eAMS-Eco: Implementation of a Tool for Climate Conscious Inhaler Prescribing

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.