Problem: Before implementation of this project, the State Tobacco Quit Line had been accessed by less than 0.5% of estimated tobacco users in Central Oregon.1 In addition, provider referrals to the Quit Line were made by fax.
PSE Change Solution: Research suggests that e-referral systems significantly increase the percentage of tobacco users referred to quit lines and illustrates the benefit of incorporating a “closed loop*” interface.2,3,4 Accordingly, the Oregon Health Authority, Public Health Division (OHA-PHD) used data to identify the largest impact for the EHR improvement, and to track patient referrals, Quit Line utilization of services, and patient outcome reports. OHA-PHD also convened partners to identify roles, responsibilities and resources and to align on a shared goal to implement the PSE change. Partners involved in this initiative included numerous private, state and local entities. As a result of their work, Quit Line referrals increased over 4,000% between August 2017 and January 2018.
*In a closed loop referral, a health care provider refers a patient to a quit line electronically, and then the outcome of the referral is sent from the quit line back to the referring provider, automatically importing any related medications in the electronic health record (EHR).2
1Oregon Health Authority. (2016). Oregon Quit Line. Unpublished data.
2Adsit, R. T., Fox, B. M., Tsiolis, T., Ogland, C., Simerson, M., Vind, L. M., & Fiore, M. C. (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, 4(3), 324-332. doi: 10.1007/s13142-014-0259-y
3Boyle, R., Solberg, L., & Fiore, M. (2014). Use of electronic health records to support smoking cessation. Cochrane Database of Systematic Reviews, (12) CD008743. doi: 10.1002/14651858.CD008743.pub3
4Greenwood, D.A., Parise, C.A., MacAller, T.A., Hankins, A.I., Harms, K.R., Pratt, L.S., . . . Buss, K.A. (2012). Utilizing clinical support staff and electronic health records to increase tobacco use documentation and referrals to a state quitline. Journal of Vascular Nursing, 30(4), 107–111. doi: 10.1016/j.jvn.2012.04.001
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Problem
Too few people who use tobacco in Central Oregon take advantage of the State Tobacco Quit Line (Quit Line). According to internal records, before implementation of this project, the Quit Line had been accessed by less than 0.5% of estimated tobacco users in Central Oregon (Oregon Health Authority, 2016). In addition, provider referrals to the Quit Line could only be made by fax.This PSE change effort was designed to address the underutilization of the State Tobacco Quit Line by electronically referring tobacco-using primary care patients in Central Oregon. Prior research suggests that e-referral systems significantly increase the percentage of tobacco users referred to quit lines and illustrates the benefit of incorporating a “closed loop” interface (Adsit et al., 2014; Boyle, Solberg, & Fiore, 2011; Greenwood et al., 2012). A closed loop referral is where a health care provider refers a patient to a quit line electronically, and then the outcome of the referral is sent from the quit line back to the referring provider, automatically importing any related medications in the electronic health record (EHR) (Adsit et al., 2014).
PSE Solution
Adsit el al. reported that the percentage of adult tobacco users referred to a quit line service increased from 0.3% to 13.9% once e-referrals were utilized (Adsit et al., 2014). Based on the evidence from this prior research, along with best practices promoted by the North American Quit Line consortium, the Oregon Health Authority, Public Health Division (OHA-PHD) has prioritized investment in the e-referral functionality for the State Tobacco Quit Line to increase access of tobacco users. E-referrals will support cessation efforts, ultimately reducing the number of tobacco users and greatly improving health outcomes statewide.Following discussions with stakeholders, OHA-PHD identified and worked with several partners across Central Oregon to support e-referral buildout implementation for the largest EHR system in Oregon through investments in local and state systems. As a result of this project, Quit Line referral is now a bi-directional referral in Central Oregon, and ongoing training and education on this referral process is being provided by the local tobacco prevention and education program to health systems with e-referral capabilities.
Actions/Results
Actions- Use data to identify the largest impact for the EHR improvement, and use data to track patient referrals, Quit Line utilization of services, and patient outcome reports
- Convene partners to identify roles, responsibilities and resources dedicated to making the policy, systems and environmental (PSE) change and align on a shared goal to implement the change
Results
The e-referrals project was completed in August 2017, and to date the project has already demonstrated a significant increase in referrals to the Quit Line. At the nine Central Oregon clinics where the e-referral functionality was implemented, 207 referrals were made to the State Tobacco Quit Line between August 2017 and January 2018. This is compared to five referrals during the same period the prior year. This is over a 4,000% increase in referrals.
