Introduction

Asthma is one of the most common chronic respiratory diseases and is responsible for a significant healthcare burden [1–3]. It is an inflammatory condition of the airways, characterised by paroxysmal or persistent symptoms, such as dyspnoea, wheezing and cough, and is associated with variable airflow limitation and airway hyperresponsiveness to various stimuli [4]. The global burden of asthma continues to rise, accounting for 21.55 million disability-adjusted life-years and with a rising prevalence of 262.41 million in 2019 [3, 5].

Asthma best-practice recommendations for diagnosis and management are published at the international and national level. The Global Initiative for Asthma (GINA) report is updated and published annually, providing a review of the scientific literature and an international strategy for asthma best-practice management and prevention [6, 7]. Jointly, the European Respiratory Society and the American Thoracic Society produce best-practice clinical recommendations for the international medical community on topics such as the diagnosis and management of severe asthma [8, 9]. At the national level, organisations such as the Canadian Thoracic Society (CTS), the British Thoracic Society and the Spanish Asthma Management Guidelines publish nation-specific guidelines advising physicians on the most current evidence-based recommendations [10–13]. Despite the publication of these guiding documents, several key asthma care gaps have been identified within the literature, particularly concerning objective diagnosis, continued monitoring of lung function, achieving adequate asthma control and patient asthma education [8, 10, 14–16].

Asthma is diagnosed based on a compatible clinical history and objectively confirmed variable expiratory airflow limitation on lung function testing [7]. Pulmonary function tests (PFTs) such as spirometry showing reversible airflow obstruction or challenge tests showing increased airway sensitivity are the gold-standard objective measures used to confirm an asthma diagnosis in various guidelines and aid in differentiating asthma from other conditions with similar symptoms, such as COPD [10, 11, 16–18].

Specifically, the diagnostic criteria in the 2024 GINA report recommend five methods to objectively confirm excessive variability in lung function, including 1) a positive bronchodilator responsiveness test with spirometry, 2) excessive variability in twice-daily peak expiratory flow (PEF) measurements over 2 weeks, 3) increase in lung function following 4 weeks of treatment with inhaled corticosteroid (ICS), 4) positive bronchial challenge test and/or 5) excessive variation in lung function between visits [7]. Furthermore, when making an asthma diagnosis, some patients already on an ICS-containing medication may not meet the above criteria. Hence, the GINA report recommends a specific methodology for confirming a diagnosis in these patients, including repeating objective lung function measures (i.e., spirometry, bronchodilator responsiveness testing, etc.) and trialling a step-down of ICS-containing treatment [7]. The main message from these recommendations is that objective lung function measurements are necessary to confirm an asthma diagnosis [6, 7, 10, 11, 16–18].

Recently, there has been discourse surrounding the prevalence and diagnostic utility of bronchodilator responsiveness for chronic airway diseases [19]. However, objective evidence of airflow limitation and/or airway hyperresponsiveness remains the accepted standard to confirm a diagnosis of asthma amongst various guidelines and practice recommendations [6, 8, 10]. As such, utilisation of PFTs to investigate suspected asthma is a key recommendation of current clinical guidelines [10, 11, 16].

Most asthma is mild or moderate in severity and can be well-controlled with therapies and self-management education [10]. However, 5–10% of individuals with asthma are classified as having severe asthma, accounting for a disproportionate 50% of asthma-related healthcare costs [20]. Recommendations for severe asthma management include referral to asthma specialists and assessment of eligibility for novel biologic therapies, including asthma phenotyping using biomarkers [20]. Addressing the care gap for severe uncontrolled asthma is a priority [8, 9, 16, 20].

Difficulties in implementing clinical guidelines into asthma care practice have been identified on a multinational stage. A 2006 paper by Boulet et al. [15] describes the proceedings of an international symposium, focusing on strategies to best implement guidelines into practice. The authors highlight that guideline dissemination alone is not sufficient, with most primary care providers remaining unfamiliar with current guidelines and practice recommendations [15, 21]. Further literature has highlighted the need for innovative implementation techniques and tools, especially within the busy and multifaceted primary care practice [22].

Hence, knowledge translation (KT) initiatives are warranted to facilitate implementation of asthma guidelines into primary care practice [15, 23–25]. According to the Canadian Institutes of Health Research (CIHR), KT is defined “as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system” [26]. A 2006 paper by Graham et al. [27] offered a conceptual framework entitled the knowledge-to-action (KTA) cycle to circumscribe the interactions between the process of knowledge creation (i.e., guidelines, KT tools, etc.) and knowledge application (i.e., applying KT tools in practice settings of interest), for use in health sciences research [28]. Since its proposition, the framework has been adopted by both the CIHR and the CTS for use in guideline dissemination and implementation, including asthma care guidelines [15, 29].

