Integrating Tobacco Dependence Treatment into Electronic Medical Records at Partners HealthCare

1. Integrating Tobacco Dependence Treatment into Electronic Medical Records at Partners HealthCare Nancy Rigotti, MD Director, Tobacco Research & Treatment Center Massachusetts General Hospital, Harvard Medical School Chair, Tobacco Treatment Task Force, Partners HealthCare Boston, MA

2. Partners HealthCare System • Largest health care delivery system in Mass. • 6 hospitals • - 2 teaching hospitals (MGH, BWH) • - 4 community hospitals • >1000 primary care physicians • Electronic medical record systems • Outpatient: locally-developed EMR • Inpatient: electronic order entry system

3. 5A MODEL OF BRIEF COUNSELING Revised to facilitate adoption into practice • ASK • ADVISE • ASSESS • ASSIST • ARRANGE Office staff Core physician role Refer to in-house or community resource

4. Tobacco in the Outpatient EMR Problems • Smoking status coded in health maintenance • Multiple clicks needed to access • Data entered for only 20% of patients • No direct way to access local or community counseling resources • E-prescribing of tobacco meds possible but no decision support • Documentation not codable or standardized

5. CEASCEComputerized EHR-Assisted Smoking Cessation Effort • Funding • NCI grant, AHRQ Practice-Based Research Network • Study Aims • Develop EMR intervention consistent with 5A model • Implement it in a practice-based research network • Assess uptake by clinicians • Partners Goals • Get smoking status as a coded field • Facilitate the clinician’s job

6. CEASCE Components • Smoking “icon” - visual smoking status cue • Written reminders to document and intervene • Enhanced Health Maintenance Screen • Tobacco “Smart Form” Integrate decision support, ordering, & documentation “One-click” referral to smoking coordinator or Quitline Printable patient handouts Prescribe medications Everything ordered is easily documented

7. Smoking status not in system Reminds physician to enter smoking status

8. Identifies patient as a smoker Reminds physician to address smoking

9. Tobacco “Smart Form”

10. Tobacco “Smart Form”

11. 18 Practices 9 Intervention Practices 9Control Practices (Usual Care) Contact Rate (%) Contact Rate (%) Randomize CEASCE - STUDY DESIGN 9 month intervention period began 12/19/06

12. National Hospital Quality Measures(JCAHO / Medicare Core Measures ) Among patients who • Smoked in past 12 months AND • Diagnosis = MI or CHF or pneumonia Does chart document that smoking cessation advice, counseling or medication was offered during hospital stay?

13. NHQM Smoking Measures MGH Scores – 1st year (2004)

14. MGH INPATIENT MODEL • Step 1: Routine smoking status ID at admit In an electronic database • Step 2: Brief care from care unit (nurse) • Nurses provide booklet, document in chart, refer • Doctor orders NRT

17. MGH INPATIENT MODEL • Step 1: Routine smoking status ID at admit in an electronic database • Step 2: Brief advice from care unit (nurse) Nurses provide booklet, document in chart, refer Doctor orders NRT • Step 3: Counseling (smoking counselor) • Step 4: Post-discharge care Fax referral to free state telephone quitline

18. Smoking Status Addition to Admission Order Template(Implemented 12/06)

19. Smoking Status Addition to Admission Order Template

20. Smoking Status Addition to Admission Order Template Smoking Status Question No Yes Yes, order patch Unknown Stop Automatic consult sent to smoking counselor AutomaticRN order to give out booklet Automatic consult sent to smoking counselor AutomaticRN order to give out booklet And NRT order generated Ask again

21. NHQM Smoking MeasuresMGH Scores: Q2 04 – Q4 06

22. MGH Post Hospital Patient Care PlanAddition made 11/06 for all hospital discharges • If you, a family member, or friend smoke or use tobacco products, please consider using these resources to help you quit: • MGH Tobacco Treatment Service: 617-726-7443 • Massachusetts Smokers’ Helpline: • 1-800-TRY-TO-STOP • 1-800-8DEJAO (En Español/ Em Portugês) • 1-800-TDD-1477 (Hearing Impaired)

23. Next Steps • Process measures have been improved • Have clinical outcomes improved? • Telephone follow-up of smokers counseled 2 weeks, 3 months after discharge Results: Regan S et al, “Outcomes of a smoking cessation counseling program for hospitalized smokers” Poster #71 - Thursday 11:30 AM

24. Lessons Learned • Electronic interventions are cumbersome to create and implement in practice • Getting to top of IT “priority list” for programmers • Simple concepts are not simple to program • Money talks (grant $) • Getting MDs to use new tools (even good ones!) is a challenge • Public reporting of performance triggers change • Brings resources • Can move your ideas to top of priority list • Focus is on fixing the measures, not the outcomes

25. Thanks to… • Partners HealthCare sponsor – Elizabeth Mort, MD • CEASCE Team BWH: Jennifer Haas, MD; Jeff Linder, MD; Louise Schneider, MD; Jennifer Kelley MGH: Nancy Rigotti, MD; Jonathan Winickoff, MD Partners Information Services programmers • MGH Tobacco Treatment Service Manager: Michele Reyen, MPH Data Manager: Susan Regan, PhD Counselors: Joanne Hilgenberg, MSW; Jean Mizer, BSN; Nancy McCleary, MSN; Kathy McKool, MSN Coordinators: Ann Richards, Karen Silva