PEDIATRIC ASTHMA PROVIDERS AND ALERTS

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Effect of Electronic Medical Record Alerts on Pediatric Asthma Providers

Devon E. Vance
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Devon E. Vance is a graduate student in the primary care pediatric nurse practitioner
program at the Edson College of Nursing and Health Innovation at Arizona State University.
She has no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Devon E. Vance, Edson
College of Nursing and Health Innovation, Arizona State University, 550 N. 3rd Street, Phoenix,
AZ 85004 email: devance2@asu.edu

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Abstract
There is a gap in primary care providers' prescribing practices for spacers and masks among
pediatric asthma patients. High-quality evidence gathered from a comprehensive literature
review revealed several potential interventions to improve pediatric asthma control. Research
findings suggest electronic medical record (EMR) alerts are cost-effective, easy to use and
evaluate, and influence clinical decision-making and prescribing practice. The purpose of this
paper is to investigate the effect of EMR alerts on pediatric primary care providers’ (PPCPs)
prescribing practices of spacers. Concepts from the Technology Acceptance Model and the PlanDo-Check-Act cycle were applied to guide the implementation framework for this project. A
well-designed EMR alert and PPCP education on its use and purpose were implemented in a
pediatric primary care office in the Southwestern United States. This project received expedited
approval from the institutional review board at Arizona State University and approval from the
project site to protect participants’ human rights. Pre/Post-EMR Alert Survey and Retrospective
Chart Audit Forms were instruments utilized to analyze eight weeks of data upon EMR alert
implementation. Data analysis includes descriptive statistics and retrospective data analysis. This
project found a 60% increase in spacer prescription rate following the intervention. The findings
from this project indicate that EMR alerts are helpful reminders, easy to implement and use,
cost-effective, and influential in prescribing practices and clinical decision making.
Keywords: asthma, pediatrics, spacers, prescribing practices, EMR alerts

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Effect of Electronic Medical Record Alerts on Pediatric Asthma Providers
Asthma is one of the most common chronic diseases in pediatrics. Asthma exacerbations
present an increase in children seen by their primary care doctor, urgent care, or emergency room
facilities. Many researchers would argue that a significant issue with managing pediatric
asthmatics is the incorrect use of inhaled medications. Lack of knowledge and understanding of
asthma can also affect how well it is managed. Pediatric primary care providers play a large role
in ensuring that their patients and parents can confidently care for their children with asthma.
Problem Statement
A pediatric primary care office located in the Southwestern United States has
acknowledged a gap within the practice of providers inadequately prescribing spacers and masks
to their asthmatic patients. Spacers are an important piece of equipment that assists in
introducing inhaled medication into the child’s lungs more effectively. Face masks are necessary
for young children, usually aged three and under, who cannot hold a mouthpiece between their
teeth and lips to aid in medication delivery (Csonka et al., 2021).
The population affected by this problem includes pediatric patients and families
diagnosed with asthma. The most recent national data from the Centers for Disease Control and
Prevention [CDC] (2023) includes 6.5% of children under 18 years old with an asthma diagnosis.
At Arizona’s state level, according to the Arizona Department of Health Services (2021), for
children with asthma from infants to four years old, the average number of hospitalizations
monthly was 19.87. Within the same year, the average number of hospitalizations per month for
children five to nine years old was 20.87. Finally, for children 10-14 years old, the state average
monthly hospitalizations of pediatric patients with asthma were 8.2, and for children 15-19 years
old, the monthly state average was 4.2. Pediatric patients and families diagnosed with asthma are

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
affected by the inadequate prescription of spacers and masks.
According to the Global Initiative for Asthma (GINA), about 70-80% of asthmatic
patients do not use their inhalers correctly (GINA, 2023). This can lead to an increased risk of
asthma exacerbations and adverse effects. Spacers have been around for over sixty-five years,
but patients continue to use them incorrectly. Primary care providers have a role to play in
assisting with this change.
Background and Significance
Based on a review of recent literature, multiple interventions are necessary to improve
pediatric asthma care and providers’ prescribing practices of spacers and masks. Following
pediatric asthma guidelines, utilizing electronic medical record alerts, and education on proper
inhaler techniques can improve providers’ adherence to prescribing masks and space chambers.
Ultimately, significant improvement in provider spacer prescription, patient spacer use, and
overall asthma control should be seen.
Asthma in Pediatrics
Asthma is one of the most common chronic diseases in pediatrics, which is not new but
continues to rise as a global health concern. The World Health Organization [WHO] defines
asthma as a significant noncommunicable disease in which the narrowing and inflammation of
the small airways in the lungs cause symptoms such as cough, wheezing, chest tightness, and
shortness of breath (WHO, 2023). Healthy People 2030 stated that their goal to improve
respiratory health is to reduce emergency department visits for children with asthma younger
than five years old (Office of Disease Prevention and Health Promotion, n.d.). It is important to
keep in mind that there are many variables to consider when dealing with children with asthma.
Severity and control of disease, patient and parent knowledge and understanding, adherence to

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medication regimen, and incorrect use of spacers and masks are all issues associated with
managing pediatric asthma (Morton et al., 2020; Root & Small, 2019; Volerman et al., 2021).
Electronic Medical Record Alerts
Incorporating electronic medical record alerts for pediatric providers when prescribing
pressurized metered dose inhalers is one potential intervention to increase provider adherence to
prescribing spacers and masks. Leibel and Weber (2019) implemented a quality improvement
project to evaluate the effectiveness of an electronic medical record-based best practice advisory
focused on asthma control that improved their response to poorly controlled asthma. In addition
to educating pediatric providers about the importance of ordering spacers and masks, provider
engagement in education is another priority intervention (Neininger et al., 2022; Root & Small,
2019). Educating providers about spacer use and why they are essential will increase the
effectiveness of medication delivery. Video-based education is another intervention that has been
considered an effective way to deliver asthma education (Frydenberg et al., 2022). Integration of
electronic medical record alerts with provider engagement in education appears to be the most
promising of the interventions examined to date.
Spacer and Mask Use
Currently, the GINA (2023) guidelines and the National Heart, Lung, and Blood Institute
[NHLBI] (2020) recommend spacers to be ordered, taught, and utilized correctly for the effective
use of inhaler devices in pediatric patients. Leibel and Weber (2019) found that 28-68% of
patients do not use inhalers efficiently to benefit from the medication that is prescribed. Inhaler
skills need continued practice with reinforcement; therefore, teaching and reinforcing inhaler
skills and adherence are recommended at every visit (GINA, 2023; Leibel & Weber, 2019;
NHLBI, 2020; Root & Small, 2019). Ensuring proper inhaler technique, although it can be

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viewed as time-consuming, can also be considered as just as important as the prescribed inhaler.
Chaicoming et al. (2020) found that homemade valved holding chambers are effective for
metered-dose inhaler use, which are also cheap, easy to make, and disposable if commercial
spacers are unavailable. To improve child asthma control, healthcare providers should prioritize
appropriate inhalers and spacer use with patient and family education to alleviate the health
disparity.
Provider Prescribing Practice
As a result of appropriate intervention, it is anticipated that pediatric primary care
providers will prescribe spacer and mask devices more frequently to their pediatric asthmatic
patients in the future. Additional benefits that should be seen with an increase in providers’
prescribing practices for spacer and mask devices are an improvement in asthma control and a
decrease in asthma exacerbations, hospitalizations, and emergency room visits. The goal is for
every pediatric asthma patient with a metered-dose inhaler prescription to have a spacer
prescription with the proper knowledge and demonstration of how to use it (Neininger et al.,
2022; Root & Small, 2019). The shift of provider buy-in for pediatric spacer prescription
utilization and education on proper techniques would increase the effective use of inhaler devices
in pediatric patients.
Common Themes
A review of the literature revealed common findings that pediatric asthma continues to be
a global health concern, although improper use of inhaler medications and teaching of inhaler
skills are an unfortunate commonality. At the state level, the number of pediatric hospitalizations
related to asthma is not improving. In current practice, there is little formal education from
pediatric primary care providers, and this occurs simultaneously with spacer prescriptions.