Several KT electronic tools (eTools) exist for asthma. EMRs present a unique opportunity to implement evidence-based guidelines at the point-of-care, providing a means for asthma surveillance and quality improvement [30]. Validated respiratory data elements and definitions for use in EMRs have been identified through the Pan-Canadian Respiratory Standards Initiative for Electronic Health Records (PRESTINE) [31]. However, many current KT eTools do not incorporate these standardised data elements, leading to inefficient asthma surveillance and quality improvement within primary care [32, 33].

In this paper we aimed to conduct a nonsystemic literature review, using the KTA cycle as a framework to understand the key asthma care gaps in primary care, outline the current landscape of KT eTools optimised for primary care EMRs in Canada and identify opportunities for improvement in current and future asthma KT eTools.

Methods

A nonsystemic literature search strategy was employed to achieve the objectives of the literature review, conducted through Ovid Medline. Additionally, a review of the most current professional organisation guidelines and position statements relevant to Canadian primary care practice (the GINA Report and CTS asthma guidelines) was conducted. The following key words were utilised: “asthma”, “knowledge translation”, “translational science”, “information dissemination”, “practice patterns”, “physicians” practice guidelines”, “guideline implementation”, “asthma diagnosis”, “primary healthcare”, “primary practice”, “electronic health records or electronic medical records”, “objective pulmonary tests” and “Canada”. The search returned 897 articles. Of these, each article title and abstract were reviewed for relevancy and a publishing date within the last 24 years (January 1999–May 2024). Following this review, 101 articles were deemed relevant to the literature review from the original search and subsequently read in full. For inclusion in the literature review, 80 articles were deemed applicable, which included articles found in the cited literature of original search publications.

We used the KTA cycle as a theoretical framework for understanding the development and implementation of asthma KT eTools within EMRs. To be deemed eligible for inclusion in the current review, the KT eTool needed to have features allowing for the integration into primary care EMRs.

Results

This review provides an overview of the KTA cycle application in asthma care. Search results yielded a variety of studies outlining the current asthma care gaps and various asthma-specific electronic KT initiatives aiming to improve overall care. A representation of the search results can be found in figure 1.

FIGURE 1

Literature search methodology and results. Keywords: “asthma”, “knowledge translation”, “translational science”, “information dissemination”, “practice patterns”, “physicians” practice guidelines”, “guideline implementation”, “asthma diagnosis”, “primary healthcare”, “primary practice”, “electronic health records or electronic medical records”, “objective pulmonary tests” and “Canada”.

Application of the KTA cycle to asthma care is synthesised in figure 2. KT tools to date have utilised the KTA cycle for goals such as quality assurance, physician-decision support, quality of life assessment and more [34–36]. Several KT eTools have also been developed for specific use in EMRs. In applying the KTA cycle to asthma care, four key themes emerged, as follows and illustrated in figure 3: 1) identification of the key asthma care gaps; 2) focus on asthma care gaps/barriers specific to primary care; 3) the current Canadian electronic KT tools; and 4) future directions for integrating electronic KT tools for asthma management within primary care EMRs. The results of the literature search will be discussed in the context of these four key themes.

FIGURE 2

Knowledge-to-action cycle in the context of asthma management in primary care. Reproduced and modified from Graham et al. [27], reprinted with permission (Creative Commons License: https://creativecommons.org/licenses/by-sa/2.0/), additional text was added. CTS: Canadian Thoracic Society; EMR: electronic medical record; e-Tools: electronic tools; GINA: Global Initiative for Asthma; KT: knowledge translation.

FIGURE 3

Literature review key themes. AMOMS: Airways Management and Outcomes Monitoring System; eAMS: Electronic Asthma Management System; e-Mini AQLQ: Electronic Mini Asthma Quality of Life Questionnaire; EMR: electronic medical record; KT: knowledge translation; PAAF: Provider Asthma Assessment Form; PFT: pulmonary function test; PRESTINE: Pan-Canadian REspiratory STandards INitiative for Electronic health records; PSCAR-EDU: Primary Care Severe Asthma Registry and Education Project; WRASQ(L)TM: Work-related Asthma Screening Questionnaire (long version).

