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OBJECTIVE: Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation. METHODS: The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies. RESULTS: The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment. DISCUSSION: Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation. CONCLUSION: As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations.
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Tecnología de la Información , Informática Médica , Comercio , Registros Electrónicos de Salud , Humanos , TecnologíaRESUMEN
OBJECTIVE: To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians. METHODS: We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author. RESULTS: Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible. CONCLUSION: Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.
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OBJECTIVES: Define a legal framework for electronic medical records (EMRs) and determine the degree to which the countries of the Region of the Americas are prepared in this regard. METHODS: The methodology consisted of two phases. In the first, a Delphi methodology was used to develop a questionnaire and define the framework and legal domains applicable to EMRs. In the second, the questionnaire was completed in each country. This included identifying national experts and the data collection process. RESULTS: Information was collected from a total of 21 countries regarding their situation with respect to legislation on EMRs in the following domains: 1) specific legislation on EMRs; 2) protection of patients' data and secondary use of the data; 3) legislation related to the actions of health professionals; 4) regulation on EMRs and the role of patients; and 5) health standards and EMR promotion programs. CONCLUSIONS: There has been progress in the Region with respect to new legislation covering the main areas related to EMRs (for example, protection of sensitive data and use of digital signatures). However, it is necessary to continue to address issues such as access to and updating of information in EMRs. This study contributes information on the essential components of legislation on EMRs, and reports on the situation in the Region of the Americas.
OBJETIVOS: Definir um enquadramento legal para os registros eletrônicos em saúde (RES) e identificar o grau de preparação dos países da Região das Américas neste sentido. MÉTODOS: A metodologia do estudo foi dividida em duas fases. Na primeira fase, foi usado o método Delphi para elaborar o questionário e definir o enquadramento e os domínios legais para RES. Na segunda fase, foi realizada a pesquisa por país, com a identificação de dados referentes nacionais e processo de coleta de dados. RESULTADOS: Ao todo, foram obtidos dados de 21 países sobre os aspectos legais e RES distribuídos nos seguintes domínios: 1) legislação específica para RES, 2) proteção dos dados dos pacientes e uso secundário da informação, 3) legislação relacionada à atuação dos profissionais da saúde, 4) regulamentação dos RES e papel dos pacientes e 5) padrões em saúde e programas de promoção dos RES. CONCLUSÕES: Houve progresso na Região quanto à promulgação de leis que abrangem os principais domínios dos RES (p. ex., proteção de dados sensíveis ou o uso de assinatura digital). Porém, alguns aspectos precisam ser reforçados, como o acesso e a atualização das informações nos registros. Este estudo contribui ao descrever os aspectos básicos da regulamentação e informar a situação dos RES na Região das Américas.
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BACKGROUND: At the point of care, evidence from randomized controlled trials (RCTs) is underutilized in helping clinicians meet their information needs. OBJECTIVE: To design interactive visual displays to help clinicians interpret and compare the results of relevant RCTs for the management of a specific patient, and to conduct a formative evaluation with physicians comparing interactive visual versus narrative displays. METHODS: We followed a user-centered and iterative design process succeeded by development of information display prototypes as a Web-based application. We then used a within-subjects design with 20 participants (8 attendings and 12 residents) to evaluate the usability and problem-solving impact of the information displays. We compared subjects' perceptions of the interactive visual displays versus narrative abstracts. RESULTS: The resulting interactive visual displays present RCT results side-by-side according to the Population, Intervention, Comparison, and Outcome (PICO) framework. Study participants completed 19 usability tasks in 3 to 11 seconds with a success rate of 78% to 100%. Participants favored the interactive visual displays over narrative abstracts according to perceived efficiency, effectiveness, effort, user experience and preference (all P values <.001). CONCLUSIONS: When interpreting and applying RCT findings to case vignettes, physicians preferred interactive graphical and PICO-framework-based information displays that enable direct comparison of the results from multiple RCTs compared to the traditional narrative and study-centered format. Future studies should investigate the use of interactive visual displays to support clinical decision making in care settings and their effect on clinician and patient outcomes.
