Workflow analysis for design of an electronic health record-based tobacco cessation intervention in community health centers.

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.

Application of community - engaged dissemination and implementation science to improve health equity.

Community engagement is critical to accelerate and improve implementation of evidence-based interventions to reduce health inequities. Community-engaged dissemination and implementation research (CEDI) emphasizes engaging stakeholders (e.g., community members, practitioners, community organizations, etc.) with diverse perspectives, experience, and expertise to provide tacit community knowledge regarding the local context, priorities, needs, and assets. Importantly, CEDI can help improve health inequities through incorporating unique perspectives from communities experiencing health inequities that have historically been left out of the research process. The community-engagement process that exists in practice can be highly variable, and characteristics of the process are often underreported, making it difficult to discern how engagement of community partners was used to improve implementation. This paper describes the community-engagement process for a multilevel, pragmatic randomized trial to increase the reach and impact of evidence-based tobacco cessation treatment among Community Health Center patients; describes how engagement activities and the resulting partnership informed the development of implementation strategies and improved the research process; and presents lessons learned to inform future CEDI research.

QuitSMART Utah: an implementation study protocol for a cluster-randomized, multi-level Sequential Multiple Assignment Randomized Trial to increase Reach and Impact of tobacco cessation treatment in Community Health Centers.

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.

Tight junctions: is there a role in dermatology?

A variety of tight junction (TJ) proteins including claudins, occludin, tricellulin, zonula occludens-proteins and junctional adhesion molecules have been identified in complex localization patterns in mammalian epidermis. Their expression and/or localization is frequently altered in skin diseases including skin tumors. However, our understanding of the function(s) of TJ and TJ proteins in the skin is, even though rapidly increasing, still limited. This review summarizes our current knowledge of the involvement of TJ and TJ proteins in mammalian skin in functions ascribed to TJ in simple epithelia, such as barrier function, polarity, gene expression, proliferation, differentiation, and vesicle transport.

Poverty-related factors associated with obesity prevention policies in Utah secondary schools.

To address the childhood obesity epidemic, numerous national agencies have outlined specific school policy recommendations for nutrition and physical activity. The extent to which current policies differ by socioeconomic status and geographic location is yet to be determined. This cross-sectional study examined select school nutrition and physical activity policies by markers for poverty among 209 middle and high schools in Utah (82% response rate). The results show that students' opportunities to establish healthful dietary and physical activity patterns differed by economic circumstances and geographic location. Schools with the highest percentage of free and reduced-price lunch enrollment and schools in rural areas were both less likely to offer a variety of healthful foods outside of the school meal program (ie, competitive foods and drinks) and intramural activities or physical activity clubs. Schools with highest free and reduced-price lunch enrollment were more likely to allow the purchase of unhealthful snacks during lunchtimes than schools with low enrollment (28.4% vs 7.6%, P=0.01). Schools in rural communities were less likely to promote walking and bicycling to school compared with other locations (47.4% rural vs 67.1% urban and 63.6% suburban, P=0.06). Current school policies related to nutrition and physical activity may not be conducive to reducing the childhood overweight problem among children attending schools in areas with increased risk factors due to poverty or rural location in Utah.