Key asthma care gaps and barriers in primary care

Several studies have identified differences between best-practice asthma care, aligning with the GINA report and/or regional guidelines and current practice [10, 14, 37]. A significant focus pertains to the diagnosis of asthma, the recognition of uncontrolled severe asthma and patient self-management education. A recent position statement by the CTS highlighted the key messages of confirming diagnosis through objective measures and assessing asthma control, in addition to referral of suspected severe asthma to specialists and asthma education [20]. Considering the CTS's recent statement, care gaps pertaining to these key messages will be reviewed, in addition to physicians’ perceptions of achieving optimal asthma care.

Practice variations between specialty groups

Practice variations have been identified in asthma management between speciality groups, chiefly primary care practitioners. Studies have identified lower adherence with guidelines compared to other specialties, such as less frequent use of spirometry [21, 38]. Within the KTA framework, these may relate to provider characteristics, such as attitudes and beliefs, and aspects of the healthcare system, such as access to diagnostic testing and specialists.

Of note, one study by Jin et al. [21] evaluated physicians’ asthma management practices Canada-wide following the introduction of the 1996 Canadian Asthma Consensus Guidelines. They found preliminary evidence indicating practice-deviations from guidelines, as well as statistically significant practice variations between speciality groups (e.g., respirology, internal medicine, paediatrics, allergy/clinical immunology and family practice) in the areas of diagnosis, treatment and patient education. This study identified a need to further study asthma management practices in Canada and abroad and determine if these differences led to a deficit in care for asthma patients.

Underutilisation of PFTs in diagnosis and monitoring

One of the most important gaps identified in asthma care is diagnosis practices that do not align with current evidence-based guidelines, specifically, underutilisation of PFTs both for the diagnosis and monitoring of individuals with asthma. Ensuring the diagnosis is confirmed by objective measures, such as spirometry and the methacholine challenge, and that objective measures are assessed at follow-up have been shown to improve asthma management [39, 40]. Nair et al. [39] found that, without PFTs, the level of paediatric asthma control was overestimated and including PFT results in clinical decision-making shaped management. National and international guidelines stipulate the need to confirm the clinician suspicion of asthma based on history, with objective measures of lung function that are consistent with asthma [10, 16]. However, the reality of objective measures of lung function being used in clinical practice at the frequency they are recommended (i.e., for every patient) has been the subject of significant analysis.

In early Canadian asthma management surveys, one study found that only 54% of patients recalled having undergone PFTs and another reported that 44% of patients surveyed communicated that they had never had spirometry [41, 42]. The Reality of Asthma Control (TRAC) study also found that specialists were more likely to use spirometry than general practitioners; however, just 25% of patients reported undergoing PFTs in a doctor's office [14]. This gave early indication to lack of PFTs being used in clinical practice. As mentioned previously, Aaron et al. [43] found that one-third of participants with a self-reported doctor-diagnosed asthma had no evidence of asthma on spirometry and/or methacholine challenge tests. These findings indicate that overdiagnosis may be a concern when objective measures of asthma are not used. Importantly, Gershon et al. [44] found that only 42.7% of newly diagnosed individuals with asthma in the province of Ontario underwent pulmonary function testing 1 year prior and 2.5 years following diagnosis. Additionally, this publication also reported that individuals seeing a specialist were more likely to receive testing than those seeing a primary care practitioner. Recently, Moloney et al. [33] found that 75% of asthma patients managed in a tertiary care family practice lacked evidence in the EMR of objective confirmation of that diagnosis by PFTs or specialist assessment.

Another study by Aaron et al. [45] verified the original finding that a large percentage of adult patients with physician-diagnosed asthma show no evidence of asthma on PFTs even after tapering asthma medications. In total, current asthma was ruled out in 33.1% of study participants and only 43.8% of participants in this group had undergone PFTs prior to the study. Notably, participants whose current asthma status was confirmed were more likely than those in the “ruled out” group to have undergone PFTs in the community at the time of diagnosis (55.6% compared to 43.8%). Additionally, 2% of participants had been misdiagnosed with asthma when they had other severe cardiorespiratory conditions [45]. In the 1-year follow-up period, 90% of participants in the “ruled out” group were able to stop asthma medication safely. Similarly, a Canadian paediatric study found that just 18% of patients with parent-reported asthma had previously undergone objective measures of pulmonary function [46]. Furthermore, the authors concluded that 45% of patients with parent-reported asthma were overdiagnosed and 10% of symptomatic controls were underdiagnosed. These studies make evident the utility of objective measures to confirm asthma diagnoses and supports the notion that misdiagnosis is common in the absence of objective testing.