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Ensayos Clínicos como Asunto/métodos , Presentación de Datos/tendencias , Toma de Decisiones/fisiología , Conducta en la Búsqueda de Información/fisiología , Femenino , Humanos , MasculinoRESUMEN
The purpose of this study is to determine the perceptions by physicians of an educational system integrated into an electronic health record (EHR). Traditional approaches to continuous medical education (CME) have not shown improvement in patient health care outcomes. Hospital Italiano de Buenos Aires (HIBA) has implemented a system that embeds information pearls into the EHR, providing learning opportunities that are integrated into the patient care process. This study explores the acceptability and general perceptions of the system by physicians when they are in the consulting room. We interviewed 12 physicians after one or two weeks of using this CME system and we performed a thematic analysis of these interviews. The themes that emerged were use and ease of use of the system; value physicians gave to the system; educational impact on physicians; respect for the individual learning styles; content available in the system; and barriers that were present or absent for using the CME system. We found that the integrated CME system developed at HIBA was well accepted and perceived as useful and easy to use. Future work will involve modifications to the system interface, expansion of the content offered and further evaluation.
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Actitud del Personal de Salud , Instrucción por Computador/estadística & datos numéricos , Sistemas de Apoyo a Decisiones Clínicas/estadística & datos numéricos , Educación Médica Continua/estadística & datos numéricos , Registros Electrónicos de Salud/estadística & datos numéricos , Registros de Salud Personal , Argentina , Evaluación Educacional , Integración de SistemasRESUMEN
Purpose: To rigorously develop a prototype clinical decision support (CDS) system to help clinicians determine the appropriate timing for follow-up visual field testing for patients with glaucoma and to identify themes regarding the context of use for glaucoma CDS systems, design requirements, and design solutions to meet these requirements. Design: Semistructured qualitative interviews and iterative design cycles. Participants: Clinicians who care for patients with glaucoma, purposefully sampled to ensure a representation of a range of clinical specialties (glaucoma specialist, general ophthalmologist, optometrist) and years in clinical practice. Methods: Using the established User-Centered Design Process framework, we conducted semistructured interviews with 5 clinicians that addressed the context of use and design requirements for a glaucoma CDS system. We analyzed the interviews using inductive thematic analysis and grounded theory to generate themes regarding the context of use and design requirements. We created design solutions to address these requirements and used iterative design cycles with the clinicians to refine the CDS prototype. Main Outcome Measures: Themes regarding decision support for determining the timing of visual field testing for patients with glaucoma, CDS design requirements, and CDS design features. Results: We identified 9 themes that addressed the context of use for the CDS system, 9 design requirements for the prototype CDS system, and 9 design features intended to address these design requirements. Key design requirements included the preservation of clinician autonomy, incorporation of currently used heuristics, compilation of data, and increasing and communicating the level of certainty regarding the decision. After completing 3 iterative design cycles using this preliminary CDS system design solution, the design was satisfactory to the clinicians and was accepted as our prototype glaucoma CDS system. Conclusions: We used a systematic design process based on the established User-Centered Design Process to rigorously develop a prototype glaucoma CDS system, which will be used as a starting point for a future, large-scale iterative refinement and implementation process. Clinicians who care for patients with glaucoma need CDS systems that preserve clinician autonomy, compile and present data, incorporate currently used heuristics, and increase and communicate the level of certainty regarding the decision. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.
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OBJECTIVE: This article reports on the alignment between the foundational domains and the delineation of practice (DoP) for health informatics, both developed by the American Medical Informatics Association (AMIA). Whereas the foundational domains guide graduate-level curriculum development and accreditation assessment, providing an educational pathway to the minimum competencies needed as a health informatician, the DoP defines the domains, tasks, knowledge, and skills that a professional needs to competently perform in the discipline of health informatics. The purpose of this article is to determine whether the foundational domains need modification to better reflect applied practice. MATERIALS AND METHODS: Using an iterative process and through individual and collective approaches, the foundational domains and the DoP statements were analyzed for alignment and eventual harmonization. Tables and Sankey plot diagrams were used to detail and illustrate the resulting alignment. RESULTS: We were able to map all the individual DoP knowledge statements and tasks to the AMIA foundational domains, but the statements within a single DoP domain did not all map to the same foundational domain. Even though the AMIA foundational domains and DoP domains are not in perfect alignment, the DoP provides good examples of specific health informatics competencies for most of the foundational domains. There are, however, limited DoP knowledge statements and tasks mapping to foundational domain 6-Social and Behavioral Aspects of Health. DISCUSSION: Both the foundational domains and the DoP were developed independently, several years apart, and for different purposes. The mapping analyses reveal similarities and differences between the practice experience and the curricular needs of health informaticians. CONCLUSIONS: The overall alignment of both domains may be explained by the fact that both describe the current and/or future health informatics professional. One can think of the foundational domains as representing the broad foci for educational programs for health informaticians and, hence, they are appropriately the focus of organizations that accredit these programs.