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Providing education from the pediatric provider to families and patients is necessary to improve
medication delivery with the proper use of inhaler medications with a spacer.
Internal Data
A pediatric primary care office located in the Southwestern United States provides
preventative services, including immunizations, annual wellness exams, sports physicals, chronic
disease maintenance, allergies, acute and sick visits, behavioral health concerns, and newborn
screenings and support. The identified gap found in this practice is that primary care providers
inadequately prescribe spacers and masks to patients diagnosed with asthma. A stakeholder
within the organization discovered this problem. If this problem goes unaddressed, pediatric
primary care providers will continue to see improper use of inhaled medications and
uncontrolled asthma, as evidenced by an increase in asthma exacerbations, missed school days,
and hospitalizations.
Purpose and Rationale
Improper use of inhaled medications and inadequate prescriptions of spacers and masks
for pediatric patients with asthma can lead to poorly controlled asthma, an increase in asthma
exacerbations, and an increase in hospitalizations. This project aims to discover the effect of
electronic medical record alerts on pediatric primary care providers’ prescribing practices of
spacer and mask devices for pediatric asthma patients. By improving providers’ prescribing
practices of spacer and mask devices, we may see an increase in asthma control, a demonstration
of proper use of inhaled medications, a decrease in asthma exacerbations, and a decrease in
hospitalizations.
PICO Question
A review of the literature led to the clinically relevant PICO question: In clinical practice

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settings (P), how do electronic medical record alerts (I), compared to standard practice (C), affect
clinical decision-making and prescribing practices (O)?
Search Strategy
A detailed appraisal of the most current evidence took place to answer the PICOT
question. Three databases were extensively searched, including the following: PubMed,
Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsychINFO. These
databases were preferred for their significance of medical relevance, research base, and peer
review process on the topics of clinical practice settings, electronic medical record alerts, and
provider prescribing practices that yielded relevant and applicable articles. The search process
has been described below.
Keyword Selection
The databases were searched using combinations of the key terms that addressed all
aspects of the PICOT question. The keywords were thoroughly considered to address the PICOT
question because key terms such as pediatrics, children, or spacers were not included, as this
narrowed the search too significantly, yielding little to no relevant research studies. There is a
scarcity of research that looks at the role of electronic medical record alerts in pediatric asthma
control. Instead, keywords that were utilized were the following: electronic medical record
alerts, best practice alerts, prescribing practices, asthma, and clinical decision-making. Mesh
terms included reminder systems, best practice alerts, and primary care providers, which helped
widen the search.
Initial and Final Search Yields
An initial search of electronic medical alerts or best practice alerts and clinical decisionmaking yielded a total of 293 results in PubMed, 397 in CINAHL, and 192 in PsychINFO.

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Utilizing that same search field but adding doctors, physicians, or health professionals brought
the results down to 157 results in PubMed, 58 in CINAHL, and 29 in PsychINFO. After
reviewing the titles and abstracts of the articles found in these database searches, 75 relevant
studies were found. Following rapid critical appraisal and exclusion of articles over five years
old, 10 studies were selected for in-depth evaluation. These 10 studies included two randomized
control trials, two cross-sectional analyses, two quality improvement projects, one retrospective
cohort study, one quasi-experimental, one prospective experimental, and one qualitative study.
Limitations, Inclusion, and Exclusion Criteria
Omitting the ideal patient population of pediatric asthma patients and spacers was key to
success in finding ample research on how electronic medical alerts affect provider prescribing
practices. The inclusion criteria consisted of studies published in English from 2019 to the
present. Articles greater than five years old were excluded. The criteria for inclusion consisted of
adults, children, primary care, and hospital settings. Studies from multiple countries were
included unless they were not published in English. Many of the studies examined were
conducted in American regions. Studies that were not primary research and opinionated studies
were omitted without evidential support. Inclusion and exclusion criteria were the same for all
databases. The limitations prescribed were English-published articles within the last five years.
Critical Appraisal and Evidence Synthesis
Melnyk and Fineout-Overholt’s (2019) rapid critical appraisal was used to evaluate the
quality and strength of the 10 articles in this literature review. The evaluation process included
analyzing the demographics, settings, study design, major variables, findings, bias, and
implications. The final studies that were proven to have strength and the highest quality are
included in the tables below (see Appendix A, Tables A1-A2). All the studies used had an

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adequate sample size, or the size was not applicable for time series analysis or systematic review.
Much of this literature review stays within the U.S., with only two studies from other countries,
including Germany and Australia (see Appendix A, Table A3).
The sample characteristics were relatively homogeneous, as most participants were males
younger than 20 years old, except for one outlier of males with a mean age of 72 years old
(Ghazi et al., 2022). In addition to being outside the pediatric age range and setting, this study
examined electronic alerts and their effect on heart failure patients in the outpatient setting, a
problem not typical for pediatric patients. Despite being an outlier, Ghazi et al. (2022) is an
important study to include for their statistically significant results and strong provider feedback,
which the majority found EHR alerts helpful. Otherwise, all studies included took place in a
pediatric hospital setting, either inpatient, outpatient, or emergency department.
Among these 10 studies, the major variable was the best practice alert; others used
electronic health/medical record alerts, which can be used synonymously. The only outlier within
these studies is McCoy et al. (2022) data analysis of their quality improvement aimed to improve
quality and safety and reduce burnout through systematic alerts. Therefore, all 10 studies
analyzed the use of systematic alerts in their unique way. Because of this, common findings or
themes were easy to identify among the 10 studies. Common themes identified were reduction in
alerts, alarm fatigue, medication adherence, and cost for implementation (Table A3).
Finally, four of the 10 articles reported their funding source, with only one study
recognizing bias for including a non-best practice alert (BPA) arm of the study that coordinated
with improved medication therapy. Three of the 10 articles reported using financial incentives,
benefits, or gamification for study participants, which could also be considered biased. Given the
topic of best practice alerts, some incentivization might be necessary to get true provider

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feedback in some cases. Reliability and validity were found to be strengths for all the selected
studies due to the tools and methodology used, and statistically significant findings (Appendix A,
Tables A1-A3).
Influence of Evidence
Electronic medical record alerts are easy to use and evaluate, cost-effective, and
influential on clinical decision-making and prescribing practices. It is important to factor in
alarm fatigue as an obvious element to influence potential future studies, prescribing practices,
and clinical decision-making. While this literature review emphasizes the prescribing practice of
spacers for pediatric asthma patients, it is apparent that best practice alerts can be employed
across all age ranges and specialties in various electronic health systems. To form a well-planned
alert, with the evidence to support the need and a specific goal in mind, electronic record alerts
can influence clinical practice change and support providers in their practice.
Theory Application
The Technology Acceptance Model (TAM) was chosen as the conceptual framework to
guide the practice change for this project (see Appendix B, Figure B1). TAM is an information
systems theory that represents how to accept and use technology (Davis, 1985). This researcher
suggests that several factors influence individuals when presented with new technology. As
depicted in Appendix B (Figure B1), perceived usefulness and perceived ease of use can
determine the attitude toward using the new technology and, ultimately, the act or behavior
toward using the new technology (Davis, 1985). This theory applies to the use of electronic
medical record alerts and their relationship with clinical decision-making and prescribing
practices. For example, a provider can be influenced by the perception of using the EMR alert if
providers believed the alert would make their job easier in clinical decision-making and

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prescribing practice. Similarly, providers will be less likely to respond to an EMR alert if it is not
easy to use, the alert is too complicated, or it slows down their workflow. In conclusion, TAM
has been found to have high reliability and predictive validity in providing practical evidence of
the relationship between ease of use and system use when presented with new technology.
Implementation Framework
The Quality Improvement Model that was selected to guide the implementation
framework of this project was the Plan-Do-Check-Act (PDCA) cycle (see Appendix B, Figure
B2). The framework for the PDCA cycle was first introduced by Dr. William Edward Deming
(1950) and is used to carry out ongoing processes focused on assessing, planning, acting,
monitoring, evaluating, reassessing, and acting again (Anderson, 2018). This framework is often
called the rapid improvement cycle, which was ideal for this project given the purpose of
effecting change quickly (Anderson, 2018). The PDCA cycle has four steps that were easily
implemented in this project. The first step, titled Plan, involves identifying what could be
improved, deciding the root cause of the problem, and collecting data to help in the evaluation
process (Anderson, 2018). Step one was completed and found in the sections leading up to the
PICO question in this review of literature, including the problem statement, purpose and
rationale, background and significance, and internal data. The problem of inadequate prescription
of spacers and masks to asthmatic patients was identified within a pediatric primary care office
located in the Southwestern United States, and a soft collection of data can be found above. After
a firm collection of data within this practice was performed, step two can be attempted.
Step two of the PDCA cycle, titled Do, tests the proposed change through data simulation
by mapping out and implementing a trial run (Anderson, 2018). This step was implemented after
meeting with stakeholders to set up the EMR alert and trial on different test patients before