A recent longitudinal practice audit by Price et al. [47] characterised significant asthma care gaps in family health teams and assessed adherence to evidence-based asthma management practices. One of the care gaps identified included limited use of objective measures in diagnosis [47]. Notably, an absence of diagnosis using objective measures was determined to be a significant predictor of controller medication initiation/escalation. Another gap found in this study was poor documentation of diagnosis status within EMRs, impacting the ability to identify asthma patients for study inclusion using an EMR-specific search strategy [47]. The strategy relied on documentation of International Classification of Diseases (ICD) 9 diagnostic billing code (asthma/allergic bronchitis) and the text-string of “asthma” within chart notes, which could exclude suspected asthma cases. The authors concluded that significant asthma care gaps persist in primary care, which is amenable to KT interventions [47].

A large proportion of asthma patients (as many as 70%) do not receive an asthma diagnosis or undergo objective lung function testing [48, 49]. The recent groundbreaking Canadian Undiagnosed COPD and Asthma Population (UCAP) randomised-controlled trial by Aaron et al. [50] used a case-finding method to identify symptomatic individuals in the population without a previous diagnosis of an obstructive lung disease. Symptomatic participants were asked to complete spirometry and, if found to have asthma or COPD, were randomised to an intervention group (guideline-based care from a respirologist and certified respiratory educator) or a control group (regular care from their primary care provider). Of the 38353 individuals interviewed and the 5631 eligible for the trial, 595 had undiagnosed asthma or COPD. Overall, participants in the intervention group had lower healthcare utilisation for respiratory illness, but both groups had improvement in respiratory disease burden, pre-bronchodilator forced expiratory volume in 1 s and quality of life [50]. In a UCAP sub-study, one of the factors associated with the reasons why symptomatic patients remain undiagnosed is failure to undergo spirometry [51]. Overall, the UCAP study demonstrated the successful use of a case-finding method to identify undiagnosed asthma and COPD in the population and further highlighted the benefit of objective testing to confirm a diagnosis of obstructive lung disease [50, 51].

In summary, these publications highlight a care gap in the use of PFTs, potentially contributing to inefficient asthma diagnosis and care.

Under-recognition of suboptimal control

Internationally, suboptimal control continues to be under-recognised by both patients and providers. An early study by Chapman et al. [41] assessed asthma symptom control in Canada according to six symptom-based criteria described in the 1996 Canadian Asthma Consensus Guidelines at the time. In a survey of patients with doctor-diagnosed asthma, less than a quarter were considered to have well-controlled asthma, despite the majority of patients and providers perceiving their asthma to be well-controlled [41]. Notably, 51% of patients had required urgent care for uncontrolled asthma in the year they were interviewed [41]. Further studies found that physicians overestimate control of asthma patients’ symptoms, particularly without the use of spirometry results in the assessment of asthma control [42, 52]. For example, the 2008 Chapman et al. [42] study, involving the use of a one-page asthma control questionnaire administered by physicians, found that 59% of patients were uncontrolled. Additionally, 59% of uncontrolled patients required one or more urgent care or specialist visits in the past year. Overall, these initial studies demonstrate the overestimation of asthma control by both providers and patients.

The TRAC study expanded on previous works, aiming to evaluate the management of uncontrolled asthma by adult patients and physicians in Canada, given the updated guidelines and guideline-implementation efforts [14]. This study found that 53% of patients had uncontrolled asthma according to the objective symptom-based Canadian Asthma Consensus Guidelines. In contrast, 97% of patients thought that their asthma was well controlled and over 88% of both family physicians and specialists felt they were achieving control of their patients’ asthma [14]. Patients in the TRAC study with uncontrolled asthma reported a higher use of healthcare resources compared to controlled asthma patients. Internationally, the European LIAISON study, which assessed asthma control using the Asthma Control Questionnaire, found that 56.5% of patients had suboptimal control [53]. Poor control was associated with lower quality of life, higher exacerbation risk and greater use of healthcare resources [53]. Determinants of poor control included patient underestimation of symptoms and complexities in disease management. The results from these studies further depict the overestimation of asthma control.

