Imperial College London, Hammersmith, London, UK NCC Education Ltd, The Towers, Towers Business Park, Manchester, UK c School of Informatics, University of Manchester, Manchester, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 June 2009 Received in revised form 5 August 2009 Accepted 16 September 2009
Objective: Self-management education and the issuing of a written action plan improve outcomes for asthma. Many do not receive a plan and some cannot use the written word. We have developed an electronic pictorial asthma action plan (E-PAAP). Methods: A pictorial action plan was incorporated into a software package. 21 general practices were offered this tool and the software was loaded onto 63 desktop computers (46 GPs and 17 nurses). Usage was assessed and health care professionals questioned as to its use. Results: 190 plans had been printed in a 4-month period (17 for test purposes). The individual usage rate ranged from 0 to 28 plans. Doctors printed 73% (139/190) a mean of 3 per doctor and nurses printed 27% a mean of 2 per nurse (37/190). Excluding the test copies, 116/173(67%) were printed as picture and text together. Conclusion: Nearly half of all healthcare professionals used the E-PAAP software. Usage was skewed with some individuals using the software significantly more than others. The software package should help overcome problems of access to paper templates, by calculating peak flow action thresholds and by prompting correct completion. Barriers to the use of asthma action plans, such as perceived time constraints, persist. Practice implications: The development of an electronic asthma action plan facilitates health professional access to a basic template and prompts the user as to correct usage. It is to be hoped that such facilitation enhances the number of action plans issued and in this study GPs were greater users than the nurses. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Self-management Asthma Pictorial Health literacy Electronic plans Primary care
1. Introduction Healthcare for those with long-term medical conditions requires a patient-centred approach with an emphasis upon supporting self-care. Both national [1,2] and international asthma guidelines [3] and systematic reviews [4], have demonstrated how self-management education can improve outcomes [5]. However only a minority of those with asthma are offered such plans [6–8]. Two-thirds wish to receive such advice [8] and this is probably also true for ethnic minorities [9]. If plans are an important part of such education they must be usable by all [10]. Published data suggests that impaired literacy is common and frequently overlooked [10–13]. Such patients can nevertheless benefit from tailored asthma self-management education [14]. Pictorial representations have been shown to
* Corresponding author at: Department of Respiratory Medicine, NHLI at Charing Cross Hospital, Imperial College London, St Dunstans Road, Hammersmith, London W6 8RP, UK. Tel.: +44 0208 846 7181; fax: +44 0208 846 7999. E-mail address: [email protected] (M.R. Partridge). 0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.09.040
improve recall of medical instructions in a clinical setting [15] and pictograms have been shown to be an effective tool, enhancing consultations and aiding understanding [16]. We have previously ‘‘translated’’ a standard written action plan into pictures and confirmed their understanding amongst a diverse population of patients with asthma [17]. However to issue plans, doctors and nurses need to have available suitable templates, know how to complete them, and where appropriate to be able to calculate peak flow thresholds and have time to explain such advice to patients. To improve this process we have developed our pictorial plans into an electronic software package for clinical use. 2. Methods 2.1. Production of the pictorial asthma action plans Written asthma action plans in common usage e.g. the Be In Control materials produced by Asthma UK [18] and those recommended in national and international guidelines [2,3] usually include four zones. With the help of a medical artist we devised pictorial representations of clinical scenarios and of
142
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
commonly used inhalers devices. These initial images were developed, designed and reviewed in consultation with medical and nursing respiratory members of staff before trialling with patients [17]. 2.2. The electronic action plan (E-AAP) A computerised software package was then developed which enabled construction of a personalised asthma action plan during a consultation. Following a series of sequential screens the user identifies appropriate images and scenarios to build a plan. The package automatically checks dosages used, and maximises inhaled therapy in Zone 2 (Fig. 1). For those self-monitoring their
peak flow, the program calculates the personalised action levels based upon the reported best peak flow. Users can print out a picture only plan, a words only version or a plan containing pictures and words (Fig. 2). 21 general practices were approached by letter to participate. 10/ 21 practices (47%) responded positively to the invitation for a demonstration of the use of the electronic asthma action plan (EAAP). The E-AAP software was installed in the 10 practices on all computers used by practice doctors and nurses for consultations. Limited training and instructions were given to all staff individually. The software was designed to monitor usage recording data to an xml file. After 4 months, the usage data was collected from each computer. Not all computer data could be obtained due to either staff changes or lack
Fig. 1. Examples of some of the electronic screens utilised in the E-AAP and by means of which a personalised plan is constructed by the health care professional and patient. Final printing produces a complete 4 zone plan.
