Enhancing the electronic health record to increase counseling and quit-line referral for parents who smoke

Acad Pediatr. 2014 Sep-Oct;14(5):478-84. doi: 10.1016/j.acap.2014.03.017.


Objective: To assess the impact of an electronic health record (EHR) modification and brief clinician training on tobacco smoke exposure (TSE) management in pediatric primary care.

Methods: Within a teaching hospital-based, urban primary care setting, we modified the EHR to include TSE screening prompts, decision support, educational literature, and simplified referral to the state quit line (QuitWorks). A brief training was conducted for the 48 clinic physicians (34 residents and 14 attendings). We collected cross-sectional, independent, random samples of EHR data from well-child visits for children ≤12 years old seen 3 months before (2024 visits) and 3 months after (1895 visits) the intervention and pooled client data from QuitWorks to evaluate TSE screening, counseling, and quit-line referrals. A needs assessment questionnaire examined preintervention attitudes and practice around TSE management; follow-up questionnaires explored satisfaction and subjective changes in skills.

Results: The baseline needs assessment revealed that although most clinicians agreed that it is appropriate for pediatricians to conduct TSE screening, counseling, and referral during well-child visits, only about half screened, 42% counseled, and 28% routinely offered to refer smoking parents. In pre-post analyses of 117 and 112 EHR-documented positive screens, the intervention was associated with a 16-fold greater likelihood of counseling among positive screens (adjusted odds ratio 16.12; 95% confidence interval 7.28, 35.68). Referrals to QuitWorks increased from 1 before to 31 after the intervention.

Conclusions: Implementation of EHR modifications and a brief training to support TSE management was associated with higher rates of counseling and quit-line referrals for parents who smoke.

Keywords: clinical decision support systems; electronic health record; guideline adherence; quit line; tobacco smoke pollution; tobacco use cessation.

Publication types

  • Research Support, American Recovery and Reinvestment Act
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Attitude of Health Personnel
  • Child
  • Child, Preschool
  • Counseling*
  • Cross-Sectional Studies
  • Decision Support Techniques*
  • Electronic Health Records*
  • Female
  • Hotlines*
  • Humans
  • Infant
  • Interrupted Time Series Analysis
  • Logistic Models
  • Male
  • Mass Screening
  • Parents*
  • Referral and Consultation*
  • Smoking / therapy*
  • Surveys and Questionnaires
  • Tobacco Smoke Pollution / prevention & control*


  • Tobacco Smoke Pollution