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deciding to implement the final EMR alert in the next step. Step three of the PDCA cycle, titled
Check, assessed the implemented change and modified the change process (Anderson, 2018).
This step of the PDCA cycle was reliant on a set date range of eight weeks’ worth of data from
September 17th, 2024, to November 12th, 2024. This data set was compared to eight weeks of
data exactly a year before the implementation of the EMR alert, which ranged from September
19th, 2023, to November 14th, 2023. These eight weeks of data analyzed the PPCPs’ prescribing
practices of spacers in this pediatric primary care office. The fourth and final step of the PDCA
cycle, titled Act, is where the tested change is implemented to improve the process (Anderson,
2018). After gathering findings from step three, it was ultimately up to the PPCPs of this
pediatric primary care office to decide if they liked the EMR alert and found it helpful to
maintain it or adjust it to better suit their practice.
Setting and Stakeholders
As previously stated, the organization in which this project took place was a pediatric
primary care office located in the Southwestern United States. This organization had two
separate locations in which this project was implemented. This primary care practice provides
several outpatient and preventative services, including annual wellness exams, immunizations,
breastfeeding support, newborn screenings, sports physicals, nutritional education, allergy testing
and immunotherapies, chronic disease maintenance, behavioral health concerns, community and
social supports, as well as acute and sick concerns. This pediatric primary care organization
strives to be understanding and available to their families, which providers are privileged to
serve with high-quality care and services.
Stakeholders play a valuable role in project outcomes. A few key stakeholders apart of
this organization include the project site champion, the director of operations, PPCPs, the chief

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executive officer, the practice manager, and the medical assistants. The project site champion
was a provider within this organization who helped identify the gap in practice and was a support
person in the practice change. The director of operations played a key role in the logistics of the
EMR and was instrumental in the process of the EMR alert. The PPCPs within this organization
are considered stakeholders as this project will impact them, as they were the participants and
vectors of change. The chief executive officer provided oversight of this project and suggestions
or feedback where needed. The practice manager has been an integral part of this project from an
organizational standpoint, and this role aided in the recruitment process. Finally, another
important group of stakeholders was the medical assistants who were involved in identifying
established pediatric asthma patients who were missing spacers from their medicine
reconciliations.
Participant Recruitment
The participants of this study were PPCPs of this organization who were willing to
participate. The one provider that was excluded from participation was the project site champion,
as it would have been a conflict of interest. Otherwise, inclusion criteria included PPCPs who
prescribe albuterol to children aged two to 18 years old, as that was the parameter set for the
EMR alert. Providers could have addressed ethical concerns before participating when presented
with the consent form and the first pre-EMR alert survey. The providers were recruited through a
lunch-and-learn presentation at each of the practice sites. Lunch was provided while PPCPs
listened to a brief presentation regarding national asthma guidelines, the importance of spacer
use, proper inhaler technique, simply how to order spacers through eClinicalWorks, and an
introduction to the implementation of the EMR alert. The practice manager was the recruiter for
this lunch by placing a block in the PPCP schedule on each day the lunches took place. No email

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or flyer was necessary for recruitment, as this organization is smaller and those would simply be
overlooked or missed.
Ethical Considerations
Three ethical principles guided this project: respect for persons, beneficence, and justice.
Respect for persons is defined as individuals who must be treated with autonomy or the ability to
make responsible decisions based on their values, beliefs, and preferences (NIEHS, 2023). The
project adhered to this principle by ensuring participants understand their right to participate
voluntarily, their ability to withdraw without fear of penalty, and decline participation if they
choose (Cheraghi et al., 2023). For this project, participants made an informed decision, clearly
declaring all risks, benefits, and likelihood of success in prescribing spacers for their pediatric
patients. Participants were given written consent to allow for an informed decision of
participation at the formal lunch and learn presentation. The project also adhered to beneficence,
which intends to do good and avoid harm to the practitioners involved (Cheraghi et al., 2023).
The project adhered to this principle by analyzing potential risks and benefits for research
participants (NIEHS, 2023). Possible risks participants could face include time constraints, alarm
fatigue, or any unforeseen side effects. Possible benefits include increased understanding of the
importance of spacers, improvement in the process of ordering spacers, and increased
satisfaction with ordering spacers through EMR.
Justice was the final principle utilized and is defined as following the right to fair
treatment and the right to privacy (Cheraghi et al., 2023). The project adhered to this principle by
fair distribution of resources, rights, and potential conflicts. For example, all providers
participated in one formal presentation before the EMR alert was established. There was no
coercion or rewards for participation. This project received expedited approval from the

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institutional review board at Arizona State University and approval from the project site in
August 2024, which reviewed the project methodology and ensured that the ethical principles
would be followed and that participants’ human rights would be protected.
Project Description
This project aims to understand the prescribing practices of spacers for PPCPs following
an educational session complemented by an EMR alert. The evaluation question to consider is as
follows: after the implementation of an EMR alert at a pediatric primary care office, is there a
measurable difference in prescribing spacers, and how do providers feel about the EMR alert?
The prescribing practice of PPCPs for spacers will be the measurement of change to evaluate
before and after the implementation of the EMR alert.
Intervention and Timeline
The project design followed the PDCA cycle, a quality improvement model, to guide the
implementation framework of this project. The first step to this cycle, the plan, was completed
from May 2023 through May 2024. This step consisted of a thorough literature review, extensive
data collection, and identification of the gap in practice to form the purpose of this project,
utilizing TAM as the conceptual framework to guide the practice change into action. The plan
affected PPCPs who prescribe spacer devices to pediatric patients with an asthma diagnosis or
prescription of Albuterol from ages two to 18 years old. Once those parameters were met, the
PPCP received an alert that pops up stating, “SPACER NEEDED? This patient has a diagnosis
of Asthma. Does this patient have a spacer?”
Following IRB approval, this EMR alert, step do, was implemented on September 17th,
2024. This EMR alert was initiated the week following the lunch-and-learn presentation at each
practice site. The educational session was a brief 15-minute presentation with clear objectives

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identified, covering the GINA 2024 guidelines, demonstration of proper inhaler technique, and
various examples of how to order spacers for pediatric asthma patients. The presentation
occurred before the EMR alert was initiated to ensure PPCPs received the disclosure of
information regarding the project and what it entails. This allowed the providers to make a
competent and unbiased decision on participation that was completely voluntary. Once the
PPCPs agreed to participate in this project, provider readiness was assessed through the fivepoint Likert scale pre-EMR alert survey immediately before the educational session.
After the EMR alert was initiated, it continued for eight weeks before the next step of the
PDCA cycle occurred. After eight weeks had passed, utilizing the EMR alert, a thorough manual
chart audit occurred for analysis of the PPCPs’ prescription rate of spacer devices, along with the
delivery of the five-point Likert scale post-EMR alert survey to assess PPCP thoughts and
feelings of the EMR alert, as well as their understanding of GINA 2024 guidelines, proper
inhaler technique, and management of pediatric asthma. This step occurred on November 19th,
2024. Data collected over the eight weeks was compared to one year ago before the EMR alert to
account for the same seasonal comparison. Finally, after collecting all the data as stated above,
the final step of the PDCA cycle, act, occurred by disseminating the findings with the PPCPs,
and the EMR alert will continue as planned following their improved prescription rates and
satisfaction with the EMR alert. The PPCPs assisted in the decision-making process of
maintaining the EMR alert. Potential barriers for implementation of this project included alarm
fatigue, heightened provider stress, perceptions of usefulness among providers, and perceived
time constraints.
Data Tools and Collection
Data collection was performed to evaluate the outcomes of EMR alerts on PPCPs’

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prescribing practice of spacers for pediatric asthma patients. The primary outcome measured was
the PPCPs’ prescription rate of spacer devices. This data was collected through retrospective data
collection utilizing a manual chart audit form, detailed in Appendix C (see Table C1). Manual
chart reviews are commonly employed in research, care assessments, and quality improvement
projects, even without substantial data on their reliability and validity (Siems et al., 2020).
Because of the absence of reliability and validity, these researchers aimed to establish a chart
review system to prove strength and dependability and identify potential therapeutic advances.
Validity and reliability were found after a structured chart review conducted by experienced
primary reviewers, supplemented by a brief secondary review, examining 327 randomly selected
cases (Siems et al., 2020). Therefore, manual chart audits constitute a credible approach for data
collection for this DNP project.
Another essential instrument for measuring observable change in this project was preand post-EMR alert surveys. These surveys were created based on the literature, featuring a fivepoint Likert scale for participants to fill out, as outlined in Appendix C (see Tables C2 and C3).
The survey will evaluate their familiarity with the Global Initiative for Asthma (2024) national
guidelines, familiarity with proper inhaler technique, familiarity with ordering spacer devices
through the EMR, the frequency of ordering spacer devices through EMR and a medical
equipment supplier, and feelings toward an EMR alert. To ensure face validity, experts in the
field, including the project site champion and other pediatric specialists in a similar setting,
thoroughly reviewed the surveys.
Additionally, demographics were collected from the PPCPs with the pre-EMR alert
survey, including the subject’s age, years of experience, gender, and ethnicity/race. In addition to
the provider demographics, the patient demographics were collected with the manual chart audit,

