Tobacco Cessation Intervention

Steps:

• Identify a Tobacco Cessation Practice Champion

• The role of a champion in tobacco cessation is an important one; they take ownership and are a point person to facilitate, promote, and monitor the overall initiative, acting as a liaison between patients and staff. The cessation champion can help to identify gaps and inefficiencies in workflow to maximize effectiveness. The champion could be a provider or any other staff member that is willing or passionate about smoking cessation. The champion can bring forward change, acting as a quality assurance professional and ensure that services are constantly improving and working towards a better standard.

  Consider the following activities for a tobacco cessation champion:

  • Attend trainings, assist with questions, and manage workflow, due dates, documentation and data.
  • Assemble the team that will work together on screening implementation, documentation, and reporting of outcomes.
  • Assist clinical staff to incorporate education and resources to support the continuing improvement and implementation of services.
  • Work with clinical staff to ensure appropriate documentation of services.
  • Lead adjustments to workflows and interventions as needed.

  The primary benefit of having a smoking cessation champion is that they identify and mitigate issues with workflows such as documentation in the EHR as well as closely monitor performance rates. A dedicated staff member monitoring rates and processing ensures that the screening will become part of the normal rooming activity and documentation is accurate.

  Links:

  Tip Sheet for Physician Champions Office Champions Tobacco Cessation National Dissemination Project

• Configure EHR

• There are different levels of EHR integration for tobacco cessation. When working on integrating tobacco cessation in your EHR and developing a workflow that is appropriate for your organization, it is important to work with your entire team (e.g., providers, receptionists, and medical assistants). Walk through the process with staff so they can see what the process looks like and can understand what their role may be. To configure an EHR system to support Tobacco Cessation efforts, utilize these steps:

  • In your EHR, locate the pre-built templates or forms specifically designed for documenting tobacco use and tobacco cessation interventions. Enable and, if needed, customize these templates to capture relevant patient information, interventions, follow-up plans, and outcomes.
  • Update patient demographics, include tobacco use status as a standard field in the patient demographics section of the EHR. This allows easy identification of patients who are tobacco users and provides a quick overview of patients.
  • Develop specific documentation templates or forms for providers to record tobacco cessation interventions. This can include counseling sessions, prescription of nicotine replacement therapy or smoking cessation medications, referrals to specialized programs, and follow-up plans.
  • Implement Clinical Decision Support (CDS) tools within the EHR to help providers in delivering evidence-based tobacco cessation Interventions. This can include pop-up reminders or alerts when a tobacco use status indicates the need for intervention or when a provider is ordering medications that may interact with smoking cessation medications. See the next section for more details on utilizing CDS functionality.
  • Integrate links or references to reliable tobacco cessation resources within the EHR. This can include patient education materials, online support programs, local smoking cessation programs, and help/quit lines. Ensure these resources are accessible to providers and patients.
  • Configure the EHR system to generate reports that summarize tobacco cessation activities within your practice. These reports can include the number of patients screened for tobacco use, the percentage of smoker’s provided with counseling/interventions, and the quit rate achieved.
  • Provide training and education to providers on how to effectively use the EHR's tobacco cessation feature. This includes familiarizing them with templates, decision support tools, and reporting functions.
  • Encourage the Clinicians to get involved in the EHR modification process. Providers use the EHR daily and have firsthand knowledge and great suggestions for its use.

  Obtain a Direct Address for your provider/practice. A Direct Address is used to exchange health information using direct secure messaging. It is a technical standard for exchanging protected health information (PHI) between healthcare entities (e.g., primary care physicians, specialists, hospitals, and clinical labs) through a trusted network.

  To enable Point of Care (POC) Clinical Decision Support (CDS) tobacco user alerts, follow these general steps:

  • Identify the Clinical Decision Support System: Determine the specific CDS system being used within your Electronic Health Record (EHR). This should have the capability to support Point of Care CDS alerts.
  • Configure the Tobacco User Alert: Access the administrative settings or configuration options of the EHR or CDS system. Look for the section related to CDS alerts or notifications.
  • Define Alert Criteria: Specify the criteria that will trigger the tobacco user alert. This may include patient demographics, smoking history, recent encounters, or documented tobacco use.
  • Set Alert Triggers: Determine the events or actions that will trigger the tobacco user alert. For example, the alert can be triggered when a patient's chart is accessed, during the medication ordering process, or when relevant clinical data is entered.
  • Customize Alert Content: Customize the content of the tobacco user alert to provide relevant information to providers. This may include the patient’s smoking status, associated health risks, recommended interventions, and available resources for smoking cessation.
  • Determine Alert Delivery: Specify how the tobacco user alert will be delivered to the providers. This can be brought up as pop-up notifications, flagging the patient’s chart, or display the alert within the workflow of the EHR.
  • Define User Actions: Determine the recommended actions for providers when the tobacco user alert is triggered. This may include offering smoking cessation counseling, ordering appropriate diagnostic tests, prescribing smoking cessation medications, or referring the patient to a tobacco cessation program such as Michigan’s Quitline.
  • Test and Validate: Conduct thorough testing of the tobacco user alert functionality to ensure it is working as intended. Validate that the alert is triggered correctly based on the defined criteria and that it is delivered to the appropriate providers.
  • Train Providers: Provide training and education to providers on the purpose, significance, and proper response to the tobacco user alert. Ensure they understand the available resources and interventions for supporting tobacco cessation efforts.
  • Monitor and Evaluate: Continuously monitor the effectiveness of the tobacco user alert. Assess whether it is leading to improved identification and intervention for tobacco users and evaluate its impact on patient outcomes and smoking cessation rates. Adjust as needed.

