Problem Statement: EHS Primary Healthcare Centers have a large cohort of Asthma patients managed according to their best practice guidelines. There was no direct, automated method of identifying asthma patients' care compliance and clinical outcomes. This project aims to create facility-level asthma information that could provide actionable insights for program coordinators.

Description: A data application based on EHR-generated data was designed to meet these requirements. The Asthma data application captures data for all active patients diagnosed with Asthma at EHS Primary Health Care Centers.It captures statistics like patient demographics, asthma visits count, clinical status, and care compliance.The application highlights the latest disease status and care compliance gaps, as EHS policies recommend. All patients can be viewed in colour-segregated sections of good to poor compliance, spread over four indicators. All this data is updated in the system regularly and can be viewed at Organization, district and PHC levels. Feeding our proactive management model, the application captures data on the patients’ ED or hospital visits for asthma-related problems. This information is consumed by a patient risk-scoring tool which automatically translates it into a risk score from 0-3 based on ED visits, hospitalizations, and Oral steroid use in the past twelve months. This categorization prompts the care coordinators to identify and follow up with high-risk patients.The facilities can view their upcoming asthma appointments through future appointment details coupled with patients’ risk profiles.

Lessons Learned: Our asthma data application supports EHS leaders with an overview of the asthma burden, which can be helpful in resource management. . It provides a proactive platform for our program coordinators to enhance their facility-level care compliance and improve patient engagement and follow-up, to impact the entire patient care process. Stakeholder perspective: This real-time data application is equipped with relevant information for asthma patient care.