Importantly, the overestimation of asthma control may be associated with limited knowledge of guidelines and hence the most current criteria for uncontrolled asthma. The TRAC study found that a low percentage of physicians stated they based their treatment on the Canadian asthma care guidelines [14]. A more recent mixed-methods needs assessment by Murray et al. [54] found that providers reported suboptimal knowledge of both the current CTS guidelines and the GINA report. Additional findings from the Chapman et al. [41] study described that physicians did not use the recommended asthma management guidelines or only referenced certain aspects of the guidelines. Hence, suboptimal control may be due to a variety of factors, including limited knowledge of guideline criteria. Overall, the literature supports the notion that suboptimal asthma control, despite the cause, remains a significant challenge.

Patient self-management education

Another substantial asthma care gap is an inadequate focus on patient self-management education. The CTS guidelines emphasise self-management education as an important aspect of asthma care [10]. A synthesised review of randomised controlled trials affirmed that asthma self-management education reduces health services utilisation (e.g. emergency department visits), absences from work/school, nocturnal symptoms and improves quality of life [55]. A core component of self-management is patients having a personalised written asthma action plan (AAP), advising on medication use, recognising and monitoring worsening asthma-symptom control (including step-up therapy), and when to seek further medical assistance [56]. Asthma education also includes teaching device technique, triggers, environmental controls, medication adherence and counselling regarding smoking cessation [55, 57].

Self-management education is ideally delivered at dedicated asthma education visits/clinics with a certified respiratory educator (CRE), where patients are taught self-monitoring including use of PEF meter and individual barriers to achieving control are assessed and addressed [55, 57]. In countries such as Canada, the United Kingdom, New Zealand and the United States, CREs are healthcare professionals (such as nurses and respiratory therapists) who have completed an accredited training program and certifying examination for respiratory educators [58]. CREs are trained to provide patient self-management education for asthma, such as appropriate inhaler technique, assessing and maintaining control, managing exacerbations, using an AAP, and advise on smoking cessation [58, 59]. CREs may also be trained on performing basic spirometry [58].

The promotion of self-management education in practice remains an area in need of improvement. The TRAC study found that only 11% of patients had a written action plan, with half of patients not using their action plans regularly [14]. A study by Murray et al. [54] reported that 47% of healthcare professionals believed providing a written action plan to patients is unnecessary. It is important to note that a current challenge is the lack of standardisation of symptom descriptors on written AAPs [60]. Furthermore, a patient's interactions with their provider concerning asthma education have been shown to shape their adherence practices and self-management behaviours, both positively and negatively [61]. Overall, asthma education programmes, including those provided at primary care sites, demonstrate notable improvements in patient asthma knowledge and medication adherence [55, 62]. The lack of asthma education services and education in clinic represents a persisting key gap in practice.

Barriers to asthma best practice in primary care

It is important to consider attitudes and beliefs as potential barriers impacting the quality of asthma care delivered in primary practice. Murray et al. [54] found that 45% of primary care physicians felt that spirometry was not necessary to diagnose asthma. One expert panel identified “reward for performance” (remuneration for practitioners based on performance rather than volume) as a determinant of primary care asthma management [63], supported by the findings of To et al. [64] that investigated the variation in quality of asthma care between Canadian primary care models. This study found that a blended fee-for-service and blended capitation models, both of which provide added incentives to physicians who offer further services to their patients, had increased use of objective PFTs for both diagnosis and monitoring, and overall improved asthma performance indicators [64]. Discordance within primary practice models could contribute to variations in the quality of care delivered.

Another significant challenge impacting guideline adherence is the availability of asthma care resources, such as high-quality PFTs [49, 54]. Studies have investigated the perceptions of primary care physicians regarding enablers and barriers to improving asthma care. Providers described a need for clinical tools (i.e., decision support tools) and improved access to PFT services [65, 66]. Barriers identified for the use of objective measures in asthma care include lack of knowledge of spirometry utility and difficulty with spirometry interpretation [66]. In summary, attitudes, beliefs and infrastructure challenges in primary care act as barriers to guidelines adherence and overall improvement in asthma control.

Current Canadian KT eTools within EMRs

A variety of Canadian KT eTools have been designed for asthma care quality improvement and disease surveillance, with many utilising direct integration into available EMRs in Canada. Various research groups have designed KT eTools using current CTS guidelines and validating/studying them in the Canadian context. However, many of the KT eTools are available widely and may be applicable to various international practice settings. Current eTools for use in primary care EMRs identified in our search and their strengths/limitations are summarised in table 1.

