Abstract
Tobacco dependence treatment for hospitalized smokers results in long-term cessation if treatment continues at least 30 days post-discharge. Health information technology may facilitate ongoing tobacco dependence treatment after hospital discharge. To describe the use and impact of a new decision support tool and order set for inpatient physicians, addressing tobacco dependence treatment for hospitalized smokers, embedded in an electronic health record (EHR). In a cluster-randomized trial, 254 physicians were randomized (1:1) to either receive or not receive the decision support tool and order set, which were embedded in the Epic (Madison, WI) EHR used at 2 hospitals in a single city. When an adult patient was admitted to a medical service, an electronic alert appeared if the patient was coded in the EHR as a smoker. For physicians randomized to the intervention, the alert linked to an order set to prescribe tobacco treatment medications and refer the patient to the state tobacco quitline. Additionally, “tobacco use disorder” was added to the patient’s problem list, and an e-mail was sent to the patient’s primary care provider (PCP). In the control arm, an alert fired with no screen visibility. Generalized estimating equations were used to model the data. Since August 2013, the alert has appeared for 10,939 patients (5391 intervention, 5548 control). Compared to control physicians, intervention physicians were more likely to order tobacco treatment medication (35 vs. 29%, P < 0.0001), populate the problem list with tobacco use disorder (41 vs. 2%, P < 0.0001), and make a referral to the state smokers’ quitline (30 vs. 0%, P < 0.0001). In addition, intervention physicians sent an e-mail to the patient’s PCP 4152 (99%) times. Designing and implementing an order set and alert for tobacco treatment in an EHR is feasible and helps physicians place more orders for tobacco treatment medication, referrals to the state smokers’ quitline, and e-mails to patients’ PCPs. Data on cessation outcomes are pending. Trial registration: www.ClinicalTrials.gov (NCT01691105).
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Fiore, M. C., Goplerud, E., & Schroeder, S. A. (2012). The Joint Commission’s new tobacco-cessation measures—will hospitals do the right thing? N Engl J Med, 366(13), 1172–1174. doi:10.1056/NEJMp1115176.
Blumenthal, D., & Tavenner, M. (2010). The meaningful use regulation for electronic health records. N Engl J Med, 363(6), 501–504. doi:10.1056/NEJMp1006114.
Buntin, M. B., Burke, M. F., Hoaglin, M. C., & Blumenthal, D. (2011). The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff, 30(3), 464–471. doi:10.1377/hlthaff.2011.0178.
Jamal, A., McKenzie, K., & Clark, M. J. (2009). The impact of health information technology on the quality of medical and health care: a systematic review. Health Information Management J, 38(3), 26–37.
Duffy, S. A., Karvonen-Gutierrez, C. A., Ewing, L. A., Smith, P. M., & Team, V. T. T. (2010). Implementation of the tobacco tactics program in the Department of Veterans Affairs. J Gen Intern Med, 25, 3–10. doi:10.1007/s11606-009-1075-9.
Adsit, R., Fox, B., Tsiolis, T., Ogland, C., Simerson, M., Vind, L., & Fiore, M. (2014). Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project. Translational Behavioral Medicine, 1–9. doi:10.1007/s13142-014-0259-y.
Rigotti, N. A., Munafo, M. R., & Stead, L. F. (2008). Smoking cessation interventions for hospitalized smokers: a systematic review. Arch Intern Med, 168(18), 1950–1960. doi:10.1001/archinte.168.18.1950.
Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. (2012). Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care, 50(3), 217–226. doi:10.1097/MLR.0b013e3182408812.
Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., & Wewers, M. E. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: US Department of Health and Human Services.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: preparing people for change (2d ed.). New York: Guilford Press.
Mojica, W. A., Suttorp, M. J., Sherman, S. E., Morton, S. C., Roth, E. A., Maglione, M. A., & Shekelle, P. G. (2004). Smoking-cessation interventions by type of provider: a meta-analysis. Am J Prev Med, 26(5), 391–401.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2d ed.). New York: Lawrence Erlbaum Associates.
Acknowledgements
We would like to thank the many hospitalists and residents in the Department of Medicine who helped us design and test the integrated tobacco order set. We also wish to thank our colleagues at Epic who assisted with E-STOPS design and implementation.
Authors’ contributions
SLB designed and led the study and takes overall responsibility for its conduct. JR managed the study on a daily basis and contributed to intervention design. MD and ALH designed and tested the Electronic Support Tool and Orders for the Prevention of Smoking (E-STOPS). JD led the statistical analyses. JT, SS, and POC designed and led the training of the physicians. BT contributed to study design and endpoint selection. All authors contributed to drafting the manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
The findings in this paper have not been previously published. The manuscript has not been submitted elsewhere. Partial results were reported at the 2014 and 2015 Annual Meetings of the Society for Research on Nicotine and Tobacco. The authors have full control of all primary data. We agree to allow the journal to review data, if requested. No animals were used in this research.
The study was approved by the Human Investigations Committee of Yale University. All subjects gave written informed consent. The study complies with the Declaration of Helsinki.
Funding
This study was supported by R18HL105208 from the National Heart, Lung, and Blood Institute of the National Institutes of Health.
Conflict of interest
The authors declare that they have no competing interests.
Additional information
Implications
Practice: Enhancing the treatment of hospitalized smokers with electronic decision support is feasible, and can lead to dramatic improvements in processes of care.
Policy: Because of the near-universality of electronic health records and telephone quitlines in developed countries, and the extensive literature demonstrating the clinical efficacy and cost effectiveness of tobacco dependence treatment, electronic decision support for tobacco is a scalable, cost-effective approach to the population-based management of the leading cause of death in the developed world.
Research: Future work should examine the impact of electronic decision support on quit rates, the incidence of subsequent tobacco-related health events, and how to electronically integrate tobacco dependence treatment across all inpatient and outpatient clinical encounters.
Appendix
Appendix
.
Tobacco order set
.
E-mail message to primary care physicians
.
Text added to discharge (i.e., after-visit) summary
.
Feedback report to physician subjects
.
Best practice alert base record
About this article
Cite this article
Bernstein, S.L., Rosner, J., DeWitt, M. et al. Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record: a randomized trial. Behav. Med. Pract. Policy Res. 7, 185–195 (2017). https://doi.org/10.1007/s13142-017-0470-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13142-017-0470-8