The goal of this study is to determine whether an 'eco' version of the Electronic Asthma Management System (eAMS) can reduce inhaler carbon emissions in primary care, in patients with asthma. The existing eAMS uses patient-specific criteria (asthma control, asthma flare-up risk, and current medications) to provide guideline-based computerized clinical decision support to clinicians, to improve the delivery of asthma care. The eAMS-Eco includes embedded cues and messaging on the environmental impact of inhaler medications and links to a patient-friendly conversation aid that facilitates shared decision-making and climate-conscious prescribing.

The study will evaluate the implementation of the eAMS-Eco in four primary care clinics that have been using the existing eAMS, using an interrupted time-series analysis (one year pre- and post-launch of the eAMS-Eco). The investigators will assess system uptake and user feedback on the eAMS-Eco, as well as changes in inhaler prescriptions (including resulting changes in carbon emissions and costs) and changes in asthma control, in the implementation period (eAMS-Eco) compared to the baseline period (eAMS).

Climate change poses a significant threat to human health and yet healthcare itself contributes substantially to climate change. Reducing the carbon emissions from healthcare is one actionable step to combat the climate crisis. In regards to asthma care, reductions in carbon emissions could be achieved by addressing the unnecessary of metered-dose inhalers (MDIs), the propellants in which contain potent greenhouse gases. This could be achieved by preferentially prescribing inhaler devices such as dry powder inhalers (DPIs) and soft mist inhalers (SMIs), which do not use propellants and have much lower carbon footprints than MDIs. These devices are almost always available in the same medication classes as MDIs (sometimes with the same active ingredient) and demonstrate comparable clinical efficacy and patient acceptability. Yet MDIs still account for the majority of prescribed inhalers.

The investigators will leverage the existing Electronic Asthma Management System (eAMS), a computerized decision support system (CDSS) that recommends guideline-based medication changes based on assessment of the patients' asthma control and exacerbation risk, to promote climate-conscious prescribing at the point-of-care. When tested in real-world settings, the eAMS improved the quality of asthma care, with a significant increase in the provision of asthma action plans, assessment of asthma control, use of guideline-based inhaler medications, including escalation of controller therapy when indicated. Subsequently, the tool has been used widely in primary care sites in Ontario. To address the issue of inhaler GHG emissions, our team has now created an enhanced version of the existing eAMS, called the 'eAMS-Eco'.

The eAMS-Eco has embedded cues and messaging that indicate the relative carbon footprint of each medication recommended by the eAMS, to provide clinicians with the knowledge needed to enact climate-conscious prescribing. A an orange or red leaf appears next to the recommended medication with hover text indicating that the device has a moderate or high carbon footprint, respectively. The medication name and hover text are clickable links which take the clinician to an inhaler conversation aid, which serves to promote shared decision-making by presenting the carbon footprint (as the equivalent to kilometers driven in a gas powered car) and cost of each inhaler in the corresponding medication class, along with usage details (dosing, number of inhalations per dose, number of doses per device). The conversation aids also include information on inhaler contents (active ingredients) and include a safety warning that emphasizes the importance of considering patient-level factors, such as adequate technique, age, disease severity, and the impact on adherence, when selecting an inhaler device.

Ultimately, the eco-features added to the eAMS are designed to promote climate-conscious prescribing of inhalers while considering the preference and ability of each individual patient. Our study will evaluate the implementation of the eAMS-Eco in four primary care clinics which are already using the eAMS, with an overall goal of reducing inhaler emissions in the primary care of patients with asthma.

Clinician eligibility criteria:

Inclusion criteria:

-Active clinician at one of the four study sites during the study period

Patient eligibility criteria:

Inclusion criteria:

• Patient at one of the four study sites with a visit during the study period

• Diagnosis of asthma (using validated algorithm for primary care of

  1. asthma billing code (493) in the past 3 years OR asthma in the cumulative patient profile (CPP) and
  2. prescription for an inhaler in the past year