TABLE 1

Current Canadian asthma knowledge translation (KT) electronic tools (eTools)

KT eToolDescriptionStrengths/limitations for use in primary care EMRsHow this tool can target key asthma care gapsAMOMSAn eCDSS
Serves as a respiratory specific clinical data repository/EMR
Can be web-based, standalone or integrated into other EMRsImproves access to KT eTools and quality improvement initiatives
Aligned with CTS guidelines and PRESTINE data elements
EMR integrated within Kingston Health Sciences Centre
Target audience includes specialists, CREs and detailed primary care useImproves EMR documentation
Facilitates access to asthma self-management education tools for providers
Captures data elements such as diagnosis status confirmed by PFTs and patients’ asthma controlAsthmaLife®A patient/provider portal allowing access to various KT tools for both providers and patients
Facilitates performance evaluation for providersEMR integrated and aligned with PRESTINE data elements
Provides access to various KT eTools for both providers and patientsFacilitates access to asthma self-management education tools for both patients and providersbreatheA patient-centred mobile health system promoting asthma control monitoring and education tools
Health information access within a patient-based EMR system and primary care EMRsAvailable through multiple platforms (mobile, desktop, etc.)
Patient-oriented and designed with clinician working groupsFacilitates access to asthma self-management education tools for both patients and providers
Prompts patients to record asthma controleAMSAn eCDSS
Patient completes an online asthma questionnaire in the waiting room, which is integrated within the EMR in real time
Information is then processed to provide clinician decision support to physicians and self-management for patientsProvides a valuable clinical decision support to physicians in real-time and incorporates patient self-management/education components
Does not integrate standardised PRESTINE data elementsFacilitates access to asthma self-management education tools for both patients and providers
Prompts patients to record asthma control
Provides clinical decision support to physicians (i.e. prompting to ameliorate suboptimal control and to use PFTs to confirm diagnoses)e-Mini AQLQEvaluates patient quality of life for individuals with asthmaHas already been integrated within EMRs
A useful supplementary asthma management tool, evaluating patients’ quality of lifeNAPAAFA novel e-form that targets key asthma care gaps in primary care including confirmation of diagnosis through objective measures, documentation of diagnosis status, medication dosing and referral of suspected/severe asthma to specialist care
An asthma-specific charting tool for clinicians with embedded decision supportAligned with PRESTINE data elements and CTS guidelines
Adapted from the LHF Asthma Care Map
EMR integrated in the PSCAR EMR at Queen's Family Health Team
Concise tool designed for use in primary care with embedded decision support and severe asthma algorithm to recognise severe/uncontrolled asthmaPrompts providers to record diagnosis status, confirm diagnosis through objective testing and document asthma control
Provides clinical decision support to physicians (i.e. prompting to ameliorate suboptimal control and to use PFTs to confirm diagnoses)PSCAR-EDUA proposed severe asthma registry with embedded education elements, which will also allow for the evaluation of primary care asthma management practicesMay inform the development of future primary care asthma KT eTools
Does not integrate standardised PRESTINE data elementsNASevere asthma algorithmProvides clinician decision support for asthma management/monitoring
Identification severe/uncontrolled asthma patients who may benefit from specialist assessmentEmbedded within the PAAF
Designed specifically for primary care
Aligned with PRESTINE data elements and CTS guidelinesProvides clinical decision support to physicians (i.e. prompting to ameliorate suboptimal control and to use PFTs to confirm diagnoses)WRASQ(L)TMAssesses work-related asthma in primary care settings through the specific evaluation of work-related symptomsHas already been integrated within EMRs
A useful supplementary asthma management tool for the assessment and identification of work-related asthmaNA

The Electronic Asthma Management System (eAMS), an electronic clinical decision support system (eCDSS), was designed to address suboptimal asthma control is [34]. The tool involves the patient completing an online, validated, self-developed questionnaire in the waiting room (asking about symptom control, medication usage, triggers, allergies, etc.), which is integrated into the EMR in real time and processed by the eCDSS to provide clinician decision support regarding control status, suggested medication adjustments and auto-populating an AAP [34, 67]. Results from the initial study proved the tool to be efficacious [34]. It has been critiqued that, although this is a promising eCDSS, it lacks assessment of physician and patient satisfaction with the tool, did not integrate a measure of asthma severity, did not address compatibility with other EMR operating systems and had limited uptake after the initial study period [68, 69].

