Abstract
The Health Information Act of 2010 has presented an opportunity to discuss, establish, and promote innovative ways to incorporate tobacco cessation assistance to patients in the health care setting. This article provides an overview of the development and implementation of an electronic tobacco cessation protocol (the eTobacco protocol), into an electronic medical record (EMR) system, while evaluating the barriers and benefits encountered. The protocol was developed to facilitate the process of electronically referring patients to a state-funded quitline service by establishing a one-click connect for providers to use within the EMR system. While evaluating the implementation of the protocol, findings indicate that several barriers were encountered including disruption of clinic workflow, EMR limitations, and training complications. In spite of the barriers, the protocol shows promising results by increasing referrals to the quitline from 7 patients the year prior to implementation to 1,254 patients after the implementation of the electronic solution. Health care systems that have the ability to modify their EMR system can help lower tobacco use rates among their patients while meeting Meaningful Use requirements. Future research should examine if referrals through the eTobacco protocol are directly associated with patients’ tobacco cessation rates.
Keywords
Introduction
Tobacco use is the leading cause of preventable disability and death in the United States (U.S. Department of Health and Human Services, 2014b). According to the 2014 Surgeon General’s Report, cigarette smoking is responsible for approximately 480,000 deaths per year in the United States, including an estimated 41,000 deaths resulting from secondhand smoke exposure. This is about one in five deaths annually, or 1,300 deaths every day. On average, smokers die 10 years earlier than nonsmokers (U.S. Department of Health and Human Services, 2014b). Tobacco cessation often requires repeated intervention and multiple quit attempts (Fiore et al., 2008). Unfortunately, most tobacco users attempt to quit with minimal cessation assistance (Fiore et al., 2008). New technology, such as electronic medical records (EMRs), has provided an effective way of integrating a systematic approach to refer patients to tobacco cessation services (e.g., tobacco quitline services). The present study examined 18 months of fieldwork related to the development, implementation, and evaluation of a tobacco referral protocol within EMRs in three health care systems in Texas. This article discusses an electronic process, identified as the eTobacco protocol, which integrates a simple option for provider referral to the quitline services, offering a practical approach to all providers in a clinic setting.
Background
Despite more than 50 years of research establishing the negative health effects of smoking (Doll & Hill, 1954; Wynder, 1997) in 2012, 18.1%, or 42.1 million U.S. adults were still current smokers (U.S. Department of Health and Human Services, 2014b). Moreover, the economic impact of cigarette smoking is substantial. For example, tobacco use costs the United States more than $289 billion a year, including at least $133 billion in direct medical care for adults and more than $156 billion in lost productivity (U.S. Department of Health and Human Services, 2014a).
Evidence indicates the majority of smokers visit a clinician annually, which provides the opportunity for regular, brief tobacco dependence interventions (Jamal, Dube, Malarcher, Shaw, & Engstrom, 2012; Schauer, Malarcher, Zhang, Engstrom, & Zhu, 2014; Schroeder, 2012; Siflen et al., 2014). Health care providers and delivery systems (e.g., hospitals and clinics) need to consistently identify and document every patient’s tobacco use status and willingness to quit, treat every tobacco user with a combination of counseling and medication, and promote each patient’s access to tobacco prevention and cessation services (Schauer et al., 2014; Schroeder, 2012; Siflen et al., 2014). This method is consistent with the ask–advise–refer framework, an amended version of the gold standard 5As model (i.e., ask–advise–assess–assist–arrange) and the 5Rs model (i.e., relevance–risks–rewards–roadblocks–repetition), which is designed to efficiently use health care providers’ time commitments (Fiore et al., 2008; U.S. Department of Health and Human Services, 2009).