• Tobacco Cessation Clinical Workflow

• Screen for tobacco use with every patient, every visit (done by the Medical Assistant or Provider). This is an approach designed to facilitate the routine assessment of tobacco use status among all patients.

  1. Ask – about tobacco product use
  2. Advise – about the benefits of quitting and the support available
  3. Connect– people that are interested in quitting, cessation counseling, and medication support

  If the patient consents to a referral for cessation support counseling, you can follow these steps below. Healthcare providers can enhance communication, promote timely sharing of information, and ensure the referring provider receives the results of the referral order, leading to improved coordination and continuity of care:

  • Send an electronic referral (if technologically available). Consolidated-Clinical Data Architecture (CCDA) is used to create documents and standardize the content and structure for clinical care summaries. CCDA files are a means to securely transfer medical records between EHR systems. (Fax from the EHR if electronic transmission of the CCDA via direct secure messaging is not yet available)
  • Provide the patient a prescription for medication support (If needed).
  • Ensure that the provider ordering the referral receives the results of the referral order (Closing the Referral Loop). Closing the referral loop, which ensures that the provider ordering the referral receives the results, is crucial for effective communication and continuity of care.
    • When making the referral, ensure that all necessary details are included, such as the reason for referral, specific tests or consultations requested, and any relevant patient information. Clear and concise instructions will help the receiving provider understand the purpose of the referral.
    • Depending on the healthcare system and available resources, referrals can be sent electronically through the EHR systems, via secure messaging, or through traditional methods like Fax.
    • Follow up with the receiving provider's office to ensure they have received the referral request. This can be done through a secure messaging system or a phone call. Document the confirmation for future reference.
    • Implement a system to track the referral from initiation to completion. This could include assigning a unique identifier or tracking number to the referral and updating its status at each stage (Sent, Received, Appointment scheduled, results obtained, etc.)
    • If the referral requires prompt attention or has a specific timeline, communicate this information to the receiving provider. It helps prioritize the referral and ensures timely follow-up. Along with the referral, specify expectation for receiving the results. Include a request for the receiving provider to send results back to the referring provider within a specified timeframe.
    • Regularly review the status of pending referrals to identify any delays or outstanding results. If there are any delays, reach out to the receiving providers office to inquire. Once the referral results are received, promptly review them to ensure info is complete and accurate.
    • After reviewing the referral results, communicate findings to the patient. Provide necessary explanations, recommendations, and next steps required. This ensures the patient is informed and involved in their care.
    • Maintain a record of the referral process, including the referral request, confirmation of receipt, any communication with the receiving provider, and the final results. This documentation helps in maintaining a comprehensive medical record and facilitates future reference if needed.
  • Follow up on progress with the patient on subsequent visit(s).

  Links:

  Workflow Analysis for design of an Electronic Health Record-Based Tobacco Cessation Intervention in Community Health Centers

• Tracking Reports

• Clinical Quality Measures can be included in reports and dashboards to provide insights into the effectiveness of smoking cessation interventions, identify areas for improvement, and track progress over time. By monitoring these measures, providers can assess the quality of care delivered, identify gaps in smoking cessation services, and make informed decisions to enhance patient outcomes in smoking cessation efforts. Generate reports for quality and performance reporting and create dashboards to monitor patient progress.

  • Generate a list of patients in your EHR who smoke/use tobacco.
  • From your EHR, obtain a list of patients referred to a tobacco cessation support service (Tobacco Cessation Champion or designated staff follows up with patients in one month after each referral).

  ADDITIONAL RESOURCES

  Undiagnosed Hypertension Partner Toolkit | Million Hearts (hhs.gov)

  Blood Pressure Control Evidence and Resources

  State System Medicaid Coverage of Tobacco Cessation Treatments Fact Sheet