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to include age and insurance status. The provider and patient demographics were protected
through a de-identification process by generating a unique subject ID for everyone.
Outcome Measurements
This project sought to investigate the prescribing practices of PPCPs of spacers for
pediatric asthma patients after an educational session paired with an EMR alert. Descriptive
statistics were utilized to analyze the data and describe the sample and outcome variables.
Specific outcomes to be measured are the prescribing practice of PPCPs for spacers for pediatric
asthma patients, the management of pediatric asthma, and the prescribers’ thoughts and feelings
toward the EMR alert. These outcomes are tied to the theoretical framework of the Technology
Acceptance Model. The outcomes suggest that PPCPs' prescribing practices may be shaped by
their perceptions of using the EMR alert. These perceptions, in turn, can impact how PPCPs
manage pediatric patients with asthma and ensure that all such patients have access to spacers.
Budget
The budget for this DNP project was $2,650 (Appendix D, Table D1). This project site
has two locations, and the budget cost was split between these two clinic locations. This budget
supports many studies that found medication adherence is associated with cost savings.
Enhancing adherence to inhaled medications through EMR alerts for providers ordering spacer
devices could lead to substantial cost savings with minimal investment. In the United States
healthcare system, there exists an extensive economic burden of asthma in the pediatric
population. According to Perry et al. (2019), the total direct cost of asthma within pediatrics in
2013 was 5.92 billion dollars. A system of cost savings via continuous improvement is an
essential sustainability asset that drove this DNP project.
Results

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After data collection, data analysis was performed to determine the effect of EMR alerts
on PPCPs’ prescribing practice of spacers for pediatric asthma patients. A password-protected
statistical software, Intellectus Statistics, was used to store, manage, and analyze the data
(Intellectus Statistics, 2023).
Demographics
A total of five Pediatric Primary Care Providers (n=5) completed this project. The
majority of the ages of this sample were between 31-35, 2 (40%), and the remaining categories
were 26-30, 46-50, 56-60, 3 (60%). The majority of the sample was female, 3 (60%), and the
remainder were male, 2 (40%). The majority of this sample was White or Asian, with two each
for a total of 4 (80%), with the remaining Hispanic or Latino of 1 (20%).
Table 1
Frequency Table for Demographic Variables
Variable
Age
26-30
31-35
46-50
56-60
Gender
Male
Female
Race
White
Asian
Hispanic or Latino
Years As Provider
< 16 years

n

%

1
2
1
1

20.00
40.00
20.00
20.00

2
3

40.00
60.00

2
2
1

40.00
40.00
20.00

2

> or = 16 years

3

40.00
60.00

Descriptive Statistics

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

21

Frequencies and percentages were calculated for each variable or question for both the
pre- and post-EMR alert surveys. The frequencies and percentages are presented in Table 2,
found below. Although a few frequencies stood out, they are worth mentioning. The most
frequently observed categories of Pre_GINA_Guidelines were Sometimes and Often, each with
an observed frequency of 2 (40.00%). The most frequently observed category of
Post_GINA_Guidelines was Often (n = 4, 80.00%). This indicated PPCPs were more frequently
following the 2024 GINA guidelines post-intervention. The most frequently observed category
of Pre_Order_Spacers was Sometimes (n = 3, 60.00%). The most frequently observed category
of Post_Order_Spacers was Often (n = 3, 60.00%). PPCPs were more frequently sending orders
for spacers post-intervention. The most frequently observed category of
Pre_Check_Inhaler_Technique was Rarely (n = 3, 60.00%). Post_Check_Inhaler_Technique's
most frequently observed category was Sometimes (n = 3, 60.00%). Indicating PPCPs were
checking the patient’s inhaler technique more often post-intervention. Please find all eight preand post-EMR alert survey variables with frequencies and percentages presented in Table 2.
Table 2
Frequency Table for Survey Variables
Variable
Pre_GINA_Guidelines
Sometimes
Often
Always
Post_GINA_Guidelines
Often
Always
Pre_Order_Spacers
Sometimes
Often
Post_Order_Spacers
Sometimes

n

%

2 40.00
2 40.00
1 20.00
4 80.00
1 20.00
3 60.00
2 40.00
1 20.00

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Often
Always
Pre_Medical_Equipment_Supplier
Never
Rarely
Sometimes
Often
Post_Medical_Equipment_Supplier
Never
Rarely
Often
Always
Pre_Send_Spacer_Rx_to_Pharmacy
Never
Sometimes
Often
Post_Send_Spacer_Rx_to_Pharmacy
Never
Sometimes
Often
Always
Pre_Check_Inhaler_Technique
Rarely
Sometimes
Post_Check_Inhaler_Technique
Rarely
Sometimes
Often
Pre_Nebulizer_Over_Spacer
Rarely
Often
Post_Nebulizer_Over_Spacer
Sometimes
Often
Always
Pre_Teach_Inhaler_Technique
Rarely
Sometimes
Post_Teach_Inhaler_Technique
Sometimes

3 60.00
1 20.00
1
1
2
1

20.00
20.00
40.00
20.00

1
1
2
1

20.00
20.00
40.00
20.00

1 20.00
2 40.00
2 40.00
1
1
2
1

20.00
20.00
40.00
20.00

3 60.00
2 40.00
1 20.00
3 60.00
1 20.00
1 20.00
4 80.00
2 40.00
2 40.00
1 20.00
2 40.00
3 60.00
2 40.00

22

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Often
Always
Pre_Educate_Rinse_Mouth
Rarely
Sometimes
Often
Always
Post_Educate_Rinse_Mouth
Rarely
Often
Always

23

2 40.00
1 20.00
1
1
1
2

20.00
20.00
20.00
40.00

1 20.00
2 40.00
2 40.00

Next, frequencies and percentages were calculated to compare pre- and post-intervention
on how often providers teach proper inhaler technique compared to years as a provider.
The most frequently observed category of Pre_Teach_Inhaler_Technique within the 0-5 category
of Years_As_Provider was Sometimes (n = 2, 100.00%). The most frequently observed category
of Pre_Teach_Inhaler_Technique within the 16-20 category of Years_As_Provider was Rarely (n
= 1, 100.00%). The most frequently observed categories of Pre_Teach_Inhaler_Technique within
the >20 category of Years_As_Provider were Rarely and Sometimes (n = 1, 50.00%). The most
frequently observed categories of Post_Teach_Inhaler_Technique within the 0-5 category of
Years_As_Provider were Sometimes and Always (n = 1, 50.00%). The most frequently observed
category of Post_Teach_Inhaler_Technique within the 16-20 category of Years_As_Provider
was Often (n = 1, 100.00%). The most frequently observed categories of
Post_Teach_Inhaler_Technique within the >20 category of Years_As_Provider were Sometimes
and Often (n = 1, 50.00%). Frequencies and percentages are presented in Table 3.
Table 3
Frequency Table for Proper Inhaler Technique and Years Practiced
Variable
Pre_Teach_Inhaler_Technique
Rarely

Years_As_Provider
0-5
16-20
0 (0.00%) 1 (100.00%)

>20

1 (50.00%)

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

24

Sometimes
2 (100.00%)
0 (0.00%) 1 (50.00%)
Total
2 (100.00%) 1 (100.00%) 2 (100.00%)
Post_Teach_Inhaler_Technique
Sometimes
1 (50.00%)
0 (0.00%) 1 (50.00%)
Often
0 (0.00%) 1 (100.00%) 1 (50.00%)
Always
1 (50.00%)
0 (0.00%)
0 (0.00%)
Total
2 (100.00%) 1 (100.00%) 2 (100.00%)
Finally, providers were asked to describe how the EMR alert was helpful to them. One
provider reported it was “A great reminder!” Another provider reported, “Reminds me to always
send the spacer along with the inhaler.” All five of the PPCPs found this EMR alert to be helpful.
“It was helpful to get the message/reminder across.” This was something another provider
reported on how the EMR alert was helpful. Another PPCP wrote, “Reminds to make sure they
have a spacer.” Finally, another provider wrote, “It brought the spacer to mind every time I Rx
inhaler.” Overall, the provider feedback was positive, with three of the five PPCPs reporting they
would not change anything about the EMR alert or that it is working fine. The other two PPCPs
suggested to “Link to spacer Rx,” or “Directly send into Rx site what type of spacer covered by
insurance.”
Retrospective Chart Audit
As stated previously, the primary outcome measured for this project was the PPCPs’
prescription rate of spacer devices. For pre-EMR alert, the number of spacer prescriptions
ordered was four out of 118 Albuterol prescriptions. Therefore, the pre-EMR alert spacer
prescription rate was found at 3%. Compared to the post-EMR alert, the number of spacer
prescriptions ordered was 66 out of 243 Albuterol prescriptions. The post-EMR alert prescription
rate was found to be 27%. Of these five PPCPs, this project found a 60% increase in spacer
prescription rate following the intervention of the EMR alert paired with the brief educational