According to the U.S. Department of Health and Human Services Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009, health care providers are required to ask about tobacco use status, and they are reimbursed for counseling, referral, and/or medication to assist in tobacco cessation efforts. However, not all health care providers are equipped to offer the type of services necessary to quit (Cohen, McGinnis, & Salsberg, 2007). This is unfortunate as research demonstrates that participation in evidence-based tobacco cessation programs can help increase success rates for quitting. One type of cessation program that may be of particular importance is evidence-based quitlines. A tobacco cessation quitline is a free telephonic service through which patients receive tobacco cessation services by speaking with a tobacco cessation counselor. Quitlines are uniquely beneficial due to their flexibility and affordability (C. M. Anderson & Zhu, 2007), with some offering nicotine replacement therapy (NRT) as part of their services. Since 2006, all 50 states have quitlines funded by the Centers for Disease Control and Prevention (Schauer et al., 2014), which are often supplemented with additional state funding, offering varying levels of support by state.
One strategy, which may allow for increased provider referral to a tobacco cessation quitline, is the utilization of EMR. An EMR enables health care providers to record and store patient information electronically (Hayrinen, Saranto, & Nykanen, 2008; Schauer et al., 2014; Siflen et al., 2014). Benefits afforded by EMRs include increased patient intake efficiency, improved access to patient information (National Transitions of Care Coalition, 2010), and decreased paperwork and errors (The Office of the National Coordinator for Health Information Technology, 2011). Additional benefits of EMRs include simpler prescription systems coordination among complementary services and efficient billing and insurance processes. EMRs can also display large quantities of population-based data and provide secure patient health information when implemented across health care systems (Herrick, Gorman, & Goodman, 2010; Schauer et al., 2014; Siflen et al., 2014).
The HITECH Act requires health care systems receiving Medicare and Medicaid reimbursements to use EMRs. As of 2013, more than 50% of physicians’ clinics and 80% of eligible hospitals in the United States have implemented an EMR system (U.S. Department of Health and Human Services, 2013). Given the transition of health care systems into using EMRs, now is an opportune time to integrate specific protocols to facilitate provider effectiveness in referring patients to tobacco cessation services (Schoen et al., 2009).
EMR-facilitated interventions show promising results for improved clinical advice and documentation of patients’ smoking status (Boyle, Solberg, & Fiore, 2010), yet few studies have assessed improvements in patient-referrals to a quitline or other cessation interventions. The EMR facilitated studies that have assessed improvements in referral numbers yield mixed findings (Wadland et al., 2007). Since health care providers have little time, and are limited in specific tobacco counseling expertise (J. E. Anderson, Jorenby, Scott, & Fiore, 2002), a one-click referral option to a quitline may be beneficial (Kruse, Kelley, Linder, Park, & Rigotti, 2012). Limited research exists that demonstrates the requirements for customizations incorporating a tobacco cessation protocol into an established EMR system.
Project Overview
The primary purpose of this study was to describe the development and implementation of a one-click tobacco referral protocol for an EMR system. The project incorporates a research to practice link. The referral protocol was specifically developed to facilitate the process of connecting health care systems to increase provider referrals to a state-funded quitline service. A secondary aim was to examine specific questions, including the following:
Was the protocol implemented with fidelity?
Did the integration of the protocol increase the number of referrals to the quitline?
What barriers existed in integrating the protocol into a clinic’s workflow?
A group of 22 stakeholders from state, local, and regional offices convened in September 2010 by a state-funded initiative to improve provider-initiated tobacco cessation referrals to the quitline. The primary goal of the consortium was to design a tobacco referral protocol and provide suggestions for modifications necessary to establish commitment from health care providers (e.g., physicians, physician’s assistants, registered nurses, etc.) who would be using the protocol. Stakeholders included members of the research team, health care system decision makers (e.g., hospital administrators, hospital CEOs), policy experts, health care providers, and EMR vendors. An EMR vendor was present to discuss how a tobacco referral protocol template could be integrated into an electronic system and how the data would be shared among health care systems. The tobacco referral protocol was developed based on recommendations by the American Academy of Family Physicians (2013) resulting from their efforts with the Ask and Act Tobacco Cessation Program.