Another KT tool is the mobile health system (mHealth) entitled breathe, a patient-centred tool promoting collaborative self-management (involving patients, physicians and monitoring through the application), allowing for asthma control monitoring, education tools, reminders and more [70–72]. The tool was integrated into participant's primary care EMR and was found to be of high usability (71.1% on the System Usability Scale), although usage by patients rapidly decreased over the study duration [70, 73]. Additionally, use of the tool was not associated with increased completion of PFTs or reduction in health services utilisation (i.e., emergency room visits, hospitalisation, etc.) [74].

Additional KT eTools have been developed in the form of questionnaires. One such tool optimised for EMR use is the electronic Mini Asthma Quality of Life Questionnaire (e-MiniAQLQ), an electronic format of the validated paper tool that evaluates the quality of life for individuals with asthma [35, 75]. This tool was validated and found to be preferred in 57.5% of participants, despite taking a longer time to complete than the paper version [35]. A paediatric version has also been validated and found to be a useful tool [76]. Another tool is the electronic work-related asthma screening questionnaire (long-version) (WRASQ(L)TM), which aims to improve work-related asthma management in primary care [77]. The questionnaire has been deemed by stakeholders and clinicians to be a highly valuable and beneficial tool for the assessment of work-related asthma in a primary care setting [77, 78].

Another area of focus has been the development of decision-support algorithms for use in EMR-based KT eTools. Following the CTS position paper on severe asthma and as part of PRESTINE, decision-support algorithms have been an area of interest to prompt and enable adherence with severe asthma guidelines and utilise Canadian standardised data elements for EMRs [20, 31]. Lougheed et al. [79] developed a four-step severe asthma algorithm for use in primary care EMRs, allowing for the detection of severe asthma, with embedded decision support for physicians that aligns with the CTS severe asthma position paper. This algorithm has potential applications in a KT tool optimised for primary care EMRs.

Recently developed KT eTools include the Provider Asthma Assessment Form (PAAF) and the Primary Care Asthma Registry and Education Project (PSCAR-EDU). The PAAF is a novel electronic KT tool optimised for use in primary care EMRs, with embedded decision support from the severe asthma algorithm [80]. The tool targets key asthma care gaps in primary care, including confirmation of diagnosis through objective measures, documentation of diagnosis status, medication dosing and referral of suspected/confirmed severe asthma to specialist care. Furthermore, the PSCAR-EDU is a proposed primary care severe asthma registry with embedded education elements, and the incorporation of a clinician behaviour index to evaluate current primary care management practices for severe asthma [81]. Both tools require further studies to elucidate their utility in primary care practice settings.

Moreover, various initiatives support the use of KT eTools within EMRs. Airway management systems have been developed which improve access to KT eTools and facilitate quality improvement initiatives. The Airways Management and Outcomes Monitoring System (AMOMS) and Windsor's Asthma Research Group's (ARGI) Best Care Asthma, aligned with CTS guidelines, have been integrated at various primary care asthma programme sites in Ontario, Canada [73, 82]. For example, AMOMS is linked to a patient/provider portal called AsthmaLife®, permitting access to asthma management KT eTools and allowing for the collection of extractable asthma data elements [82]. Thus, AMOMS aids in collecting information regarding key asthma care gaps, such as the use of objective measures for diagnosis. Overall, these point-of-care tools have the potential to promote best-practice asthma management and facilitate access to useful asthma KT eTools such as the eAQLQs and the WRASQ(L)TM [73]. Lastly, EMR case definitions for confirmed or suspected asthma in EMRs, has recently been validated [33]. This will allow for sentinel surveillance and quality improvement in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) [32, 83].

Importantly, there is convincing evidence that the use of these KT eTools aid in improving asthma management in primary care. In a study comparing usual care versus eAMS, the eTool improved asthma quality of care including increased AAP delivery, asthma control assessment and appropriate pharmacologic therapy [34]. In a study on the breathe mobile app, there were greater nonsignificant decreases in emergency department visits and physician office visits when the eTool was used compared to usual care [74]. Further studies such as randomised control trials evaluating patient outcomes would add to the literature supporting the advantages of using EMR-based eTools in clinic compared to usual care. However, the existing evidence speaks to the benefits of implementing validated eTools including enabling detailed documentation, early detection and outcomes monitoring. For example, in its intervention trial, the WRASQ(L)TM was found to identify 60% more exposures and 38% additional work-related symptoms in participants compared to the existing primary care asthma care map [78]. Furthermore, airway management systems (such as AMOMS) and PRESTINE standardised data have been found to enable detailed asthma management and outcomes monitoring, including asthma-visit specific outcomes (i.e., control assessment, self-management education, etc.) [82, 84]. Overall, the existing KT eTools enable evidence-based best practice and support asthma management in the primary care setting.

