An electronic health record–based interoperable eReferral system to enhance smoking Quitline treatment in primary care

Abstract

Objective The study sought to determine whether interoperable, electronic health record–based referral (eReferral) produces higher rates of referral and connection to a state tobacco quitline than does fax-based referral, thus addressing low rates of smoking treatment delivery in health care. Materials and Methods Twenty-three primary care clinics from 2 healthcare systems (A and B) in Wisconsin were randomized, unblinded, over 2016-2017, to 2 smoking treatment referral methods: paper-based fax-to-quit (system A =6, system B = 6) or electronic (eReferral; system A = 5, system B = 6). Both methods referred adult patients who smoked to the Wisconsin Tobacco Quitline. A total of 14 636 smokers were seen in the 2 systems (system A: 54.5% women, mean age 48.2 years; system B: 53.8% women, mean age 50.2 years). Results Clinics with eReferral, vs fax-to-quit, referred a higher percentage of adult smokers to the quitline: system A clinic referral rate = 17.9% (95% confidence interval [CI], 17.2%-18.5%) vs 3.8% (95% CI, 3.5%-4.2%) (P < .001); system B clinic referral rate = 18.9% (95% CI, 18.3%-19.6%) vs 5.2% (95% CI, 4.9%-5.6%) (P < .001). Average rates of quitline connection were higher in eReferral than F2Q clinics: system A = 5.4% (95% CI, 5.0%-5.8%) vs 1.3% (95% CI, 1.1%-1.5%) (P < .001); system B = 5.3% (95% CI, 5.0%-5.7%) vs 2.0% (95% CI, 1.8%-2.2%) (P < .001). Discussion Electronic health record–based eReferral provided an effective, closed-loop, interoperable means of referring patients who smoke to telephone quitline services, producing referral rates 3-4 times higher than the current standard of care (fax referral), including especially high rates of referral of underserved individuals. Conclusions eReferral may help address the challenge of providing smokers with treatment for tobacco use during busy primary care visits. ClinicalTrials.gov; No. NCT02735382.

Tobacco Treatment Program Implementation at NCI Cancer Centers: Progress of the NCI Cancer Moonshot-Funded Cancer Center Cessation Initiative

“…Yet, more progress is needed as evidenced by relatively low tobacco treatment program reach in some settings, even using a broad definition of engagement. However, average reach rate in the C3I programs (about 25%) should be interpreted in light of the fact that reach rates for tobacco treatment in primary care settings are typically 15% or much lower (26,27). At baseline, even among these highly resourced NCI-Designated Comprehensive Cancer Centers, only one Center had already implemented automatic EHR-based referrals to tobacco treatment for all patients who smoke.…”

Health System Implementation of a Tobacco Quitline eReferral

“…The Helpline treatment reach of 61% is comparable or higher than others reported in the clinical trials by Vidrine et al (68.7%) 26 and Fiore et al (30% connected but not necessarily treated). 12 The similar treatment reach between the Helpline and group class suggest that these offerings are not mutually exclusive and can be promoted concurrently. Our treatment reach (1.6%) is higher than the ask-advise-refer group (0.5%) but lower than an ask-advise-connect group (14%) in a study by Vidrine et al 26 This may reflect our inclusion of inpatient eReferrals which had lower rates of accepting services.…”

“…4,36 Even the "complete case" quit rate of 21.9% may reflect an underestimate of the higher range, as only half of the patients who had a eReferral had a follow-up clinic visit within the year. 12,26 We did not measure utilization of medications, which may improve quit rates, as these may not have been prescribed and documented in the EHR but used over the counter. There was also a concurrent Helpline offer for free nicotine patches mailed directly to patients in the Medi-Cal Incentives to Quit Smoking project (2012-2015) 30 which would also not have been documented in the EHR.…”

“…9 In "bidirectional" eReferrals, the outcomes of the quitline are reported back to the health system's ordering provider and have higher referral rates than traditional fax-based referrals. [10][11][12] Most eReferral studies relied on team-based models and are focused on either inpatient or outpatient implementations rather than changes across a health care system or in specialty settings. 9,[13][14][15][16] Specialty services like oncology are important settings for promoting tobacco cessation.…”

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

“…There is growing evidence, however, that with this approach, the QL is unable to contact and/or keep enrolled a large percentage of the patients who agree to be connected (12,(14)(15)(16). Adsit et al found that among tobacco users consenting to be eReferred to the QL, 64.8% later declined cessation services (14).…”