Implementation of an electronic health record-based care management system to improve tobacco treatment

Abstract

Background: Tobacco treatment is underused in primary care. We designed a Tobacco Care Management system to increase the delivery of treatment and reduce the burden on primary care providers (PCPs). A one-click functionality added to the electronic health record (EHR) allowed PCPs to refer smokers to a centralized tobacco treatment coordinator (TTC) who called smokers, provided brief counseling, connected them to ongoing treatment and gave feedback to PCPs.

Objective: To study the system's feasibility and acceptability among PCPs, and its utilization by smokers.

Design: Using a mixed methods design, we documented system utilization quantitatively from February 1, 2010 to July 31, 2011, and conducted two focus groups with PCPs in June 2011.

Participants: Thirty-six PCPs and 2,894 smokers from two community health centers in Massachusetts.

Main measures: Quantitative: One-click referral utilization by PCPs, proportion of smokers referred and connected to treatment. Qualitative: PCPs' reasons for use, barriers to use, and experiences with feedback.

Key results: Twenty-nine PCPs (81 %) used the functionality more than once, generating 466 referrals for 15 % of known smokers seen during the study. The TTC reached 260 (56 %) of the referrals and connected 135 (29 %) to additional treatment. The director of one center sent PCPs monthly feedback about their utilization compared to peers. These PCPs referred a greater proportion of their known smokers (18 % vs. 9 %, p<0.0001) and reported that monthly feedback motivated referrals. PCPs attending focus groups (n=24) appreciated the system's simplicity, access to updated resources, and time-efficient way to address smoking, and wanted more feedback about cessation outcomes. They collectively supported the system's continuation.

Conclusions: A novel EHR-based Tobacco Care Management system was adopted by PCPs, especially those receiving performance feedback, and connected one-third of referred smokers to treatment. The model has the potential to improve the delivery and outcomes of evidence-based tobacco treatment in primary care.

Figure 1.

One-click option to refer to a tobacco treatment coordinator.

Figure 2.

Referrals to the Tobacco Care Management system in two Community Health Centers, February 1, 2010 through July 31, 2011. * Health Center 1 provided primary care providers with monthly performance feedback and made 366 referrals for 325 individual smokers; Health Center 2 did not send monthly feedback and made 100 referrals for 97 individual smokers, chi-squared test for proportion of referred smokers, p < 0.001. † Proportion reached in Health Center 1 vs. Health Center 2, two-tailed Fisher’s exact test, p = 0.65. ‡In terms of individual smokers, 133 (32 %) were connected to further services. § Proportion connected to services in Health Center 1 vs. Health Center 2, two-tailed Fisher’s exact test, p = 0.62.