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
Fig. 2. An example of a pictorial asthma action plan.
Fig. 3. Usage of the E-AAP in general practice.
143
144
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
Table 1 Primary care health care professional (HCP) usage of the E-AAP. General practice
Patient list size
Number of weeks software was installed on practice computers
1 2 3 4 5 6 7 8 9 10
9,429 12,598 8,178 4,588 5,146 5,467 11,137 6,000 3,561 6,500
20.1 19.4 17.1 21.0 19.9 19.7 17.1 19.6 18.3 20.1
Total
19.24 (mean)
Total number of computers usage data was collected from (per practice)
Number of doctors from whom usage data was collected (per practice)
Number of nurses from who usage data was collected (per practice)
Number of plans doctors printed
Number of plans nurses printed
Total
4 1 5 3 7 4 8 5 3 3
3 1 3 3 5 3 8 3 1 2
1 0 2 0 2 1 0 2 2 1
12 2 5 14 1 0 78 5 0 27
1 0 6 0 2 22 0 0 12 3
13 2 11 14 3 22 78 5 12 30
43
32
11
144
46
190
of computer access on the day of retrieval. A short questionnaire was also given to the doctors and nurses who had access to the software to assess their views regarding the program. 3. Ethical approval This study was approved by Riverside Research Ethics Committee. 4. Results 4.1. Use of the electronic asthma action plan (E-AAP) 10 practices participated and the software was installed on 63 computers, 46 used by doctors and 17 used by practice nurses. A
total of 190 plans had been printed with doctors printing 73% (139/ 190) and nurses 27% (37/190) (Table 1, Fig. 3). Amongst those that used the software the number of plans issued varied with a range of 1–28 plans printed by individual staff. The software was used 17/190 (9%), times for test or demonstration purposes. Excluding this data, most of the plans were printed in the format of symbols and text together 116/173 (67%), with a smaller proportion printing pictures alone (31/173, 18%) or text alone (26/173, 15%). 32 health care professionals (HCPs) (21 doctors and 11 nurses) completed the questionnaire. 4/32 (12.5%) reported that they had no access to the software in their consulting room. 18/32 (56%) stated that they had not used the software at all, and 14/32 (44%) reported using it between 1 and 5 times. 12/30 (40%) see between 3 and 5 asthma patients (adult) per week; only 6/30 (20%) seeing more than that. Reasons (Table 2) for non-usage included seeing
Table 2 Why was the software not used (32 doctors/HCP completed the questionnaire). 1. Inappropriate patients ‘‘Patients attending opportunistically not for annual review’’ ‘‘Not clinically indicated’’ ‘‘Used software [only] at annual asthma reviews’’ ‘‘I tend to see diabetic patients and the other nurse deals with asthma/COPD’’ ‘‘Most adults with well controlled or perceived well controlled asthma present with other issues and ‘‘while I’m here Doctor can I have an inhaler’’—few attend for ‘‘asthma check’’ with GP more with nurses’’ ‘‘Most patients seen by nurse’’ ‘‘If I did use it I would usually ask the patient to return for a longer appointment, I suppose they don’t always come back. Sometimes I was unable to proceed with the software. (1) When the patient had not used peak flow meters. (2) When their medication did not lend itself to changes in dosages i.e. seretide (they might need a completely different device to step up/down treatment levels’’ ‘‘It looks very useful, I do not see patients with asthma so was not shown how to use it when it was installed’’ ‘‘I did use the software when the patient did not already have a plan, sometimes there was a time constraint because the patient had an acute exacerbation—routine follow-ups are done by nurse’’ ‘‘Unaware software was to be used, unaware of setup, no guidelines for use, no information provided’’ 2. Lack of motivation ‘‘Inertia’’ ‘‘Too lazy to learn to use something new, sorry!’’ ‘‘Time, habit, not suitable for current presentation, felt patient not suitable, patient expressed wish not to have when offered’’ ‘‘Insufficient time to do the annual review and go through management plan, however appointment times now increased’’ 3. Time constraints ‘‘Generally because I forgot to use it. Some patients have multiple complaints so did not have time to go through the software’’ ‘‘Did not do any asthma reviews and time limited otherwise’’ ‘‘Time, some difficulties finding options, initial problems saving plan’’ ‘‘Too busy!’’ ‘‘Comfortable in current practice, time pressures during consultations often over-running surgery sessions can mean it may not be possible’’ ‘‘I was concerned about the length of consultations as patients come in with a long agenda’’ 4. Other (including technical issues) ‘‘Only just had it installed, looks very useful and have already used it once’’ ‘‘Couldn’t get it to run on my terminal a file in the initialisation folder was missing’’ ‘‘Really thought the software was good. However did not get myself organised enough to use it. Did not realise it was 3-month trial’’ ‘‘It was not installed on my computer and I was not aware a disc had been sent’’ ‘‘[I was] late finding out about it but it looks good’’
