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.

Quitting smoking leads to improved outcomes for patients with cancer, yet too few patients receive cessation services during their oncology healthcare visits. The National Cancer Institute (NCI) dedicated Cancer Moonshot funding for NCI-Designated Cancer Centers to develop a population-based approach to reach all patients who smoke with tobacco treatment services. As a result, the Cancer Center Cessation Initiative (C3I) offers an unparalleled opportunity to identify effective implementation strategies and barriers to delivering tobacco treatment services across multiple clinical oncology settings. Over one year after receiving funding, the first cohort of C3I funded Centers demonstrated progress in hiring tobacco treatment specialists, adding new tobacco treatment programs, and integrating EHR-based tobacco treatment referrals. However, tobacco treatment program reach remains low in some settings, even using a broad definition of patient engagement. Centers identified implementation challenges related to staff training needs, devising new clinical workflows, and engagement of IT leadership. Understanding implementation challenges may help other clinical oncology settings effectively implement tobacco treatment programs, leading to improved cancer outcomes by helping patients quit smoking.

Introduction Low income populations are especially likely to smoke and have difficulty quitting. This study evaluated a monetary incentive intended to increase smoking treatment engagement and abstinence amongst Medicaid recipients who smoke. Study Design 2-group randomized clinical trial of Incentive (n=948) and Control interventions (n=952) for smoking. Setting/Participants Medicaid recipients recruited from primary care patients (n=920) and callers to the Wisconsin Tobacco Quit Line (WTQL; n=980). Intervention Participants were offered five quitline cessation calls and were encouraged to obtain cessation medication (covered by Medicaid). Only Incentive condition participants received compensation for taking counseling calls ($30 per call) and for biochemically-verified abstinence at the 6-month visit ($40). All participants received additional payment for completing a baseline assessment and a 6-month smoking test. Main Outcome Measures 7-day point-prevalence smoking abstinence 6-months post study entry and cost/quit. Results Incentive condition participants had significantly higher biochemically determined 7-day point-prevalence smoking abstinence rates 6 months after study induction than did Controls (21.6% vs. 13.8%, respectively: p<.0001). A positive treatment effect of incentives was present across other abstinence indices, but the size of effects and levels of abstinence varied considerably across indices. Incentive condition participants were also significantly more likely than non-incentivized Control participants to accept WTQL treatment calls and their acceptance of calls mediated their attainment of higher abstinence rates at 6-month follow-up. The cost/quit/participant averaged $4,268.26 for the Control participants and $3,601.37 for the Incentive participants. Conclusions This study shows that fairly moderate levels of incentive payments for treatment engagement and abstinence (a total possible payment of = $190) increased very low income smokers’ engagement and success in smoking cessation treatment.

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