Initial meetings consisted of discussing state-level tobacco use, the benefits of a tobacco referral protocol, and hospital systems’ readiness for implementation within an EMR system. The consensus from the group was that tobacco cessation should be addressed by incorporating a tobacco referral protocol within EMRs, formally known as the eTobacco Protocol. These meetings also included discussions of modifications needed to gather appropriate information from each patient to aid in tobacco cessation and identifying workflow changes necessary to promote the use of the protocol.
The final version of the eTobacco protocol was designed to follow the ask-advise-refer framework, consisting of three questions asked by health care providers to initiate and facilitate a tobacco cessation discussion. During patients’ intake process, the eTobacco protocol prompts health care providers to ask for patients’ current tobacco use, followed by their willingness to quit tobacco. If a patient was willing to quit or was considering quitting, providers would then offer information to the patient regarding treatment availability and support services. At this point, the health care provider was usually charged with further educating the patient about the benefits of quitting, and providing a proactive referral to cessation services (for patients willing to quit), as well as further prescribing NRT and/or other medication to aid tobacco cessation. Once the patient was referred, the quitline contacted the patient and offered cessation services, specifically counseling support and free NRT. A report outlining patient enrollment status and services delivered was sent to the health care provider via the EMR system.
Pilot Test/Implementation
Approximately 3 months after the eTobacco protocol was developed, three health care systems (two urban and one rural) agreed to participate in a pilot implementation with a planned start date of January 2011. Two systems had a large provider presence (i.e., 20 or more), while the other had as little as three providers per setting. Eligibility to participate in the pilot testing was determined by level of readiness (EMR platform integrated or in process, receptive to adding to the existing tobacco protocol for referrals) assessed by the Healthcare Information Management Systems Society’s EMR Adoption Model (Healthcare Information Management Systems Society Analytics, 2007) as well as data from the Texas Medical Association and the Texas Hospital Association.
One staff member from each health care system was chosen to receive training on the ask-advise-refer protocol and the operation of the eTobacco protocol. Additionally, the chosen staff member was held responsible for training staff at their corresponding health care system. Training included different training styles specific to health care system needs, such as face-to-face, classroom style, and interactive training sessions. An hour-long training for each designated staff member was provided at each site 2 to 3 weeks prior to pilot test initiation. The pilot itself occurred over a 6-week period of time.
Method
The study proposed three specific evaluation questions listed above. Quantitative data from the quitline were used to evaluate the study’s impact based on the change in quitline referrals by the providers. Qualitative data were used to address questions regarding barriers and fidelity to the implementation of the referral protocol. Two semistructured focus groups consisting of staff from the three health care systems were conducted to evaluate their experiences using the eTobacco protocol (see questions in Table 1). The first focus group was conducted following training, and the second was conducted 6 weeks after the pilot. There were a total of 52 participants (3 physicians, 12 nurses, 19 physician assistants, and 20 medical assistants) in the focus groups who were asked open-ended questions designed to gauge the fidelity of protocol delivery through the perspective of the providers’ experiences with the protocol. Participants were also asked to identify any barriers and lessons learned concerning implementation of the eTobacco protocol. Finally, the participants were asked to suggest any potential modifications for the eTobacco protocol.
Evaluation Questions Assessing Results From Implementation
Results
The study evaluation aimed to determine (1) if the protocol was implemented with fidelity, (2) if the integration of the protocol increased the number of referrals to the quitline, and (3) what barriers existed in integrating the protocol into a health care systems workflow.
Was the Protocol Implemented With Fidelity?
The focus group data indicated that the process of integrating the eTobacco protocol into an EMR system was conducted consistently with health care systems’ workflow, indicating the protocol was implemented with fidelity. The protocol was specifically designed to ask three questions to identify tobacco users, to discuss patients’ level of readiness to quit, and to determine if the patient wanted to be referred to the quitline. Health care providers indicated that the design created a streamlined approach that maximized the time health care providers spent with patients to address other issues that contributed to tobacco-related health problems. Once the eTobacco protocol was integrated into each health care system’s EMR, it functioned as a one-click referral process. Provider interviews indicated that the protocol reduced intake time and incorporated a more strategic and planned approach for tobacco cessation referrals.