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

25

session upon implementation.
Project Impact
Implementation of a well-designed EMR alert, with proper education to the PPCPs on the
utilization and purpose of EMR alert to support the correct use of inhaled medications by
properly prescribing spacers and teaching the proper technique to patients and their families.
Applying this evidence to a pediatric primary care office located in the Southwestern United
States led to a practice change in prescribing spacers at the individual provider level. In addition,
the patient level should see an improvement in correct use of inhaled medication through
improved spacer use and impact overall asthma control. Therefore, this practice and system
should see fewer ER visits, school absences, and hospitalizations for pediatric asthma patients
over time.
Sustainability
The practice of building, refining, and improving a project or initiative is necessary to
achieve sustainability when implementing a quality improvement project. This DNP project
aimed to investigate the effect of EMR alerts on PPCP’s prescribing practices of spacers. The
project site champion at this organization was one of the PPCPs within this practice who helped
identify this gap in the practice of inadequate prescriptions of spacers for pediatric asthma
patients. The project site champion will continue to act as a resource, advocate, and leader in
guiding colleagues on ordering spacers, while monitoring and assessing the effectiveness of the
EMR alert through manual chart audits following implementation. Eventually, sustainability will
be reached with the long-term goal in mind of PPCPs adapting to ordering spacers for their
pediatric patients with asthma without an EMR alert, which can be seen in the logic model in
Appendix F (see Figure F1).

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

26

The framework that guided this quality improvement project was the Plan-Do-Check-Act
(PDCA) cycle, which provides a natural iterative developmental process that will be continued
upon project completion until the PPCPs are satisfied with the result of 100% of pediatric asthma
patients obtaining spacers with their inhalers. Upon project completion, the PPCPs have found
the EMR alert beneficial to their practice and would like to continue the alert. The PPCPs have
also been left with a quick, saved template to be inserted into their notes to provide patient spacer
care and instructions. Along with the note template, the PPCPs were provided with a spacer care
instruction handout to give to the patients and their families with their spacers.
The sustainability of this quality improvement project will be ensured through the
establishment of a dedicated site champion, an effective EMR alert, a note template, a care
instruction handout, and ongoing evaluation and adaptation. PPCPs play a large role in educating
families on how to confidently care for their children with asthma, which will evolve through
this sustainable project plan. This approach will foster a culture of continuous improvement in
pediatric asthma management, ultimately enhancing the quality of care provided to pediatric
patients with asthma.
Discussion
Strengths and Limitations
Upon implementing an effective EMR alert paired with an educational session for the
PPCPs on the utilization and purpose of EMR alerts at a pediatric primary care office located in
the Southwestern United States, a 60% increase in the spacer prescription rate was observed.
This intervention was cost-effective, received strong support from the project site, and positively
impacted the PPCPs. This relates back to the initial literature review findings that EMR alerts are
easy to use and implement, cost-effective, and influential on clinical decision making. All

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

27

participating PPCPs for this project want to keep the EMR alert as a reminder always to send the
spacer and inhaler.
While this project has several strengths, there are limitations and barriers that must be
acknowledged. Since this project is unique in its kind, no standardized tool was utilized, as such
a tool does not exist. Also, this project timeline was implemented before the respiratory season in
the pediatric setting. The timeline followed was what best suited the project site for
implementation. Finally, there was a lack of support from the medical equipment supplier
supporting this practice. The medical equipment supplier generates more revenue from
nebulizers sent through them than from spacers, which were found to have an influence on the
amount of equipment supplied within each practice location. One challenge was that the medical
equipment supplier was reluctant share their data, which could have provided additional
information within this project.
Recommendations
Future study recommendations include implementation during the respiratory season
within the pediatric setting. Another future recommendation would be to implement this EMR
alert across various pediatric primary care offices. This should take careful care and
consideration of alarm fatigue when implementing across various practices. Finally, create an
EMR alert to have the ability to link directly to the order set, smart enough to factor in what
spacer would be accepted per each patient’s insurance, making this a seamless and simple
transition for the PPCPs.
Conclusion
Ultimately, asthma in pediatrics remains among the most common chronic diseases.
PPCPs are responsible for bridging the gap of inadequate prescription of spacer devices for

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

28

children with asthma and empowering families with knowledge on how to care for their child
with asthma confidently. This quality improvement project acknowledged the positive effect of
an EMR alert complemented with an educational session and the PPCP prescribing practice of
spacer devices for children with asthma. Upon conclusion of this project, PPCPs are expected to
be more likely to order spacers over nebulizers for pediatric patients with asthma, and more
likely to teach proper inhaler technique. While alarm fatigue and provider perceptions must be
acknowledged as potential barriers to this project, EMR alerts can be easy to use and evaluate,
cost-effective, and influential on clinical decision-making and prescribing practice in various
specialties and electronic health systems.

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

29

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Appendix A
Evaluation and Synthesis Tables

Table A1
Evaluation Table for Quantitative Studies
Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Ghazi et al.,
(2022), Electronic
alerts to improve
heart failure
therapy in
outpatient
practice: a cluster
randomized trial.

Theories of
persuasion
and
motivation

Design: cluster
RCT

N= 1,310
n= 685 (alert)
n= 625 (no alert)

IV: PROMPTHF clinical
trial; EHR
embedded
BPA

Tools:
- O’Brien and
Fleming stopping
rule
- binomial
distribution
- log link
intention-to-treat
principle

Statistical
Tests Used:

DV1: p=0.03
Absolute
increase=10%
2-sided alpha=
0.05
intraclass
correlation
coefficient=0.0
5

Country: USA,
New Haven,
Connecticut.
Funding:
AstraZeneca
funded and
several author
disclosures listed
Bias: non-BPA
arm of study
coordinated with

Purpose: EHR
alerts
recommending
medical treatment
in eligible patients
with heart failure
with reduced
ejection fraction to
improve
prescription rates of
therapies compared
to usual care

Demographics:
Mean Age of 72
Female 30.7%
Black 18.1%
White 71.7%
Asian 1.5%
Hispanic 9.5%
Medicaid 85.3%
Setting: Yale-New
Haven Health
System
Exclusion: PTs on
hospice care (n= 7)

DV1: addition
of GDMT
prescription at
30 days
DV2: Increase
in Dose or
Addition of
GDMT Class
at 30 Days

Validity/
Reliability:
- comparing two
treatments
- only one
outcome in each
trial
- non-negative and
well-behaved
predictions
- unbiased
comparison

chi-square
test
Wilcoxon
rank sum test

DV2: p=0.01

Level of Evidence;
Application to
practice;
Generalization
LOE: I
Strengths: statistically
significant results,
strong provider
feedback, majority
found helpful
Weakness: single
health system examined
increase in medication
start rather than dosing;
tested in one EHR
Feasibility: costeffective, targeted,
individualized, and
scalable
Application: apply
outside of single health
system, variety of EHR

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Citation

improved
medication
therapy
Wengryn et al.,
(2022), Use of
electronic health
record best
practice alerts to
improve
adherence to
American
urological
association
vesicoureteral
reflux guidelines.
Country: Aurora,
Colorado, USA
Funding:
American
Urological
Association data
grant
Bias: none nor
conflicts of
interest

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

35
Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of Evidence;
Application to
practice;
Generalization

IV: BPA
implementation

Tools:
- Statistical
Analysis System
- open-source
programming
language

Statistical
Tests Used:

No significant
findingsDV1: P values
height- <0.001
BP- 0.72
UA- 0.11
ABX- 0.34

LOE: II

DV2: P values
height- 0.88
BP- 0.79
UA- 0.25
Follow up 47.2%

Weakness: AUA 2010
guidelines, formatting
alert, alert fatigue, time
constraints in clinic,
lack of workflow,
limited by study design,
possible clinic staff
change over course of
study, outpatient
setting, lack for survey
for providers feedback

Attrition: not
mentioned
technology
acceptance
model theory

Design:
Retrospective
cohort study
Purpose: evaluate
the effect of BPA in
the EHR on
adherence to AUA
VUR guidelines

N= 123
(pre- 68)
(post- 55)
Demographics:
Mean Age= 3.7
Female= 65.9%
Male= 34.1%
White= 61.8%
Other Race= 32.5%
Reflux Grade:
1-2= 37, 3= 41, 45= 39
History of BBD:
Yes- 32, No- 91
Family History
Reflux: Yes- 12,
No- 110
Setting: Children’s
Hospital Colorado
outpatient tertiary
referral center
Exclusion: missing
5 data points
Attrition: not
applicable,
retrospective

DV1: provider
guideline
adherence at
initial visit
DV2: provider
guideline
adherence at
follow-up visit

Validity/
Reliability:
- consistent data
overtime
- enhance security
and transparency

