Development of a patient-centred electronic review template to support self-management in primary care: a mixed-methods study

Qualitative exploration

The preliminary qualitative exploration with 33 general practice staff (23 GPs, seven nurses, three administrative staff) found that annual asthma reviews and supporting self-management was largely a nurse-led task, and reviews were mostly structured around electronic templates.¹⁷ In addition to describing templates as an aide memoire, clinicians considered that templates had the potential to promote and facilitate supported self-management, including provision of asthma action plans. Poor integration with IT systems, alert fatigue, duplication of effort, and too many tick boxes were identified as barriers.

Interviews with patients living with asthma (n = 10 [seven male, three female]) across four UK general practices) found that most were aware that their clinician used the computer, or some form of template on the computer, during their review. However, this did not restrict the review process, as most felt able to discuss any issues they had about their asthma, and they felt involved in the decisions that were made regarding their asthma.

Systematic review

The IMP²ART systematic review concluded that templates can improve documentation of key measures, and act as a reminder tool during consultations; however, concerns were raised that templates may act as a barrier to providing patient-centred care⁵ by restricting the review process and prioritising the healthcare professional's agenda over the patient’s.⁵ In line with the findings by Morrow et al,¹⁷ the review recommended that templates should incorporate free-text options for documentation (as well as coded items), and should include education and self-management items to prompt healthcare professionals to encourage and support patient self-management practices. A specific suggestion to improve patient-centredness was that templates should begin with an opening question to establish the patient’s agenda, and also a closing question to confirm concerns have been addressed.

Prototype IMP²ART asthma review template development

The PCRS Professional Advisory Group welcomed the patient-centred and shared-decision making approach to the template, and specifically highlighted that the generic opening question about the patient’s agenda (‘What is the patient’s agenda?’) should focus on asthma reviews ('Thank you for coming to an asthma review, is there anything in particular you would like to talk about?'). Utilising the evidence base, following professional advice, and including the necessary Quality and Outcomes Framework (QOF)¹⁹ components, a prototype IMP²ART asthma review template was produced by OPC.

Helpful components

Clinicians found a range of the IMP²ART template features helpful. These included the following: electronic health record auto-populated information; links to information for patients; the dedicated section for assessment of uncontrolled asthma; user-friendliness; patient-centred questions; and the closing summary of management recommendations. For less experienced staff, a prompt to ensure the review was complete was found to be helpful.

Content, design, and timing

Clinicians thought the IMP²ART template covered the pertinent aspects of a review. Both GPs thought the template was long, with one commenting on several items she was unlikely to use. The nurses and pharmacist, however, thought the amount of content was as expected, with some implication that more content was better than less:

'There’s a lot to work with … you’ve covered most bases that I would see anyway.' (Nurse 2, female)

Clinicians welcomed the addition of template-embedded patient information links, although it was noted they should be used within the context of a range of different resources for different patients. All interviewees considered that the template appeared to be simple to navigate. Despite this, the volume of questions initially seemed daunting (this was because the prototype template was printed in a single screen without visualisation of discrete tabs). Once clinicians explored the content further, they concluded the template fitted with their current review sequence; it would be user-friendly as there was less complex navigation, and fields were optional. Clinicians had mixed opinions on whether the template was achievable in time-limited reviews. Several thought it was appropriate for a 20-minute consultation but others expressed some concerns about the time required for completion. Clinicians observed that timing is often patient or practice-dependent:

'So although I initially said "oh, it’s quite long," you’re not going to be asking your well-controlled asthmatics all of these questions.' (GP 2, female)

Patient-centredness

The IMP²ART template was viewed as patient-centred. Clinicians regarded the opening agenda question, 'Thank you for coming to an asthma review, is there anything in particular you would like to talk about?', positively. Several expressed that it facilitated holistic care by concentrating on what the patient wants to address, helping divert focus from the clinician, and engaging the patient by making them feel as if they were gaining something from the review. Clinicians thought this cue-based approach had the potential to make patients more open to education:

'What’s the thing YOU want to talk about ... that’s absolutely what we’re interested in in our practice is trying to have a holistic review … focusing on the patient’s agenda first … it’s hard to engage them in this so I think that’s a useful opening line.' (GP 2, female)

Implementing into practice

All clinicians said they would be comfortable with implementing the IMP²ART template in their practice. Reasons for comfort with the template included similarity to their current template and compliance with the QOF, which determined performance-related payments:¹⁹

'I don’t think it’s dissimilar to what we already use so I don’t see the issue there.' (GP 1, female)

Recommendations

Three clinicians highlighted that the opening agenda question needed to be open enough to allow the patient to express their concerns, but should avoid shifting the focus of the consultation from asthma:

'You want it to be open but you’re wanting to be focused on their asthma rather than whether they got parked or not.' (GP 1, female)

Four clinicians recommended changes to template content including the addition of missing content and removal of superfluous items. Suggested additional content included inhaled corticosteroid adherence and/or dose, spacer use, and replacement. More detail on asthma triggers was regarded as important to note, owing to their possible impact on quality of life.

The proposed removals were as follows: age of asthma onset; eosinophil count; spirometry; smoking questions (shorten to fewer questions); and use of the asthma control test (ACT)²⁰ as opposed to the Royal College of Physicians three questions (RCP3Q)²¹ or Global Initiative For Asthma (GINA) assessment of asthma control.²² Recommendations for IT use included the following: software-compatible templates; the ability to print off the link to the patient-facing website (or a code that could be scanned); and attachment of completed action plans to the electronic health record for re-evaluation at subsequent reviews.

Perceptions of the template

Clinicians were positive about the IMP²ART template available on their systems, and considered that it covered what was expected:

'… it is actually quite comprehensive.' (Nurse 1, female)

Participants welcomed the patient-centred focus of the template, in particular the opening question:

'… I think it’s good … because obviously we’re trying to create that holistic care.' (GP 2, male)

Template implementation

Participants indicated that they had implemented, or planned to implement, the IMP²ART template into their care delivery:

'We have spoken to everyone and started to use the template now because it has a lot more information there than what was given in our original template …' (GP 2, male)

Suggested changes to the template

Participants made a number of detailed suggestions about items they would like to be included, revised, or omitted (see Supplementary Table S1), and one participant asked if the personalised asthma action plan could be saved to the record for future reference.