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UNLABELLED: This study investigates the implementation of an alert system for the isolation of vancomycin resistant enterococci (VRE) colonized patients. Given the risk of admitting a patient colonized by VRE it is necessary to implement efficient isolation measures. An electronic alert system integrated into a health information system (HIS) could help with the detection of these patients and their isolation in proper units. OBJECTIVES: Determine the efficacy of an electronic alert system in improving the rate of properly isolation of patients colonized with VRE. METHODS: two consecutive series of admission in adults units of 67 patients that were infected or colonized with VRE were compared. The time period of the study was six months before the implementation of the alert system and six months post-implementation of the system. RESULTS: The proportion of admission with proper isolation of the patient in correct units increased 44% after the alert system implementation. CONCLUSION: The implementation of an alert system improved the proportion of properly isolated patients with VRE.
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Infección Hospitalaria/prevención & control , Registros Electrónicos de Salud , Enterococcus , Registros de Salud Personal , Sistemas de Entrada de Órdenes Médicas , Aislamiento de Pacientes , Resistencia a la Vancomicina , Alarmas Clínicas , Humanos , Almacenamiento y Recuperación de la Información/métodos , Interfaz Usuario-ComputadorRESUMEN
OBJECTIVES: To summarize significant research contributions published in 2021 in the field of clinical decision support (CDS) systems and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook. METHODS: The authors searched the MEDLINE® database for papers focused on clinical decision support (CDS) systems. From search results, section editors established a list of candidate best papers, which were then peer-reviewed by at least three external reviewers. The IMIA Yearbook editorial committee selected the best papers on the basis of all reviews including the section editors' evaluation. RESULTS: A total of 337 articles were retrieved from which 13 candidate papers were identified. Finally, from the candidate papers, the top three papers were selected. The first paper introduces an innovative evaluation approach to CDS systems, the second compares six health institutions on how they are measuring CDS alert fatigue and the last one adds new evidence on how CDS can help to reduce unnecessary interventions.
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Sistemas de Apoyo a Decisiones Clínicas , MEDLINE , Bases de Datos Factuales , Revisión por ParesRESUMEN
OBJECTIVES: To summarize research contributions published in 2020 in the field of clinical decision support systems (CDSS) and computerized provider order entry (CPOE), and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook 2021. METHODS: Two bibliographic databases were searched for papers referring to clinical decision support systems. From search results, section editors established a list of candidate best papers, which were then peer-reviewed by seven external reviewers. The IMIA Yearbook editorial committee finally selected the best papers on the basis of all reviews including the section editors' evaluation. RESULTS: A total of 1,919 articles were retrieved. 15 best paper candidates were selected, the reviews of which resulted in the selection of two best papers. One paper reports on the use of electronic health records to support a public health response to the COVID-19 pandemic in the United States. The second paper proposes a combination of CDSS and telemedicine as a technology-based intervention to improve the outcomes of depression as part of a cluster trial. CONCLUSIONS: As shown by the number and the variety of works related to clinical decision support, research in the field is very active. This year's selection highlighted the application of CDSS to fight COVID-19 and a combined technology-based strategy to improve the treatment of depression.
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Sistemas de Apoyo a Decisiones Clínicas , Sistemas de Entrada de Órdenes Médicas , Telemedicina , COVID-19 , Depresión/terapia , HumanosRESUMEN
Background: In order to prevent spread and improve control of infectious diseases, public health experts need to closely monitor human and animal populations. Infectious disease surveillance is an established, routine data collection process essential for early warning, rapid response, and disease control. The quantity of data potentially useful for early warning and surveillance has increased exponentially due to social media and other big data streams. Digital epidemiology is a novel discipline that includes harvesting, analysing, and interpreting data that were not initially collected for healthcare needs to enhance traditional surveillance. During the current COVID-19 pandemic, the importance of digital epidemiology complementing traditional public health approaches has been highlighted. Objective: The aim of this paper is to provide a comprehensive overview for the application of data and digital solutions to support surveillance strategies and draw implications for surveillance in the context of the COVID-19 pandemic and beyond. Methods: A search was conducted in PubMed databases. Articles published between January 2005 and May 2020 on the use of digital solutions to support surveillance strategies in pandemic settings and health emergencies were evaluated. Results: In this paper, we provide a comprehensive overview of digital epidemiology, available data sources, and components of 21st-century digital surveillance, early warning and response, outbreak management and control, and digital interventions. Conclusions: Our main purpose was to highlight the plausible use of new surveillance strategies, with implications for the COVID-19 pandemic strategies and then to identify opportunities and challenges for the successful development and implementation of digital solutions during non-emergency times of routine surveillance, with readiness for early-warning and response for future pandemics. The enhancement of traditional surveillance systems with novel digital surveillance methods opens a direction for the most effective framework for preparedness and response to future pandemics.