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
145
Table 3 What problems did you encounter using the software? (for example, technical problems, organisational issues such as working at other computers, forgetting that it was available, etc.) (n = 32 completed questionnaires). 1. No problems ‘‘None’’(10) ‘‘None but can be time consuming probably more appropriate to use it during dedicated annual asthma review appointment’’ ‘‘None—very good software. Patient like the plans; you can print off, easy to use’’ 2. Forgot about the software ‘‘Forgetting it was available, sorry’’ ‘‘Forgetting it was available’’ ‘‘Forgot what it is for a while after it was first installed otherwise fine’’ ‘‘Sometimes I forget that it is there, would be helpful if it came up on desktop (i.e. can minimise)’’ 3. Technical problems ‘‘I seem to have deleted my name from it, and have to type it in each time. Once I could not find it on my desktop then as if by miracle; It reappeared. I think it is a great piece of software just wish we could link it to patients’ records. At present it is only available to print off as paper record. Also currently we can not print off in colour’’ ‘‘Not easy to save, some preventor options not available (non-standard doses/preps)’’ ‘‘It looks a bit small when printed out, I am not sure how much it helps’’ ‘‘Front screen needs to be improved—confusion adding pts name, would be nice to have management plan linked to asthma template’’ ‘‘I didn’t like the addition of fluticasone on the plan’’
patients who were deemed unsuitable for a plan (n = 9), perceived time constraints (n = 4) or Dr/HCP reporting lack of motivation (n = 2). 12/25(48%) reported no problems (Table 3), 4/25 (16%) ‘‘forgot the software was available’’, and 6/25 (24%) reported other issues. The HCPs were asked to list details of any aspect they found unhelpful, and the commonest comment related to a perceived time constraint. 4/25 (16%) respondents suggested developing a link between the software and the practice systems or asthma template/register. 25/32 (78.1%) thought that similar plans for children and COPD patients 21/32 (65.6%) would be useful. 5. Discussion and conclusion 5.1. Discussion The first British Asthma Guidelines published in 1990 [19] stated that ‘‘as far as possible patients should be trained to manage their own treatment rather than be required to consult their doctor before making changes’’. Systematic reviews have shown the importance of receipt by the patient of a written asthma action plan advising when to increase their preventative therapy, when to start steroid tablets, and when to seek urgent medical attention [5]. However few patients receive such plans [6–8]. Reasons for nonreceipt may reflect poor dissemination of the content of guidelines, doctors’ lack of faith in delivering advice or a lack of suitable materials. The concept may be perceived as too complicated, and calculation of peak flow thresholds time consuming. Some might regard plans as being too complex for their patients. Simple pictorial plans may have wider appeal and applicability in minority groups and there is clear evidence that literacy is overestimated by doctors [11]. Paper-based pictorial plans have to be available in several different formats to encompass different inhaler devices and to cover those monitoring symptoms and or peak flow. Busy healthcare professionals will not always have time to seek out the correct paper template and healthcare professionals may not know how to complete an asthma action plan. Our software prompts the HCP with the action to take and ensures that correct doses and frequencies are selected. These electronic plans take only a few minutes to construct and can be printed out for the patient to take away in several formats and can be stored in the patient’s record electronically. Such software is only of value if it is used. We anticipated nurses using the tool and were encouraged that doctors did so also. However half did not issue any plans and whilst ambivalence towards this subject has been reported previously [20] our respondents were generally positive about