Chi-square
test
Wilcoxon
rank sum test

Strengths: height
recorded for patients
significantly increased,
customize EHR to
enhance clinical
practice

Feasibility:
inexpensive, can be
repeated with room for
improvement
Application: BPA must
fit into workflow of

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

36

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of Evidence;
Application to
practice;
Generalization
clinic or inpatient
settings

Leibel et al.,
(2019), Utilizing a
physician
notification
system in the
EPIC electronic
medical record to
improve pediatric
asthma control:
A quality
improvement
project

Model for
improvement

Design: quality
improvement

N= 439 encounters
with asthma, 207
completed
questionnaire

IV: BPA
implementation

Tools: Asthma
Therapy
Assessment
Questionnaire

Statistical
Tests Used:
Slicer Dicer
Component
of EMR

99%
documented
action taken
DV1: 55%

LOE: I

Country: San
Diego, California,
USA
Funding: none
Bias: internal
peer-approved
“pay-forperformance
initiative”

Method: clinical
informaticist with
EMR system
created BPA,
observe over 3
months
Purpose: evaluate
EMR- based BPA
centered on asthma
control

Demographics: not
disclosed
Setting: Division of
Allergy,
Immunology, and
Rheumatology at
Rady Children’s
Hospital
Exclusion: none
listed
Attrition: 47%
completion rate

DV1:
medication
changes
DV2: inhaler
technique
review
DV3: further
evaluation
DV4: no action
necessary

Validity/
Reliability:
Cronbach α of .75

DV2: 65%
DV3: 56%
DV4: 11%

Strengths: easy to use,
improve clinician
compliance, increase
prescription for
controller medications,
follow asthma care
plans, improved
pulmonary function
tests
Weakness: no
before/after
comparison, small
sample size, short
duration, alarm fatigue,
increase in provider
stress
Feasibility: cost
effective, targeted,
individualized, and
scalable
Application: apply
outside of single health

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

37

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of Evidence;
Application to
practice;
Generalization
system/office, variety
of EHR

Lawrence et al.,
(2024),
Retrospective
analysis of the
impact of
electronic medical
record alerts on
low value care in
a pediatric
hospital

technology
acceptance
model theory

Design: time series
analysis, quasiexperimental
method

N= four different
LVC practices

IV: EMR alerts

Tools:
-STATA statistical
software
version 16 (Texas,
USA)
-Akaike
information
criterion
-Bayesian
information
criterion
-Bradford-Hill
criteria

Statistical
Tests Used:
Descriptive
statistics

DV1: p <.001
Pre: 56.7%
Post: 31.0%

LOE: II

Method: evaluate
EMR data over 76months
Purpose: evaluate
EMR alerts and
effectiveness at
reducing pediatric
LVC towards
hospital cost

Country:
Melbourne,
Australia.
Funding: Digital
Health Fellowship

Demographics: not
specified
Setting: Royal
Children’s Hospital
in Melbourne,
Australia
Exclusion: timing
in the workflow,
wording, action
required
Attrition: not
stated

DV1: full iron
studies for iron
deficiency
anemia
DV2:
bronchodilators
in bronchiolitis
DV3: full
thyroid
function tests
DV4: ECG
sleeping
bradycardia

Bias: none

Farmer et al.,
(2020), Inhaled
corticosteroids

technology
acceptance
model theory

Design: prospective
cohort study

N= 125
Demographics:
Mean Age= 7.4
Female= 45% (36)

IV: electronic
alert

Poisson
regression
analysis
Sensitivity
analysis

DV3: p <.001

Pre: 25.1%
Post: 9.9%

DV4: p .305
Pre: 28.8%
Post: 28.1%

Validity/
Reliability:
- numerical
accuracy tests
- Lower= better,
measuring
variation
- lower= better,
likely function
- nine criterion for
causation deduced
Tools:
Fisher exact

DV2: p <.001
Pre: 6.9%
Post: 3.2%

Strengths: cost
reducing, improvement
in LVC ordering
practice, consistent,
Weakness: introduced
in sequential order not
as intentionally
designed, efficacy of
alerts vary, method
detects association not
causation, large EMR
data sets
Feasibility: cost
effective, targeted,
individualized, and
scalable
Application: apply
outside of single health
system/office, variety
of EHR

Statistical
Tests Used:

DV1: p-value
<0.0001

LOE: II

Strengths: specific
prompts for physicians
DV2: 95% CI
Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Citation

Theoretical/
Conceptual
Framework

prescriptions
increased in the
ED for recurrent
asthma
exacerbations by
automated
electronic
reminders in the
ED

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Purpose: evaluate
impact of electronic
alert on prescription
rate of ICS by ED
providers

Male= 80% (64)
Hispanic=78%(62)
White= 24% (19)
Black= 14% (11)
Native= 8% (6)
Other= 1% (1)
Medicaid= 100% (80)
Non-Medicaid= 18%
(18)
Self-pay= 7%(7)
No Prior ICS= 86%
(69)
Yes Prior ICS=39%
(31)

DV1: ED
asthma visits

Fisher–Freedman–
Halton test

Confidence
interval

DV2: ICS
prescribed

Kruskal–Wallis
test

Fisher exact
test

Country:
Phoenix, Arizona,
USA

Validity/
Reliability:

based on 10000
random samples

Results/
Findings

KruskalWallis test
FisherFreemanHalton test

Feasibility: cost
effective, targeted,
individualized, and
scalable
Application: apply
outside of single health
system/office, variety
of EHR

Exclusion:
comorbiditiesdevelopmental delay,
broncho- pulmonary
dysplasia, cystic
fibrosis, sickle cell
disease, interstitial
lung disease

Bias: financial
incentive offered
to physicians
ordering ICS

Model for
improvement

Design: serial
cross-sectional
analysis

Attrition: not
applicable
N= (6606) 2014,
(6945) 2018
Demographics:
2014
Male=3745 (56.7)
Female 2861 (43.3)

Level of Evidence;
Application to
practice;
Generalization
to order ICS; improved
rate in ICS prescription
Weakness: unknown
sustainability/affect
sustained, not able to
track prescription fill
rates; unable to assess
reasoning for not
prescribing ICS

Binomial
ClopperPearson exact
calculation

Setting: Phoenix
Children’s Hospital
ED

Funding: none

Fierro et al.,
(2023), A pilot
study to improve
provider
adherence to

38

IV: CDS
embedded into
EMR

Tools:
Asthma control
test

Statistical
Tests Used:
General
Linear

DV1: OR
=14.95, 95%
CI 12.67,
17.65, p <.001

LOE: III
Strengths: statistically
significant findings;
adherence to NAEPP
guidelines improved;

Purpose: improve
DV1: Asthma
Cerner EMR
control test
provider adherence
Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Citation

Theoretical/
Conceptual
Framework

NAEPP
guidelines

Design/ Method/
Purpose

Sample/Setting

to NAEPP
guidelines in EMR

0–4 years: 2396(36.3)
5–11 years:
2828(42.8)
≥12 years: 1382(20.9)
Hispanic 5099 (77.2)
Caucasian 740 (11.2)
2018
Male=3977 (57.3)
Female= 2968 (42.7)
0–4 years: 1399(20.1)
5–11 years: 3223
(46.4)
≥12 years: 2323(33.4)
Hispanic 5089 (73.3)
Caucasian 888 (12.3)
Setting: Children's
Hospital of Orange
County
Exclusion: > 21 years
old, asthma diagnosis
after 2015; Cerner
Standard 2017
Pediatric
Asthma Registry
Requirements
Attrition: not
applicable

Country: Orange
County,
California, USA
Funding: none.
Bias: none nor
conflicts of
interest

39
Variables

DV2: Asthma
action plan
DV3: inhaled
corticosteroids
DV4: spacers

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

HealtheIntent
database

Mixed
Models

Validity/
Reliability:

Chi Square
test

DV2: OR
=12.70, 95%
CI 11.10,
14.54, p <.001

Reliability= 0.77

DV3: OR
=1.85, 95% CI
8.52, 14.54, p
<.001
DV4: OR =
1.45, 95% CI
1.31, 1.6, p <
.001

Level of Evidence;
Application to
practice;
Generalization
easy access to NAEPP
guidelines
Weakness: diagnostic
coding changed in
2015; difficult
determination of
patients benefitting
from ICS; limited
Medi-Cal patients only;
reduced generalizability
of one site; 4 year study
questions internal
validity; provider years
of practice effect
guideline
implementation
Feasibility: cost
effective, targeted,
individualized, and
scalable
Application: health
policy decision making;
direct impact to patient
care
LOE: I