Discussion

The KTA cycle can be used as a conceptual framework to identify key asthma care gaps, understand specific barriers within primary care practice, evaluate current KT eTools and recognise how future KT eTools can be optimised for use in primary care EMRs. Several asthma care gaps persist in healthcare delivery, associated with suboptimal asthma control and the potential for asthma misdiagnosis in primary care [14, 45]. Specific barriers in primary care include underuse of objective pulmonary tests for diagnosis and monitoring [45, 47], suboptimal identification of uncontrolled and severe asthma, including poor documentation within EMRs [14, 47], and limited access to resources, such as spirometry and asthma education [65, 66]. Many of these identified care gaps are amenable to KT interventions, such as point-of-care tools to be integrated within primary care practices, designed to improve provider knowledge of best-practice guidelines.

A significant effort has been made in Canada to develop KT eTools to improve asthma management in both specialist and primary care practices. Various electronic tools integrated within EMRs have been investigated for feasibility, and many have been validated to date such as the eAQLQs, WRASQ(L)TM and the eAMS [34, 35, 76, 77]. Various projects facilitate using these tools such as data standards and case definition initiatives, decision-support algorithms and speciality care management systems, such as AMOMS [31, 32, 79, 82]. However, there is still a need to increase the uptake of these tools to ensure they are of perceived utility to the end-user (i.e., primary care providers) and assess their impact on practice patterns and patient outcomes [85].

Connecting key asthma care gaps and Canadian asthma KT eTools

Many of the current Canadian asthma KT eTools begin to address the key asthma care gaps within primary care practice, namely lack of objective pulmonary function testing, limited documentation within EMRs, suboptimal control and limited access to resources supporting asthma self-management education.

Several of the asthma KT eTools that were found address the underuse of pulmonary function tests to confirm an asthma diagnosis and suboptimal asthma control. For example, both the PAAF (embedded with the severe asthma algorithm) and the eAMS include clinical decision support prompting providers to confirm diagnosis through objective measures and/or to address reasons for poor control (i.e., medication dosing, adherence issues, exposure to triggers, etc.) [34, 80]. These decision-support functions aid providers through the identification of patients in need of these assessments and simplifying their workflow. Additionally, eAMS and the breathe app simplify asthma control assessment by allowing the patient to complete an asthma control questionnaire (based on CTS guidelines and control criteria) which can be accessed seamlessly within the primary care EMR by the provider [34, 72]. Overall, these EMR-integrated KT eTools facilitate adherence to best-practice guidelines by identifying patients who may benefit from objective diagnosis and aiding providers to best manage patients with suboptimal control.

Furthermore, many of these KT eTools provide access to various patient self-management education tools, for both patients and providers. Self-management education resources such as AAPs improve health outcomes for adults with asthma, however there is a significant gap in the provision of AAPs in primary care [55, 86]. eTools such as eAMS, AMOMS, AsthmaLife® and breathe provide seamless access within the EMR to tools such as the generation of Asthma Action Plans and supplementary asthma management eTools such as the WRASQ(L)TM and the e-Mini AQLQ [34, 72, 73, 82]. Hence, the process for creating and distributing AAPs to the patient is simplified. Additionally, eTools such as AsthmaLife® and the breathe app allow patients to access useful tools and their AAP on their own electronic devices.

In summary, many of the identified asthma KT eTools begin to address the key asthma care gaps. All of the eTools support increased documentation within EMRs by providing asthma-specific charting tools/resources. They support the KT of clinical guidelines into practice by focusing on implementation tools, rather than simply dissemination.

Current limitations and future directions for asthma KT eTools

Although the existing landscape of KT eTools aiming to align current practice with best-practice guidelines is promising, limitations exist. Importantly, there has been limited inclusion of end-users in developing and maintaining these tools. Including primary care providers in the research and development phase will help ensure future KT eTools target their perceived specific needs. This should be a priority to improve asthma management within their practice. An encouraging start to this work was described recently by Moloney et al. [85, 87] from the proceedings of a focus group of primary care experts aiming to identify the best method to integrate KT eTools into primary care EMRs across Canada. Several themes emerged, including prioritising end-users, increasing the adaptability and efficiency of systems, ensuring current practice workflows are considered and more [85]. One of the asthma indicators deemed to be of high i