This Comment argues that economic analysis provides an inadequate account of judicial behavior because economic models are incompatible with a jurisprudence that recognizes basic rule-of-law values. Whereas standard economic theory is committed to thinking of a judge as exclusively self-interested, two fundamental problems with this conception exist. First, as application of Amartya Sen's critique of the behavioral foundations of economic theory to judicial behavior reveals, the decision of a judge who meets her judicial obligations may fail to maximize her selfinterest. Second, even if the self-interest-maximizing decision coincides with the behavior that her judicial obligations require, economic models still fail to provide an accurate explanation of judicial decision making. This inability is attributable to economic theory's failure to recognize the distinguishing feature ofjudicial behavior-what H.LA. Hart compellingly describes as relating to a rule from the internal point of view. In Overcoming Law, Richard Posner anticipates this Comment's challenge to the economic analysis of judicial behavior, but significant problems exist with his attempt to meet it. Because Posner assumes away the problem of obligation and reduces judicial motivation to self-interest, his method neglects Hart's concern with the internal aspect of obligatory
Electronic referrals provide an efficient solution for clinicians to connect patients to free tobacco cessation services, such as the tobacco Quitline. However, strategic planning is necessary for the successful adoption of this method across the health care system. The purpose of this study was to develop an implementation strategy for electronic referrals to the tobacco Quitline in a large health system. A clinical decision support tool created a closed-loop e-referral pathway between the electronic health record system and the Quitline. Multilevel strategies were developed to implement the e-referral process across the entire health system, including leadership buy-in, Epic tip sheets, newsletters, training for practice champions and staff, physician educator, patient-focused advertisements, and video clips distribution by the Maryland Department of Health Center for Tobacco Prevention and Control. The implementation of a system-wide e-referral pathway for tobacco cessation involved continuous clinician education and training, systematic quality control, and engaging “champion” clinicians. Postimplementation data analysis revealed that 1,790 e-referrals were received by the Quitline in 2018–2019, of which 18% accepted follow-up services, 18% declined, and 64% were not reached after multiple attempts. Among 322 patients who accepted Quitline services, 55% requested nicotine replacement therapy. Overall, 282 clinicians referred patients, including 107 primary care physicians and 175 specialists; 62 clinicians e-referred 72% patients, thereby emerging as “tobacco champions.” The e-referral process is an efficient method for tobacco users to receive a cessation referral from clinicians. Sustainability can be achieved through leadership buy-in, physician ease of use, patient motivation, information technology supports, and reminders.
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