N= 15,343
IV: EHR
Tools:
Statistical
DV1: 54.0 vs.
Demographics:
reminder
Regional IIS CDS
Tests Used:
50.3%
Chi Square
Strengths: compared
Male= 50.0 %
p=0.0001;
DV1: captured Allscripts Sunrise
across four different
Female= 49.5%
difference
test
Method: EHRHispanic/Latino=
opportunities
Clinical Manager
3.7%; 95% CI: sites, improved
[1.8–5.6%]
captured opportunities,
based immunization 28%, Other=
Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux
Stephens et al.,
(2021), Effect of
electronic health
record reminders
for routine

Social
contract
theory

Design:
randomized cluster
cross over trial

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Citation

immunizations
and
immunizations
needed for
chronic medical
conditions.
Country: New
York, USA
Funding: Agency
for Healthcare
Research and
Quality grant
Bias: none stated,
no conflicts of
interest disclosed

Theoretical/
Conceptual
Framework

40

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

reminder using
open-source
resource

66.8%, White=
10.4%, Other=
83.6%
Public Insurance=
94.7%, Language:
English= 41.1%
Spanish= 52.7%

DV2: underimmunization

Synchronized
Immunization
Notifications
Survey

Purpose: assess
impact of EHR
reminders for
immunizations

Setting: four
community
pediatric health
clinics in New
York, low-income,
urban population
Exclusion: none
listed
Attrition: not
available

Definitions:
Captured
opportunitiesmedical visit
which PT was
eligible and
received an
immunization
Underimmunization
percent
overdue for
CDC
recommended
immunization

Validity/
Reliability:
Accuracy-verified
extensively with
test patients
Usability- test trial
conducted with
small group of
physicians
61% survey
respondence rate,
95% somewhat
satisfied with alert

Data
Analysis

Results/
Findings

DV2: 89.1 vs.
88.3% p= 0.16;
difference=
0.8%; 95% CI:
[0.3 to 1.8%]

Level of Evidence;
Application to
practice;
Generalization
maybe useful in settings
without routine check
of immunizations
Weakness: overly
complex study, low
survey respondence
rate, questioned
accuracy of alert, not all
data is depicted,
experienced ceiling
effect with little room
for improvement, no
impact on condition
specific immunizations
Feasibility: difficult to
replicate
Application: not
generalizable in other
settings

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

41

Table A2
Evaluation Table for Qualitative Studies
Citation

Theory/
Conceptual
Framework

Design/ Method/
Sampling

Sample/ Setting

Major Themes
Studied/
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/ Themes

Chaparro et al.,
(2022), Clinical
decision support
stewardship:
best practices
and techniques
to monitor and
improve
interruptive
alerts

Alert
evaluation
framework

Method: systematic
review and crosssectional analysis

Sample: not
applicable

(1) assess
interruptive
alert burden

Data Collection:
1) two patientfocused
denominators
a. alerts/
inpatient-day
b. alerts/
encounter
2) two clinicianfocused
denominators
a. alerts/ 100
orders
b. alerts/
clinician day
3)Proximal
measures
4) Distal
measures

No current
standard
metrics exist
for
comparison
of BPA
burden on
EHR users or
effectiveness
at improving
outcomes

(1) require multiple
metrics for burden
reduction strategies
(2) alert address
target quality/safety
problem, examine
process adherence
plan-do-study-act
cycles
(3) identify
malfunctioning alerts,
gather user feedback,
and human factors
(4) 1-overall model
approval,
maintenance/review
needs established
2- ensure alerts
justified, establish
standards
3- alert design
maximize
effectiveness

Country:
Stuttgart,
Germany

Donabedian
model
Medical
Research
Council’s
Framework

Purpose: preserve
value of BPA via
EHR, physiologic
monitor, or mobile
device

Demographics:
not disclosed
Setting:
academic
pediatric health
systems
Attrition: not
applicable

Funding: none

(2) reduce
excessive
firings
(3) optimize
alert
effectiveness
(4) establish
quality
governance

Bias: none

Souganidis et al.,
(2022),
Physician-

Theory of
acceptance

Design: qualitative
analysis

Sample: (n=22)
Demographics:

(1) BPA
utilization

Data Collection:
semi structured
interviews

constant
comparison
analysis

(1) 32% reliance on
PT characteristics:

Level/ Quality of
Evidence; Decision
for/ Application to
practice;
Generalization

LOE: I

Strengths: welldesigned with
framework depicted,
identifies need for
standard metrics for
BPA burden on EHR
users, provides
holistic view, review
questions knowledge
check
Weakness: no
current standard
metrics, no negative
consequences
Feasibility: low-cost
Application:
standardize across
EHR
LOE: V

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Citation

specific
utilization of an
electronic best
practice alert for
pediatric sepsis
in the emergency
department
Country: USA
Funding: not
applicable
Bias: none and
declare no
conflict of
interest

Theory/
Conceptual
Framework

42

Design/ Method/
Sampling

Sample/ Setting

Major Themes
Studied/
Definitions

Method: collected
data through semi
structured
interviews, analyzed
through iterative
coding process

Male=8
Female=14
Years since
completing
residency:
<5: 11
5–10: 1
10–15: 4
15–20: 4
>20: 2
Work at
institution
before protocol
initiation
Yes 9
No 7

(2) BPA
rejection
(3)
Management of
shock protocol
PT
(4)
Functionality of
BPA

Purpose: identify
common reasons for
acceptance/rejection
of a sepsis BPA in
ED & how BPA
affects physician
management of
suspected sepsis

Setting:
quaternary-care
children's
hospital ED
Attrition: not
applicable

Definitions:
Sepsis- body's
overwhelming
response to
infection with
subsequent
organ
dysfunction

Measurement/
Instrumentation

triangulation
with 2 coders
κ statistic for
interrater
reliability
between the
investigators and
the EHR
Data
Dependability:
κ statistic= 0.97

Data Analysis

Findings/ Themes

(a) preexisting
conditions
(b) developmental
status
(c) BPA strongly
influenced physician
decision
Non-PT
characteristics:
(a) ED-specific
factors
(b) provider- specific
utilization
(c) BPA-specific
characteristics
(2) PT
characteristics:
(a) medical history
(b) clinical
presentations
Non-PT
characteristics:
(a) work environment
(b) BPA timing
(3) fluid
resuscitation, empiric
antibiotics, illness
severity, & medical
history
(4) incomplete
understanding of

Level/ Quality of
Evidence; Decision
for/ Application to
practice;
Generalization

Strengths: thematic
saturation achieved;
BPA strong influence
on decision making;
first study of its kind
to understand
provider-specific
practice patterns
Weakness: physician
limited understanding
of BPA; 1 institution
by volunteer
sampling over 1 year;
not all attitudes
collected in sample
size; may not
generalize in other
settings; no
anonymity; no triage
nurses involved
Feasibility: low-cost
Application: specific
to this 1 institution

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Citation

McCoy et al.,
(2022), Clinician
collaboration to
improve clinical
decision support:
The Clickbusters
initiative
Country:
Nashville,
Tennessee, USA
Funding:
funding for
prizes not listed
Bias:
gamification
process to
incentivize
participants,
winning Amazon
gift cards
1st- $250
2nd- $150
3rd- $100

Theory/
Conceptual
Framework

Plan-DoStudy-Act
Model

Design/ Method/
Sampling

Design: descriptive
analysis
Method: x2, threemonth rounds of ten
step Clickbusters
program
Purpose: improve
safety & quality &
reduce burnout
through CDS alerts

Sample/ Setting

Sample: n=24
Round 1 (n=8)
Round 2 (n=20)
Demographics:
Not applicable
Setting:
Vanderbilt
University
Medical Center
Attrition: not
stated

43
Major Themes
Studied/
Definitions

(1) individuals
or committees
reviewing EHR
(2) sentiment
analysis of
comments
entered by
clinicians when
overriding
alerts
(3) anomaly
detection

Measurement/
Instrumentation

Data Collection:
Atlassian Jira
Epic EHR
Tableau
Dashboard
health
information
technology
analyst

Data Analysis

Findings/ Themes

Descriptive
analysis

BPA & BPA design
barriers
(1) very effective,
requires high effort
(2) lower barrier with
build/personnel effort
but limited by alerts
that clinicians
see/respond
(3) identify alerts that
no longer functioning
as designed, machine
learning approach

Level/ Quality of
Evidence; Decision
for/ Application to
practice;
Generalization

LOE: VI
Strengths: ten-step
process with clear
instructions, found
reduction in
unnecessary alerts
Weakness: requires
active Physician
Builder program or
group of people
dedicated to program
Feasibility: easy to
follow plan, must
evaluated for safety
& efficiency to
justify cost
Application: readily
replicable, can be
applied to other
assets of EHR

