Closed-Loop Electronic Referral From Primary Care Clinics to a State Tobacco Cessation Quitline: Effects Using Real-World Implementation Training

Abstract

Introduction: Patients who use tobacco are too rarely connected with tobacco use treatment during healthcare visits. Electronic health record enhancements may increase such referrals in primary care settings. This project used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the implementation of a healthcare system change carried out in an externally valid manner (executed by the healthcare system).

Methods: The healthcare system used their standard, computer-based training approach to implement the electronic health record and clinic workflow changes for electronic referral in 30 primary care clinics that previously used faxed quitline referral. Electronic health record data captured rates of assessment of readiness to quit and quitline referral 4 months before implementation and 8 months (May-December 2017) after implementation. Data, analyzed from October 2018 to June 2019, also reflected intervention reach, adoption, and maintenance.

Results: For reach and effectiveness, from before to after implementation for electronic referral, among adult patients who smoked, assessment of readiness to quit increased from 24.8% (2,126 of 8,569) to 93.2% (11,163 of 11,977), quitline referrals increased from 1.7% (143 of 8,569) to 11.3% (1,351 of 11,977), and 3.6% were connected with the quitline after implementation. For representativeness of reach, electronic referral rates were especially high for women, African Americans, and Medicaid patients. For adoption, 52.6% of staff who roomed at least 1 patient who smoked referred to the quitline. For maintenance, electronic referral rates fell by approximately 60% over 8 months but remained higher than pre-implementation rates.

Conclusions: Real-world implementation of an electronic health record-based electronic referral system markedly increased readiness to quit assessment and quitline referral rates in primary care patients. Future research should focus on implementation methods that produce more consistent implementation and better maintenance of electronic referral.

Figure 1.

Wisconsin Tobacco Quit Line (WTQL) electronic referral (eReferral) workflow and feedback. Notes: This workflow documents decision points and possible outcomes of eReferral workflow, beginning with identification of a patient as currently smoking during a primary care encounter. HER, electronic health record; HL7v2, High Level Seven International messaging version 2; ORM, object relational mapping; NRT, nicotine replacement therapy; ORU, object results mapping.

Figure 2.

Box-and-whisker plots of rates of assessing patient interest in quitting, patient readiness to quit within 30 days, and eReferral to the WTQL. Notes: Means are marked with an X, medians are marked with a horizontal black line, and quartiles (25th and 75th percentiles) are marked by the lower and upper borders of the colored boxes, respectively. Whiskers depict range within 1.5 times the interquartile range, and dots indicate outliers that are more than 1.5 times the interquartile range outside the box. Panel A shows distributions of implementation rates across roomers (MAs/licensed practical nurses) primarily responsible for implementation of assessment and eReferral. Panel B shows distributions of implementation rates across clinicians responsible for approving eReferral orders. Only roomers and clinicians who saw at least ten patients who smoked during the 8-month implementation period were included in these analyses. eReferral, electronic referral; WTQL, Wisconsin Tobacco Quitline; MA, medical assistant; LPN, licensed practical nurse.

Figure 3.

Plots of implementation maintenance across time. Notes: Panel A shows rates of roomer documentation of assessment of patient readiness to quit within the next 30 days (solid line) and documentation of patient reports of readiness to quit within 30 days (dashed line) in the 4 months preceding and 8 months following electronic referral (eReferral) launch. Panel B shows rates of eReferral to the Wisconsin Tobacco Quit Line (WTQL) during implementation (solid line), fax referral to the WTQL pre-implementation and during implementation (dotted line; in months −4 to −1 this includes referrals from all clinics in the healthcare system; in months 0–7, this includes fax referrals from only the 30 primary care clinics of interest in this study), and acceptance of WTQL services among all referred (regardless of referral method, dashed line). ^aThe rate for this outcome at this time point is significantly higher than the rate for the same outcome at all subsequent time points combined at p<0.05 in a χ² test. ^bThe rate for this outcome at this time point is significantly lower than the rate for the same outcome at all subsequent time points combined at p<0.05 in a χ² test.

Figure 3.

Plots of implementation maintenance across time. Notes: Panel A shows rates of roomer documentation of assessment of patient readiness to quit within the next 30 days (solid line) and documentation of patient reports of readiness to quit within 30 days (dashed line) in the 4 months preceding and 8 months following electronic referral (eReferral) launch. Panel B shows rates of eReferral to the Wisconsin Tobacco Quit Line (WTQL) during implementation (solid line), fax referral to the WTQL pre-implementation and during implementation (dotted line; in months −4 to −1 this includes referrals from all clinics in the healthcare system; in months 0–7, this includes fax referrals from only the 30 primary care clinics of interest in this study), and acceptance of WTQL services among all referred (regardless of referral method, dashed line). ^aThe rate for this outcome at this time point is significantly higher than the rate for the same outcome at all subsequent time points combined at p<0.05 in a χ² test. ^bThe rate for this outcome at this time point is significantly lower than the rate for the same outcome at all subsequent time points combined at p<0.05 in a χ² test.