Computer-Mediated Guideline Implementation Projects
Overview
AsthMonitor
Information Management Services Model
PalmAsthma
Object-Oriented Framework
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We have developed a computer application (called "PalmAsthma") that is intended to assist in the implementation of the asthma guidelines from the National Heart, Lung and Blood Institute. The design of PalmAsthma was heavily influenced by the critique provided by the AsthMonitor users. In contrast to AsthMonitor--which was useful only for management of acute exacerbations of asthma--PalmAsthma supports the chronic care of asthmatic children.
The PalmAsthma system provides a wide range of information management services to enhance its acceptability to clinicians, which include:
- Documentation of the clinical encounter with templates and prompts. Both structured and unstructured data collection are permitted;
- Recommendations from the guideline regarding correct asthma severity classification and appropriate selections of pharmacologic therapies;
- Explanation of which clinical observations contributed to the computer's diagnostic classification;
- Calculation of peak flow variability and the appropriate dosages of pharmacologic agents;
- Presentation via graphical user interface of encounter components and of paper-based prescription forms, tailored patient handouts, and encounter summaries;
- Communication with a desktop computer via serial cable. We are exploring the use of wireless infrared and radio frequency communication; and
- Aggregation of clinical information in a database to afford a population-based view
PalmAsthma software was written in the C++ programming language and can operate on any computer that runs the Windows CE operating system. We have specifically tested the software on both palmtop devices--the Freestyle (Everex Corp.) and Cassiopeia (Casio, Inc.)--and a handheld machine--the Clio (VADEM). Like AsthMonitor, users can enter data with a "pen" stylus by writing on a touch-sensitive screen and can navigate through the program by tapping on virtual buttons that appear
In the PalmAsthma system, several handheld computers can upload data to a single desktop machine that maintains a long-term clinical database. The desktop machine is connected to a 7 page-per-minute color printer, which produces a visit summary, prescriptions, and patient handouts (in English and Spanish) keyed to a clinicians' plan. Data from the desktop computer can be uploaded to a central patient care or research database.
Handheld devices vary in size and shape. The Casio and Freestyle fit easily in a shirt pocket. The Clio is larger with a 9.4-inch color screen that accepts pen input. Its innovative hinge design allows it to be configured as a clamshell notebook with a traditional keyboard or folded into a flat tablet. Both computer styles are sufficiently lightweight to be carried by clinicians during clinical encounters. In spite of their small size and relatively low price, the H/PCs contain powerful microprocessors and a sophisticated operating system. Each H/PC is supplied with software that can maintain a personal calendar, address book, and notepad, thus increasing its potential value to busy clinicians.
Operation. After recording patient-identifying information, the user is presented with a main menu that divides the program into 4 components, which parallel the structure of the clinical encounter&emdash;Interval History, Physical Examination, Assessments, and Plans.
Within the Interval History component, 7 tabbed screens can be completed as the user desires. They include symptom frequency, pulmonary function, functional status, current medications, exacerbation history, triggers, and environmental controls. In contrast to the AsthMonitor application, in which most of the computer logic was triggered by physical findings, the PalmAsthma logic is dependent on historic data.
After selection of the Assessment component, the user is prompted to classify the patient's asthma into one of the 4 severity categories defined in the NHLBI guideline (mild intermittent, mild persistent, moderate persistent, or severe persistent). If the user's classification does not conform to the NHLBI categorization, a dialog box appears that states the discrepancy and the data upon which it is based. The user is offered an opportunity to change his/her category but is not obliged to do so. Other screens document the clinician's assessment of the patient's inhaler technique and medication adherence.
In the Plans Component, a screen appears with a set of recommended medications based on the asthma classification, the patient's level of control, the duration of symptoms, and the presence or absence of exercise-induced symptoms. The user can select these medications by tapping a single button, can de-select any (or all) of the medications, can go to a medication screen that allows prescription of any asthma medications stored in the device, or can Step Up or Step Down to the medications recommended for adjacent asthma classifications. The Step Up strategy is useful for patients who are not doing well, and the Step Down strategy can be used to wean patients to the minimal regimen that will maintain control.
Another Plan component permits selection of individualized materials including Action Plans (with patient specific Red/Yellow/Green PEFR zones), instructions in inhaler technique, discussion of asthma pathophysiology, recommendations for environmental controls, reminders about influenza vaccination, and school medication forms. Patient handouts can be tailored to the needs of individual practices. We will prepare materials for both standard and low-literacy populations and make them available in both English and Spanish.
Examples of data entry screens from PalmAsthma. (a) Symptom frequency, (b) PEFR, (c) medication recommendations.