Key: AUA American Urological Association, ABX Antibiotics, BBD Bowel Bladder Dysfunction, BP Blood Pressure, BPA Best Practice Alert, CDS Computerized/Clinical Decision
Support, CI Confidence Interval, DV Dependent Variable, ECG Electrocardiogram, ED Emergency Department, EHR Electronic Health Record, EMR Electronic Medical Record,
GDMT Guideline Directed Medical Therapy, ICS Inhaled Corticosteroids, IV Independent Variable, LOE Level of Evidence, LVC Low Value Care, NAEPP National Asthma
Education and Prevention Program, OR Odds Ratio, PT Patient, PCP Primary Care Provider, PROMPT-HF PRagmatic trial Of Messaging to Providers about outpatient Treatment of
Heart Failure, RCT Randomized Control Trial, UA Urine Analysis, VUR Vesicoureteral Reflux

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

44

Table A3
Synthesis Table
Study
(Author, year)
Design
LOE
Demographics
Sample size
M-Age/Age range
% Male
Setting
USA
Hospital
ED
Outpatient/Academic
Interventions
Best Practice Alert
EMR Alert
Quality Improvement
Common Theories
model for improvement
technology acceptance
model theory
Outcomes/ Themes
Reduction in alerts
Alarm fatigue
Medication adherence
Cost for implementation

Chaparro et
al., (2022)
SR/CSA
I

Farmer et al.,
(2020)
Cohort Study
II

Fierro et al.,
(2023)
CSA
III

Ghazi et al.,
(2022)
Cluster RCT
I

Lawrence et
al., (2024)
TSA/QEM
II

Leibel et al.,
(2019)
QI
I

McCoy et al.,
(2022)
DA
VI

Souganidis et
al., (2022)
QA
V

Stephens et
al., (2021)
RCCOT
I

Wengryn et
al., (2022)
Cohort Study
II

n/a
n/a
n/a

125
7.4
80.0 %

6606/6945
0-20
56.7%/57.3%

1,310
72
69.0 %

n/a
n/a
n/a

439
n/a
n/a

24
n/a
n/a

22
0-20
36.36 %

15,343
0-17
50.0 %

123
3.7
34.1%

X

X
X

X
X

X
X

X

X

X

X

X
X

X

X

X

X

X
X

X
X

X

X

X

X

X
X

X
X

X

X

X
↓
↓

?
↑
↓

X

X

X
↓
↑
↓

↑
↓

↓

↑
↓

↑

↓

↑

↑

?

↓

Key: CSA Cross-Sectional Analysis, DA descriptive analysis, ED Emergency Department, LOE Level of Evidence, M-Age Mean Age, QA Qualitative Analysis, QEM Quasi-Experimental Method, QI
Quality Improvement, RCCOT Randomized Cluster Cross Over Trial RCT Randomized Control Trial, SR Systematic Review, TSA Time Series Analysis, USA United States of America, ↑ increased, ↓
decreased, ? unknown

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Appendix B
Models and Frameworks
Figure B1
Technology Acceptance Model

(Davis, 1985)

45

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Figure B2
The Plan-Do-Check-Act (PDCA) Cycle

(Deming, 1950)

46

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

47
Appendix C

Data Tools and Collection
Table C1
Chart Audit Form
Subject
ID

100
101
102
103
104
105

Age
(years)

Groups
Pre
Post

Insurance Status:
Private Insurance
AHCCCS
No Insurance

Inhaled Medication
Ordered:
Yes/No

Spacer Ordered in
EMR:
Yes/No

Spacer Ordered through
medical equipment supplier:
Yes/No/UK

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Table C2
Pre-EMR Alert Survey
Choose one of the following options for the questions below by placing a checkmark or “X”
in the box that most applies.
Never
Rarely
Sometimes
Often
Always
How often do you follow
GINA 2024 guidelines?
How often do you order
spacer devices for
children ages 2-18?
How often do you utilize
a medical equipment
supplier to distribute
spacer devices from the
office?
How often do you send a
prescription for a spacer
to the pharmacy?
How often do you check
your patient’s inhaler
technique?
How likely are you to
order a nebulizing
machine over a spacer
for children under 5?
How often do you teach
proper inhaler
techniques?
How often do you
educate your patients to
rinse their mouths after
inhalation of
corticosteroids?

48

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Table C3
Post-EMR Alert Survey
Choose one of the following options for the questions below by placing a checkmark or “X”
in the box that most applies.
Never
Rarely
Sometimes
Often
Always
How often do you follow
GINA 2024 guidelines?
How often do you order
spacer devices for
children ages 2-18?
How often do you utilize
a medical equipment
supplier to distribute
spacer devices from the
office?
How often do you send a
prescription for a spacer
to the pharmacy?
How often do you check
your patient’s inhaler
technique?
How likely are you to
order a nebulizing
machine over a spacer
for children under 5?
How often do you teach
proper inhaler
techniques?
How often do you
educate your patients to
rinse their mouths after
inhalation of
corticosteroids?
Please describe how the EMR alert was helpful to you.

If you could change anything about the EMR alert, what would you change?

49

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

50

Appendix D
Budget to Improve Provider Prescribing Practices
Table D1
Direct Cost

Item/Service
Cost
Design, print, and distribute promotional materials
$100
to potential providers
Create PowerPoint for provider presentation
$200
Design, and develop EMR Alert in
$50
eClinicalWorks
Lunch for providers and personnel at each
$200
presentation (x2)
Design and print evaluation surveys (10 of each)
$100
Design and print spacer care handout (50)
$100
Spacer Devices provided by medical equipment
$10 per spacer
supplier
Indirect Cost
Personnel/Service
Cost
Utilize time from Director of Operations to help
$200
design and implement EMR alert in
eClinicalWorks
Project site champion
$300
Use of eClinicalWorks, already established EMR
$500
eClinicalWorks IT Support team
$400
Total Cost

Subtotal

Total

$500

$1,250

Subtotal

Total

$1,400
$2,650

Funding Sources: The project site and the DNP student will fund this quality improvement
project.
Budget Justification: Asthma in pediatrics imposes an extensive economic burden on the
United States healthcare system. It has been estimated that in 2013, the total direct cost of
pediatric asthma was $5.92 billion (Perry et al., 2019). Many studies have found medication
adherence to be associated with cost savings. Improving inhaled medication adherence rates
using an EMR alert to providers ordering spacer devices, this practice could save thousands of
dollars at minimal cost, as displayed above.

PEDIATRIC ASTHMA PROVIDERS AND ALERTS
Appendix E
Retrospective Chart Audit Results
Graph E1

51

PEDIATRIC ASTHMA PROVIDERS AND ALERTS

52
Appendix F

Logic Model: Effect of Electronic Medical Record Alerts on Pediatric Asthma Providers
Figure F1
Goals: The purpose of this evidence-based project is to investigate the effect of electronic medical record (EMR) alerts on pediatric
primary care providers’ prescribing practices of spacers to pediatric patients with asthma.
INPUTS
Pediatric patients
requiring inhaled
mediations
Pediatric providers
Electronic Medical
record software
EMR alert
Support Staff: Medical
assistants (MAs),
director of operations,
time
Lunch and learn
presentation
Medical equipment
supplier
Pre- and post-EMR
alert survey

OUTPUTS
Activities
Perform manual
EMR audits of
provider prescribing
practices for spacers
for > 30 patient
charts in 8 weeks
Implementation of
EMR alert
Educate and recruit
participating
providers on the
importance of
ordering spacers
(Neininger et al.,
2022; Root & Small,
2019)
Pre- and post-EMR
alert survey for
providers to assess
their understanding
and feelings towards
EMR alert

Target

Pediatric
primary care
providers’
spacer
prescribing
practices

Pediatric asthma
patients using
spacers for
inhaled
medications

Red arrows indicate and rapid improvement cycle utilizing the Technology

Short

OUTCOMES
Medium

IMPACTS

Continued
increased rate
of Rx in spacers
manual audits

Continued
increased rate
of Rx in spacers
manual audits

Positive attitude
towards EMR
alert

Continued
positive attitude
towards EMR
alert

Adapted to
ordering spacers
without EMR
alert

Providers
demonstrate of
proper use of
inhaler (Leibel
& Weber, 2019)

Providers
continue to
demonstrate
proper use of
inhaler

Increased rate
of Rx in spacers
manual audits

Providers
continue to
demonstrate
proper use of
inhalers,
included in
patient
education

Compliance
with national
standards
Ongoing
clinic
utilization of
EMR alert
Improve
control of
asthma

Improved
spacer use
by pediatric
patients
Improve
control of
asthma

Acceptance Model Framework (Anderson, 2018; Davis, 1985).
Assumptions: Pediatric providers are receptive to the EMR alert. Pediatric providers understand and agree on the importance of spacer use for patients
with asthma. The EMR alert will function appropriately and benefit providers. Pediatric providers will adapt to the EMR alert and follow recommended
guidelines.