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OBJECTIVE: Tobacco use is the leading cause of preventable morbidity and mortality in the United States. Quitlines are effective telephone-based tobacco cessation services but are underutilized. The goal of this project was to describe current clinical workflows for Quitline referral and design an optimal electronic health record (EHR)-based workflow for Ask-Advice-Connect (AAC), an evidence-based intervention to increase Quitline referrals. MATERIALS AND METHODS: Ten Community Health Center systems (CHC), which use three different EHRs, participated in this study. Methods included: 9 group discussions with CHC leaders; 33 observations/interviews of clinical teams' workflow; surveys with 57 clinical staff; and assessment of the EHR ecosystem in each CHC. Data across these methods were integrated and coded according to the Fit between Individual, Task, Technology and Environment (FITTE) framework. The current and optimal workflow were notated using Business Process Modelling Notation. We compared the requirements of the optimal workflow with EHR capabilities. RESULTS: Current workflows are inefficient in data collection, variable in who, how, and when tobacco cessation advice and referral are enacted, and lack communication between referring clinics and the Quitline. In the optimal workflow, medical assistants deliver a standardized AAC intervention during the visit intake. Referrals are submitted electronically, and there is bidirectional communication between the clinic and Quitline. We implemented AAC within all three EHRs; however, deviations from the optimal workflow were necessary. CONCLUSION: Current workflows for Quitline referral are inefficient and ineffective. We propose an optimal workflow and discuss improvements in EHR capabilities that would improve the implementation of AAC.
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OBJECTIVE: To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations. MATERIALS AND METHODS: We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations. RESULTS: University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape. DISCUSSION: Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation. CONCLUSION: EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.
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This paper describes the development and implementation of a web based electronic health record for the Homecare Service program in the Hospital Italiano de Buenos Aires. It reviews the process of the integration of the new electronic health record to the hospital information system, allowing physicians to access the clinical data repository from their Pc's at home and with the capability of consulting past and present history of the patient health care, order, tests, and referrals with others professionals trough the new Electronic Health Record. We also discuss how workflow processes were changed and improved for the physicians, nurses, and administrative personnel of the Homecare Services and the educational methods used to improve acceptance and adoption of these new technologies. We also briefly describe the validation of physicians and their field work with electronic signatures.
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Prestación Integrada de Atención de Salud/organización & administración , Registros Electrónicos de Salud/organización & administración , Servicios de Atención de Salud a Domicilio/organización & administración , Modelos Organizacionales , Argentina , Integración de SistemasRESUMEN
Numerous studies have shown that the quality of health care is inadequate, and healthcare organizations are increasingly turning to clinical decision support systems (CDSS) to address this problem. In implementing CDSS, a highly promising architectural approach is the use of decision support services. However, there are few reported examples of successful implementations of operational CDSS using this approach. Here, we describe how Hospital Italiano de Buenos Aires evaluated the feasibility of using the SEBASTIAN clinical decision support Web service to implement a CDSS integrated with its electronic medical record system. The feasibility study consisted of three stages: first, end-user acceptability testing of the proposed CDSS through focus groups; second, the design and implementation of the system through integration of SEBASTIAN and the authoring of new rules; and finally, validation of system performance and accuracy. Through this study, we found that it is feasible to implement CDSS using a service-based approach. The CDSS is now under evaluation in a randomized controlled trial. The processes and lessons learned from this initiative are discussed.
