Sutter Health and Helpline Collaborate On Pilot Study To Integrate Tobacco Cessation Into Electronic Medical Records

By Deborah Greenwood, RN, MEd, CNS, BC-ADM, CDE

July, 2010

Tobacco users who receive advice and resources to quit from their provider have higher satisfaction rates yet, only 33% of tobacco users report being advised to quit and referred to a program by a doctor during the past 12 months. In addition, providers and clinic staff often do not have the time in their busy schedules or the necessary counseling skills to effectively counsel patients on tobacco cessation.

The growing implementation of electronic medical records (EMR) in primary care may provide an opportunity to more systematically identify and refer smokers to state quitlines, thereby increasing the number of smokers who receive help for tobacco dependence.

In an attempt to improve the identification of tobacco users and increase referrals for tobacco cessation, Sutter Health collaborated with the California Smokers’ Helpline to implement a pilot study at three Sutter Medical Foundation (SMF) Care centers in the Sacramento Sierra Region. Medical Assistants (MA) were designated as “tobacco cessation promoters” and utilized EPIC, the Sutter Health EMR software, to generate proactive referrals to the California Smoker’s Helpline.

The pilot had significant support from the Director of Clinical Operations as well as clinician support at the pilot care centers. As part of the new work-flow, MA’s were responsible for implementing the Ask, Advise, Refer (AAR) brief intervention with every patient, at every encounter.

The MA’s attended a 60 minute initial training to learn about AAR and the work-flow. MA’s Ask all patients if they use tobacco or if anyone in their household uses tobacco, and then document the response in the EMR. For all tobacco users, the MA’s Advise them that it is in the best interest of their health to quit. Finally, the MA’s Refer them to the California Smoker’s Helpline for free telephone counseling. If the patient accepts assistance, a proactive letter is generated via the EMR, attached to the encounter and sent directly to the California Smoker’s Helpline via the communication management fax.

Key to the work-flow is the knowledge that the MA is not making a personal recommendation but is making a health-system directive in which our health system and the patient’s clinician encourage the patient to quit using tobacco, following MA scope of practice. Also key to the process is the understanding that the patient must be ready to quit and must be willing to have the Helpline contact them.  The Helpline letter includes a verbal consent field that allows the MA to send the letter immediately to the Helplinebefore the encounter is closed.

The MA then documents “301-Tobacco Cessation education” in the chief complaint field to cue the clinician that the AAR intervention has occurred and that the patient has agreed to counseling.  The provider is then encouraged to dialog with the patient and discuss the potential need for medication support, as research indicates that a combination of counseling and medication is most effective.

To facilitate documentation by the clinician, a Smart Set was developed for use in the EMR.  The Smart Set includes the typical diagnosis used for this encounter as well as current formulary medications that may be prescribed.

Sutter Health will be tabulating the pre and post intervention outcome data soon and look forward to sharing the results. A systematic approach to tobacco cessation in primary care is essential.  Engaging MA’s and utilizing the EMR to connect patients to state quitlines may improve tobacco cessation counseling utilization.

UCSD Health Sciences and Medical Center Campuses Go Smoke-Free

By Alicia Gormican, Zachary Schlagel, John West, M.D., UCSD Smoke-Free Task Force

May 31, 2010

As part of its commitment to provide a healthier environment for patients, visitors, faculty, staff and students, all UC San Diego Health Sciences academic and Health System campuses became entirely smoke-free on World No Tobacco Day, May 31, 2010.

We began by convening a Smoke-Free Task Force of representatives from all areas of the Health System, neighboring communities, local community health organizations, and the California Smokers’ Helpline, which is operated by UCSD. Task Force members conducted initial research among other hospitals that had implemented successful smoke-free policies and then developed a strategy for promoting, implementing, and enforcing the new policy.

To capitalize on this opportunity to help smokers quit, we worked with the California Smokers’ Helpline to integrate cessation messages into our policy efforts since a growing body of evidence demonstrates smoke-free policies not only reduce exposure to secondhand smoke but also encourage smokers to quit.

The Helpline has played an important role in the Task Force by educating members about Helpline services and the importance of integrating cessation messages into policy implementation, and by participating in Task Force events designed to educate patients, students, faculty, employees, and visitors about the new policy and about cessation resources.

The Task Force is implementing a comprehensive campaign about the new policy and resources for quitting smoking. The campaign includes providing smoking cessation resources, a new Web site at http://blink.ucsd.edu/HR/policies/conduct/smoke/health-sciences.html and a smoke-free commemorative event on June 1. In addition, the new permanent, no-smoking signs at UC San Diego Medical Center – Hillcrest and La Jolla will feature the Helpline’s toll-free telephone number: 1-800-NO-BUTTS.

Feedback has been positive -- staff and patients alike have been happy to hear about the policy change and the many cessation resources available to smokers. The Smoke-Free Task Force has been very pleased to participate in this effort to maximize the positive impact of UC San Diego’s policy change on both secondhand smoke exposure and cessation among all those who learn, work, visit, and seek medical services at UC San Diego.

Have a success story or strategies to increase cessation that you would like to share with others? Please e-mail Kirsten Hansen at k3hansen@ucsd.edu.