Did the Integration of the Protocol Increase the Number of Referrals to the Quitline?
The project was able to generate annual data comparing the use of paper-based/fax referrals (the only way to proactively refer patients prior to protocol integration) to the quitline (July 1, 2010–June 30, 2011) to referrals received through the EMR system for the participating clinic systems (July 1, 2011–June 30, 2012). Baseline data indicated a total of seven patients were referred to the quitline service the year prior to the integration of the eTobacco protocol. Since the implementation of the eTobacco protocol, more than 80% (285,678) of patients were screened for tobacco use (80% is the Federal requirement per the HITECH Act of 2009). Of the more than 80% who were screened, approximately 11% (31,985) were identified as tobacco users. Of those patients identified as tobacco users, 4.4% (1,418) stated they were ready to quit. Patients who were ready to quit had a referral rate of 88.4% (1,254) to the quitline service, which is a dramatic increase from the previous year.
What Barriers Existed in Integrating the Protocol Into a Clinic’s Workflow?
The following barriers were reported by the research team, as well as by health care providers in the participating health care systems during the focus groups. Overall, barriers included technical issues within clinics, workflow adjustments, and overall staff capacity. Due to technical issues, the intended implementation date was extended eight times, ultimately postponing the pilot test more than 6 months after the development of the protocol. The health care system workflow was affected, and providers at all levels needed extensive training during the pilot test on using the EMR to gather the tobacco cessation information from each patient. Additionally, focus group participants indicated that not all staff members, especially new staff, were aware of the protocol’s purpose, full capabilities, and how to use it properly. Finally, staff turnover, trainers not fulfilling their training duties, and the varying levels of EMR sophistication hampered staff members from being properly trained, and it proved to be a major barrier to the implementation of the eTobacco protocol.
Discussion
Health care systems using prompts from EMRs offer a unique setting for providers to advise and refer patients to cessation services. Research indicates that a referral to quitline services made by a health care provider not only increases quitline awareness and utilization but also more than doubles the chances of a patient actually quitting tobacco (Centers for Disease Control and Prevention, 2011; Schauer et al., 2014; Siflen et al., 2014). EMRs offer an opportunity for providers to refer patients to tobacco cessation services through a simple systematic approach. The 18 months of fieldwork conducted in this study answered questions about the fidelity for the implementation of the protocol, increased quitline referrals as a result of the integration, identified barriers specific to health care system workflow, and identified implications for other public health integrations.
Fidelity
The eTobacco protocol was integrated through a standard process for three health care systems in this study, incorporating a one-click option into the existing EMR at all participating health care systems. While the approach was implemented consistently across health care systems, a number of challenges arose throughout the process affecting fidelity. For instance, each health care system was different, and each clinic in the system had a specific and unique workflow. Moreover, trainings were originally developed for physicians conducting the intake, which included the tobacco use question; however, most of the time a nurse, medical assistant, or physician assistant completed this task. As the protocol was integrated, trainings were tailored to meet the needs of individual clinic settings. In order to implement the eTobacco protocol with fidelity, it was critical to have the commitment and support of the health care systems’ providers and staff.
Quitline Referrals
The findings of this study are consistent with results from research conducted by Greenwood and colleagues (2012), demonstrating that implementation of a system to track tobacco use status in EMRs improved the documentation and ongoing verification of tobacco use and increased referrals to a quitline (Schauer et al., 2014; Siflen et al., 2014). This research adds to the literature by describing the integration and testing of a simple one-click process of referring a patient to a quitline service. While not a defined program outcome, results showed the benefit of establishing a training program designed for all clinic staff to be able to effectively determine tobacco use status and ultimately conduct an electronic referral to a quitline. The dramatic increases in quitline referral numbers indicated that the integration process was successful at improving referrals to the quitline.
Barriers
Clinical staff members identified numerous barriers during focus group sessions, such as technical issues, workflow adjustments, and staff capacity. Clinical staff can address workflow and capacity issues within their own system. Technical issues involve the EMR vendor and often take additional time to address.