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Sistemas de Apoyo a Decisiones Clínicas , Atención a la Salud , Registros Electrónicos de Salud , Estudios de Factibilidad , Departamentos de Hospitales , InternetRESUMEN
Preanesthetic evaluation purpose is to reduce morbidity and mortality through the review of the patient's medical history, clinical examination, and targeted clinical studies, providing referrals for medical consultations when appropriated. Changes in patient care, standards of health information management and patterns of perioperative care, have resulted in a re-conceptualization of this process where the documentation of patient medical information, the efforts in training and maintaining the integrity of the medical-legal evaluation are areas of concern. The aim of this paper is to describe the design, development, training, and implementation of a computerized preanesthetic evaluation form associated to the evaluation of the user satisfaction with the system. Since the system went live in September 2008 there were 15121 closed structured forms, 60% for ambulatory procedures and 40 % for procedures that required hospital admission. 82% of total closed structured forms had recorded a risk of the procedures of 1-2, according to the American Society of Anesthesiologists classification. The survey indicates a positive general satisfaction of the users with the system.
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Anestesia/normas , Registros Electrónicos de Salud , Informática Médica/métodos , Cuidados Preoperatorios , Computadores/estadística & datos numéricos , Documentación , Humanos , Satisfacción PersonalRESUMEN
Social determinants of health (SDH) are a valuable source of health information which still are not fully utilized in the clinical space. Knowing that a certain patient has trouble finding transportation, has a potentially hazardous relationship with a family member or close relative, is currently unemployed, or various other social factors would allow providers to tailor treatment plans in a way to best help that patient. However, these SDH must be gathered, represented, and stored in a standardized way before they can be leveraged by informatics tools designed for health providers. This process of translating SDH to standardized clinical entities includes two main steps. The first is a collaborative effort to establish an ontology of medical terminology codes (i.e., ICD, SNOMED, LOINC, etc.) which can be used to uniformly represent SDH as coded concepts. The second is a collaborative effort to use the FHIR standard to create profiles and extensions which will allow FHIR resources to be used to store the coded SDH as clinical entities. Each of these steps has their own complexities that must be considered and accounted for in future efforts to create interoperable clinical informatics solutions which utilize SDH.
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Determinantes Sociales de la Salud , Atención a la Salud , Logical Observation Identifiers Names and Codes , Systematized Nomenclature of MedicineRESUMEN
OBJECTIVE: To identify needs in a clinical decision support tool development by exploring how primary care providers currently collect and use family health history (FHH). DESIGN: Survey questionnaires and semi-structured interviews were administered to a mix of primary and specialty care clinicians within the University of Utah Health system (40 surveys, 12 interviews). RESULTS: Three key themes emerged regarding providers' collection and use of FHH: (1) Strategies for collecting FHH vary by level of effort; (2) Documentation practices extend beyond the electronic health record's dedicated FHH module; and (3) Providers desire feedback from genetic services consultation and are uncertain how to refer patients to genetic services. CONCLUSION: Study findings highlight the varying degrees of engagement that providers have with collecting FHH. Improving the integration of FHH into workflow, and providing decision support, as well as links and tools to help providers better utilize genetic counseling may improve patient care.
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BACKGROUND: Tobacco use remains the leading cause of death and disability in the USA and is disproportionately concentrated among low socioeconomic status (SES) populations. Community Health Centers (CHCs) are a key venue for reaching low SES populations with evidence-based tobacco cessation treatment such as Quitlines. Electronic health record (EHR)-based interventions at the point-of-care, text messaging (TM), and phone counseling have the potential to increase Quitline reach and are feasible to implement within CHCs. However, there is a lack of data to inform how, when, and in what combination these strategies should be implemented. The aims of this cluster-randomized trial are to evaluate multi-level implementation strategies to increase the Reach (i.e., proportion of tobacco-using patients who enroll in the Quitline) and Impact (i.e., Reach × Efficacy [efficacy is defined as the proportion of tobacco-using patients who enroll in Quitline treatment that successfully quit]) and to evaluate characteristics of healthcare system, providers, and patients that may influence tobacco-use outcomes. METHODS: This study is a multilevel, three-phase, Sequential Multiple Assignment Randomized Trial (SMART), conducted in CHCs (N = 33 clinics; N = 6000 patients). In the first phase, clinics will be randomized to two different EHR conditions. The second and third phases are patient-level randomizations based on prior treatment response. Patients who enroll in the Quitline receive no further interventions. In phase two, patients who are non-responders (i.e., patients who do not enroll in Quitline) will be randomized to receive either TM or continued-EHR. In phase three, patients in the TM condition who are non-responders will be randomized to receive either continued-TM or TM + phone coaching. DISCUSSION: This project will evaluate scalable, multi-level interventions to directly address strategic national priorities for reducing tobacco use and related disparities by increasing the Reach and Impact of evidence-based tobacco cessation interventions in low SES populations. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT03900767) on April 4th, 2019.