plans, even if not utilising the tool. Respondents to the questionnaire pointed out the advantages of linking the E-AAP to asthma registers and as many commented on how good it was but had forgotten it was there, other reminder systems might help. Others clearly believed plans should be introduced only in a planned way during annual review of patients and not opportunistically during other consultations. 5.2. Conclusion In summary we have produced a simple desktop package to enable health professionals to provide for those with asthma, personalised asthma action plans. This real life study showed that such a package is used by approximately one half of the healthcare professionals to whom it was available. Some healthcare professionals may require additional encouragement and reminders to use new computer tools. Further modification of the software to improve communication between different systems and databases is likely to improve usage in every day clinical practice. 6. Practice implications The development of an electronic asthma action plan facilitates health professional access to a basic template and prompts the user as to correct usage. It is to be hoped that such facilitation enhances the number of action plans issued and in this study GPs were greater users than the nurses. Funding This study was funded by a Trevor Clay Memorial Grant from the British Lung Foundation Acknowledgement We acknowledge with considerable gratitude the skill of our Medical Artist colleague Mrs A Wadmore. References [1] British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guidelines on the management of asthma. Thorax 2003;58(Suppl. 1). [2] National Asthma Education and Prevention Program. Quick Reference of the NAEPP Expert Panel Report: guidelines for the diagnosis and management of asthma. Update on selected topics; 2002. [3] Global strategy for asthma management and prevention. Global initiative for asthma (GINA); 2006, http://www.ginasthma.org (accessed 18 July, 2007).
146
N.J. Roberts et al. / Patient Education and Counseling 80 (2010) 141–146
[4] Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003;CD001117. [5] Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59:94–9. [6] Price D, Wolfe S. Delivery of asthma care: patients’ use of and views on healthcare services as determined from a nation-wide interview survey. Asthma J 2000;5:141–4. [7] Pinnock H, Martin N, Walters P. Acute asthma attacks: the patient’s perspective. Asthma J 2000;5:130–2. [8] Haughney J, Barnes G, Partridge M, Cleland J. The Living and Breathing Study: a study of patients views of asthma and its treatment. Prim Care Respir J 2004;13:28–35. [9] Hussein S, Partridge M. Perceptions of asthma in South Asians and their views on educational materials and self-management plans: a qualitative study. Patient Educ Couns 2002;48:189–94. [10] U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health, 2nd ed., Washington, DC: U.S. Government Printing Office; 2000 [accessed 01 December, 2000]. [11] Kelly PA, Haidet P. Physician overestimation of patient literacy: a potential source of health care disparities. Patient Educ Couns 2007;66:119–22. [12] Gordon M, Hampson R, Capell H, Madhok R. Illteracy in rheumatoid arthritis patients as determined by the Rapid Estimate of Adult Literacy in Medicine (REALM) score. Rheumatology 2002;41:750–4.
[13] Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114:1008–15. [14] Paasche-Orlow MK, Riekert KA, Bilderback A, Chanmugam A, Hill P, Rand CS, et al. Tailored education may reduce health literacy disparities in asthma selfmanagement. Am J Respir Crit Care Med 2005;172:980–6. [15] Houts P, Bachrach R, Witmer J, Tringali C, Bucher J, Localio R. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns 1998;35:83–8. [16] Houts P, Doak C, Loscalzo M. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns 2006;61:173–90. [17] Roberts NJ, Mohamed Z, Wong PS, Johnson M, Loh LC, Partridge MR. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns 2009;74:12–8. [18] Asthma UK—Be in Control materials. http://www.asthma.org.uk/health_ professionals/ordering_materials/be_in_control_2.html [accessed July 12, 2007]. [19] British Thoracic Society, Research Unit of the Royal College of Physicians of London, Kings’ Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults. 1. Chronic persistent asthma. Br Med J 1990;301:651–3. [20] Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. Br Med J 2000;321: 1507–10.