Technical Issues
Researchers found that EMR knowledge between health care systems varied. Rural health care systems, compared with urban systems, lacked developed EMR systems due to their technological limitations (i.e., lack of reliable internet service, updated equipment, and server capabilities, etc.). Moreover, EMR vendors differ widely by state and across the nation, with each vendor offering different electronic platforms and interfaces. The differences in electronic platforms and interfaces posed a challenge in the implementation of the eTobacco protocol. While no vendor appeared to be better or more efficient for the eTobacco protocol specifically, the protocol had to be flexible enough to be integrated across various vendors. Substantive background work must be done with EMR vendors to institute the protocol in an easy-to-use format.
Workflow Adjustments
Based on information gleaned from the focus groups, it was clear the implementation of the eTobacco protocol had to have limited disruption to the overall clinic workflow for the EMR system to be effectively integrated. Providers were hesitant to change tobacco status documentation procedures by adding an additional question to the existing tobacco protocol. Some clinics continued to operate within their original patient intake workflow, causing errors and incomplete/incorrect patient information. These issues were addressed with additional modifications to workflow and training.
Several workflow questions needed to be taken into consideration when integrating the eTobacco protocol: (1) when would tobacco use be assessed, (2) what member of the clinical team would conduct the assessment, and (3) when should the referral be made during the patient’s visit? Since every health care system had different ways of integrating the eTobacco protocol into their respective EMR systems, many of the clinics found it challenging to modify their original clinic workflow. The changes to overall clinic workflow made it difficult to properly implement the protocol.
Staff Capacity and Training
Staffing issues also proved to be a considerable barrier, especially during evaluation. Two clinics experienced significant turnover, while in another an employee’s leave limited the speed of integration. These challenges were addressed by development of a sustainable training video for clinical staff members who were designated as trainers. Additionally, health care providers varied on levels of EMR competency, hindering acceptance of EMR use in their health care system. For example, while administrative staff members were ready for EMR integration, clinical staff members were not similarly prepared for workflow changes.
Recommendations
It is important to conduct background research on health care systems and to collaborate with EMR software vendors to ensure the protocol is implemented in an easy-to-use format. This will assure the changes to the EMR are easy to use, and address specific workflow challenges for each health care system. Additional recommendations for implementing the eTobacco protocol into health care systems include attaining buy-in from administrative staff, health care providers, and EMR vendors for efficient integration. Initial involvement of health care system providers, including feedback on the referral templates, is crucial for successful implementation. Moreover, it is imperative to work with and recruit systems with a certain level of readiness in order to efficiently implement EMR system changes. Health care systems that may be at the early stages of implementation of an overall EMR integration may not be able to dedicate time to integrate other changes.
Based on findings from the present study, eTobacco protocol-specific training and technical support should be offered once the protocol is integrated (see Table 2). The integration within an EMR system can be a lengthy process, and there are additional measure requirements, other than tobacco, that health care systems have to receive reimbursement through the requirements in the HITECH Act. Consideration of staff time, clinic priorities, and vendor specifications as part of the overall integration is recommended for the tool to be implemented successfully. The HITECH Act provided policy and regulation changes that made the integration of the eTobacco protocol into EMRs timely. It is important to communicate the benefits that integration of the eTobacco protocol can provide to the health care system, including meeting Medicaid/Medicare requirements, lowering tobacco use rates, less complications for chronic disease conditions over time, cost savings, etc.
Key Steps for Implementing a Tobacco Referral Protocol
Further research is needed to establish whether tobacco users connected through the eTobacco protocol received appropriate tobacco cessation services and quit tobacco use completely. Future research should examine the association between referrals to tobacco cessation services and tobacco cessation rates. In addition, future research is needed to overcome the challenges associated with the various EMR vendors and the implications to the eTobacco protocol.
Footnotes
This project was supported by funding from the Texas Department of State Health Services. The article’s contents are solely the responsibility of the authors and do not necessarily represent the official views of the Texas Department of State Health Services.