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What is the role of your quitline in encouraging or supporting health-systems change? How is this role changing?

Posted By Natalia A. Gromov, Monday, June 18, 2012
Updated: Monday, June 11, 2012

Let’s move to systems-change and some discussion of the valuable role of quitlines in encouraging and supporting health-systems change. To open up this discussion, NAQC asked Todd Hill, LiCSW, LADC, Cessation Program Manager for the Vermont Department of Health and the Vice Chair of the Multi-State Collaborative for Health Systems Change Executive Committee for his thoughts on the important role quitlines play in health-systems change efforts.

A good illustration of how quitlines have contributed to systems change within healthcare is demonstrated in how they have become a valued additional option for healthcare providers that are providing the 5 A’s to address tobacco use and dependence (Ask, Advise, Assess, Assist, Arrange). This integration is often promoted or implemented as the now familiar 2 A’s and an R (Ask, Advise, Refer).

As a respected and trusted "R” quitlines step in and provide an effective, evidence-based treatment. The ready availability of quitlines to healthcare providers may lead not only to an increased volume of referrals but also to increased downstream interventions by providers. As Mike Cummings mentioned in his March 11, 2012 NAQC blog post, "Quitlines have a huge potential to contribute to population-based tobacco control efforts, but this potential has not been effectively exploited so far.”

Tobacco Control Programs and their quitline partners will rely, in part, upon increased activity in the form of referrals from the healthcare community to effectively expand reach. There are case studies that demonstrate small scale healthcare/quitline integration effectiveness however, in talking with Tobacco Control Program colleagues from around the country, it seems that low rates of provider referral remains a huge issue just as it did when I entered Tobacco Control in 2004.

Here in Vermont, according to our last Adult Tobacco Survey (2010), 36% of smokers who visited their doctor in the past 12 months were given a specific recommendation on how to address their tobacco dependence. While this is up from the pre-Vermont Tobacco Control Program baseline of 21%, I think that we can all agree that this still falls short of where it needs to be.

The early work done to integrate quitlines into healthcare has resulted in sustained improvements in healthcare practice. Identification of tobacco users became a required measure for providers for CMS Stage I – Meaningful Use. As more practices participate in CMS incentive programs and as Meaningful Use evolves, provider interventions are likely to increase and there is greater opportunity to increase referrals to quitlines.

With Meaningful Use the next frontier for quitlines will come with the incorporation of referrals into electronic health records. Quitlines cannot continue to rely upon a paper fax system to remain relevant. Tobacco Control Programs and their quitline partners are undertaking some initiatives that evolve beyond paper referrals, but the confusing and sometimes daunting world of electronic health records can make this process difficult. The solutions are not apparent.

We have to accept the fact that electronic health records do not now come "out of the box” with ability to interface with a state tobacco control program’s quitline. Can a universal solution to electronically integrate electronic health records with quitlines be found that allows for a bi-directional flow of data? Quiltines will need to continue to push for an agenda where the treatment of tobacco dependence is included in healthcare. The role of electronic health records can become a significant integration point.

This remains only part the story, as a full integration will not occur unless the providers themselves are motivated to address tobacco use and supported by clinical and electronic systems and performance goals. The quitline community must also keep up a vigilant fight (as touched on in other blog posts) to ensure that there is adequate funding for quitlines to provide services for those that are referred.

Thank you so much, Todd. What ever will we do without you? Yes, that’s right…Todd is leaving the tobacco control world to take an exciting position within Vermont’s Medicaid agency to develop better systems to treat opiate-addicted Vermonters. We wish Todd all the best and thank him so much for all of the wisdom he has shared with NAQC members over the past 8 years!

By the way – what is the role of your quitline in encouraging or supporting health-systems change? How is this role changing?

Tags:  electronic health record  health-systems change  Todd Hill  Vermont Department of Health 

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Teresa M. Brown says...
Posted Monday, June 18, 2012
Teresa from NH, here....Todd, we will miss you dearly as our "go to" tobacco control partner. Thanks for starting the conversation about systems change.

Through a small contract we partnered with the Community Health Access Network (CHAN) has 9 NH Community Health Center members and a few out of state members. The membership cost shares a Centricity EMR and established a "data user committee" that collaborates on data collection/dissemination.

The scope of the contract asked that a CHC site pilot test the implementation the 2A and R into their system for fully electronic referral AND feedback from JSI to the referring provider. Elena List was sub-contracted with to guide the implementation process because of the successful work she has done in MA with systems change.

With Elena's guidance and the expertise of CHAN's OIT staff, JSI and CHAN have established a paperless referral system (QuitWorks-NH / www.quitworksnh.org) throughout their entire CHC membership. Each fax referral is customized with the logo of the CHC and the referring provider's information is pre-populated. On the EMR page that appears when the patient is identified as using tobacco, there is a large yellow button marked QuitWorks-NH, With a click of this button the patient's information is populated into the fax referral and a hand-out is generated for the patient to read about what to expect from this referral process.

This description, of course, is a simplification of what the project really entailed. NH has created a poster presentation and displayed at a number of conferences. As word has spread, other practices have asked to join the e-fax system with JSI. The tobacco counselor protocol for following up with patients receiving tobacco treatment meets the Level III Medical Home Model criteria. Once practices hear that QuitWorks-NH offers services to assist practices meet the criteria they are eager to begin the change. Getting the word out is a challenge due to budget limitations, but there are a few practices in the process of mapping current work flow to see where 2A and R can be adopted with the least upheaval to current work patterns.

Dartmouth Hitchcock Medical Center changed their EMR from Centricity to EPIC. As I understand it, tobacco use and treatment is somewhat buried and the Care Management Department continutes to fax in paper referrals to JSI.

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