Boston Children's physicians' organization implements EHR tools to identify at-risk asthma patients

The Pediatric Physicians' Organization at Boston Children's Hospital is expanding its medical home asthma program, which uses EHR data to help identify children at-risk of asthma.

The medical home asthma program, or MAP, is in collaboration with Boston Children Hospital's Community Asthma Initiative, which aims to improve the health of children with asthma and their families. HHS awarded CAI a five-year grant to help support PPOC's efforts to implement asthma home visiting programs for all its practices outside of Boston from 2018 to 2023.

MAP is offered to practices that are part of the PPOC, which comprises more than 400 clinicians at 90-plus locations statewide. The program uses EHRs to analyze patients who may need asthma treatment. Once a patient is identified, MAP sends a community health worker to visit the patients' home to address social determinants of health that can aggravate asthma. SDOH include economic and social factors that can impact a person's health, such as poverty, food insecurity, housing insecurity and lack of transportation.

To determine patients who are higher-risk for asthma, MAP developed a risk score based on data from prescription filling patterns, the number of outpatient visits for asthma and occurrence of asthma exacerbations. MAP members conduct monthly reports for each PPOC practice to identify patients who may be at an elevated risk for uncontrolled asthma.

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