Closed-Loop Electronic Referral From Primary Care Clinics to a State Tobacco Cessation Quitline: Effects Using Real-World Implementation Training.

INTRODUCTION: Patients who use tobacco are too rarely connected with tobacco use treatment during healthcare visits. Electronic health record enhancements may increase such referrals in primary care settings. This project used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the implementation of a healthcare system change carried out in an externally valid manner (executed by the healthcare system). METHODS: The healthcare system used their standard, computer-based training approach to implement the electronic health record and clinic workflow changes for electronic referral in 30 primary care clinics that previously used faxed quitline referral. Electronic health record data captured rates of assessment of readiness to quit and quitline referral 4 months before implementation and 8 months (May-December 2017) after implementation. Data, analyzed from October 2018 to June 2019, also reflected intervention reach, adoption, and maintenance. RESULTS: For reach and effectiveness, from before to after implementation for electronic referral, among adult patients who smoked, assessment of readiness to quit increased from 24.8% (2,126 of 8,569) to 93.2% (11,163 of 11,977), quitline referrals increased from 1.7% (143 of 8,569) to 11.3% (1,351 of 11,977), and 3.6% were connected with the quitline after implementation. For representativeness of reach, electronic referral rates were especially high for women, African Americans, and Medicaid patients. For adoption, 52.6% of staff who roomed at least 1 patient who smoked referred to the quitline. For maintenance, electronic referral rates fell by approximately 60% over 8 months but remained higher than pre-implementation rates. CONCLUSIONS: Real-world implementation of an electronic health record-based electronic referral system markedly increased readiness to quit assessment and quitline referral rates in primary care patients. Future research should focus on implementation methods that produce more consistent implementation and better maintenance of electronic referral.

Closed-loop electronic referral to SmokefreeTXT for smoking cessation support: a demonstration project in outpatient care.

Too few smokers who present for outpatient healthcare receive evidence-based interventions to stop smoking. Referral to nationally available smoking cessation support may enhance tobacco intervention reach during healthcare visits. This study evaluated the feasibility of outpatient electronic health record (EHR)-enabled, closed-loop referral (eReferral) to SmokefreeTXT, a National Cancer Institute text message smoking cessation program. SmokefreeTXT eReferral for adult patients who smoke was implemented in a family medicine clinic and an allergy and asthma clinic in an integrated Midwestern healthcare system. Interoperable, HIPAA-compliant eReferral returned referral outcomes to the EHR. In Phase 1 of implementation, clinicians were responsible for eReferral; in Phase 2 this responsibility shifted to Medical Assistants and/or nurses. EHR data were extracted to compute eReferral rates among adult smokers and compare demographics among those eReferred versus not referred. SmokefreeTXT data were used to compute SmokefreeTXT enrollment rates among those eReferred. Descriptive analyses of clinic staff surveys assessed implementation context and staff attitudes toward and adaptations of eReferral processes. During clinician implementation, 43 of 299 adult smokers (14.4%) were eReferred. During medical assistant (MA) implementation, 36 of 401 adult smokers (9.0%) were eReferred. Overall, among those eReferred, 25.7% completed SmokefreeTXT enrollment (3.1% of patients eligible for eReferral). Staff survey responses indicated that eReferral was efficient and easy. eReferral rates and relevant attitudes varied meaningfully by clinic. Thus, interoperable eReferral via outpatient EHR to SmokefreeTXT is feasible and acceptable to clinic staff and enrolls roughly 3.0% of smokers. Clinic context and implementation approach may influence reach.

Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project.

Few smokers receive evidence-based tobacco treatment during healthcare visits. Electronic health records (EHRs) present an opportunity to efficiently identify and refer smokers to state tobacco quitlines. The purpose of this case study is to develop and evaluate a secure, closed-loop EHR referral system linking patients visiting healthcare clinics with a state tobacco quitline. A regional health system, EHR vendor, tobacco cessation telephone quitline vendor, and university research center collaborated to modify a health system's EHR to create an eReferral system. Modifications included the following: clinic workflow adjustments, EHR prompts, and return of treatment delivery information from the quitline to the patient's EHR. A markedly higher percentage of adult tobacco users were referred to the quitline using eReferral than using the previous paper fax referral (14 vs. 0.3 %). The eReferral system increased the referral of tobacco users to quitline treatment. This case study suggests the feasibility and effectiveness of a secure, closed-loop EHR-based eReferral system.