Success Factors and Key Questions Addressed
Which stakeholders needed to be included in your efforts and how did you assemble them?It was important for private, state and local entities involved in Quit Line referrals to be included in this effort. Participants included:
- Oregon Health Authority: Provided funding to the Quit Line to develop its capabilities to accept the bi-directional referral.
- PacificSource Community Solutions Coordinated Care Organization (CCO)/Central Oregon Health Council: Provided quality incentive metric funding to support the e-referral build within the selected Central Oregon clinics for the bi-directional referral.
- Crook County Health Department: Local public health authority that convened CCO and clinic partners, and coordinated implementation and training of bi-directional referral to clinic providers.
- Deschutes County Health Services: Local public health authority that convened CCO and clinic partners, and coordinated implementation and training of bi-directional referral to clinic providers.
- Jefferson County Health Department: Local public health authority that convened CCO and clinic partners, and coordinated implementation and training of bi-directional referral to clinic providers.
- La Pine Community Health Center: Clinic provider that implemented the bi-directional referral to the Quit Line.
- Mosaic Medical: Clinic provider that implemented the bi-directional referral to the Quit Line.
- OCHIN: The EPIC electronic health records provider.
- Optum: Oregon Tobacco Quit Line contractor that provides quit line services (counseling and pharmacological support) throughout Oregon.
How did the missions of diverse stakeholders align for the purpose of the PSE change effort?
Stakeholders involved in all aspects of Quit Line referrals shared the goal of increasing referrals to the Quit Line. This bi-directional interface serves as a closed loop referral, making it easier for providers to submit referrals and receive useful information back on patient outcomes, improving cessation outcomes. This allowed clinics to also demonstrate increased efficiency of EHRs to send out referrals and accept patient utilization information to improve patient care.
What resources (tangible and intangible) were needed that stakeholders could provide?
Funding was needed to enable electronic referrals. Deschutes County Health Services secured Quality Incentive Measure funding from its local coordinated care organization, PacificSource Community Solutions and from the Central Oregon Health Council. Quality Incentive Measures are measures that CCOs use to show how well they improve care, by making quality care accessible, eliminating health disparities and reducing health care costs.
CCOs are eligible to receive payments based on their performance each year connected to the different measures. This funding supported the functionality of OHCIN Epic EHR within clinics in Central Oregon, which allowed electronic referrals to the Quit Line. Additional funding was provided by OHA-PHD to Optum, the State Tobacco Quit Line contractor, to be able to accept referrals via the OCHIN Epic EHR system.
Related Resources
For more information, please see the Oregon Tobacco Quit Line or North American Quit Line Consortium. Additional guidance is available through resources on Tobacco Cessation Electronic Referrals Frequently Asked Questions, Tobacco Cessation Technical Assistance for CCOs, and this webpage on CCO Incentive Measures.
References
Adsit, R. T., Fox, B. M., Tsiolis, T., Ogland, C., Simerson, M., Vind, L. M., & Fiore, M. C. (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, 4(3), 324-332. doi: 10.1007/s13142-014-0259-y
Boyle, R., Solberg, L., & Fiore, M. (2014). Use of electronic health records to support smoking cessation. Cochrane Database of Systematic Reviews, (12) CD008743. doi: 10.1002/14651858.CD008743.pub3
Greenwood, D.A., Parise, C.A., MacAller, T.A., Hankins, A.I., Harms, K.R., Pratt, L.S., . . . Buss, K.A. (2012). Utilizing clinical support staff and electronic health records to increase tobacco use documentation and referrals to a state quitline. Journal of Vascular Nursing, 30(4), 107–111. doi: 10.1016/j.jvn.2012.04.001
Resources to Support Similar Evidence-Based Initiatives
The Community Guide:
• Tobacco Use: Quitline Interventions
Evidence-Based Cancer Control Programs:
• Air It Out
• Clinical Effort Against Secondhand Smoke Exposure (CEASE)
• Project WISE
What Works for Health:
• Tobacco quitlines