NAQC's Draft Comments for ONC on Inclusion of Electonic Quitline Referral as Part of Meaningful Use
Wednesday, January 2, 2013
Posted by: Natalia Gromov
NAQC's Draft Comments for ONC on Inclusion of Electonic Quitline
Referral as Part of Meaningful Use Stage 3!
NAQC’s draft comments for ONC on inclusion of electronic quitline referral as
part of meaningful use stage 3 are below. As you will see, there are some notes
within the comments about information and citations that still need to be
We ask that you review
the comments and send any feedback to NAQC@NAQuitline.org by Tuesday, January 8. We
plan to submit our final comments to ONC on Friday, January 11, and will circulate
the final document as soon as it is ready.
NAQC encourages you to submit individual comments and to also encourage your
partners (especially health care providers and hospitals) to submit comments
that are supportive of electronic quitline referral. You are welcome to use the
text of this letter in your comments (please let us know if you would like a
word version). The submission deadline is Monday, January 14th.
The ONC recommendations are available at: http://www.healthit.gov/sites/default/files/hitpc_stage3_rfc_final.pdf
January xx, 2013
Office of the National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
Patriots Plaza III
355 E Street, SW
Washington, DC 20201
Re: ONC request for comment regarding draft recommendations for stage 3 of
meaningful use of electronic health records (EHRs)
On behalf of the North American Quitline Consortium (NAQC), I would like to
thank ONC for the opportunity to provide comments on the draft recommendations
for stage 3 of meaningful use, as proposed by the Health Information Technology
Policy Committee (HITPC). It is our hope that ONC will include electronic
quitline referral as part of its stage 3 recommendations on meaningful use of
EHRs. NAQC is committed to working with EHR vendors and eligible providers,
hospitals and acute care hospitals to implement a thoughtful, patient-centered
and cost-effective process for electronic quitline referral.
As you may know, a quitline is a health service that offers telephone support –
information, counseling, medication and other support – for people who want to
quit using tobacco. Quitlines were first demonstrated to be effective in
randomized clinical trials (1), and they are recommended for treating tobacco
use and dependence by the U.S. Public Health Service’s Clinical Practice Guideline
(2). In the U.S., quitlines exist in all 50 states, the District of Columbia,
Puerto Rico and Guam.(3)
NAQC is a non-profit organization that aims to maximize the access, use and
effectiveness of quitlines; provide leadership and a unified voice to promote
quitlines; and offer a forum to link those interested in quitline operations.
NAQC is comprised of over 400 quitline professionals at state and provincial
health departments, quitline service provider organizations, research
institutes and national organizations in the United States and Canada. The
Consortium enables professionals from these organizations to learn from each
other and improve quitline services.
The adoption of quitlines by state health departments occurred very rapidly in
the U.S. The first state quitlines were established in the early 1990’s. By
2000, over 35 state health departments were offering quitline services to
smokers who want to quit. Currently, all 50 states, the District of Columbia,
Puerto Rico and Guam have mature quitlines. Each year, state quitlines receive
about one million calls; about half of these calls are from tobacco users. In
addition, quitlines receive over 117,000 referrals annually from health care
providers, primarily through fax-referrals. The number of referrals from health
care providers has grown steadily over the past 5 years and demonstrates the
important role quitlines play in supplementing providers’ in-office treatment
for tobacco dependence.
NAQC’s most recent annual survey data show that 50 quitlines have active
fax-referral programs with health care providers and hospitals.(10) As ONC has
begun implementing the HITECH portion of the American Recovery and Reinvestment
Act of 2009 and as EHRs have become more prevalent, health care providers and hospitals
have begun discussions with quitlines about the importance of moving from fax
referral systems to electronic referral systems (that utilize EHRs), and have
encouraged quitlines to take action now.
By including electronic quitline referral as part of stage 3 of meaningful use,
ONC would facilitate nationwide implementation of these referral systems. NAQC
believes a decision to include electronic quitline referral to support the
tobacco cessation requirements for meaningful use stage 3 is justified by the
1.Tobacco cessation is a
national health priority and should be a priority for ONC’s work on meaningful
use. Although we have made great progress in reducing by 50%
the prevalence of smoking (and thereby reducing the toll of tobacco-related
diseases on the health of Americans) since the 1960’s, tobacco use continues to
be a leading cause of preventable disease and deaths in our nation. Today,
national adult prevalence is about 20%, annual tobacco-related deaths number
over 430,000, and the annual cost of smoking is estimated at over $195
billion.(2, 7, 8). Although 44% of smokers attempt to quit each year, only 4-7%
are successful.(9) Evidence-based treatment is needed to advance tobacco
treatment is both effective and cost-effective. The U.S. Public
Health Services clinical guideline on tobacco dependence treatment recommends
the use of counseling, FDA-approved cessation medications and social support
for tobacco dependence treatment.(2) Quitlines are recommended as effective
treatment by the clinical guideline. In addition, the guideline recommends that
clinicians employ the 5 A’s (ask, advise, assess, assist and arrange) with
patients. Research has shown that the return-on-investment (ROI) is high for
health care care provider interventions (5A’s and 5As plus NRT) as well as
provider-quitline interventions (5A’s plus quitlines and 5A’s plus quitlines
plus NRT). As shown in the table, 5A’s and 5A’s plus quitlines have the highest
member per month ROI for years 1-5 after treatment.(4) Helping patients quit is
Table: Cumulative Health Plan ROI Per Member Per Month (PMPM) by Intervention,
Worst Case Scenario
5A’s 5A’s + NRT 5A’s + QL 5A’s + Both
2009, Kaiser Permanente Center for Health Research (Fellows JL et
referral has broad applicability, lessens the burden on health care providers
who provide tobacco dependence therapy and improves patient outcomes. All
eligible providers and hospitals have patients who use tobacco but not all of
them have the time for or expertise in tobacco dependence treatment to offer
intensive therapy to patients. Having evidence-based treatment available via
referral to quitlines reduces the burden on physicians and other providers to
use precious in-office (or in-hospital) time for intensive counseling. Instead,
for most patients, providers can ask patients about their tobacco use, advise
them to quit, prescribe medication as appropriate, and refer them to a quitline
for continuing treatment. Electronic quitline referral has broad applicability
for all eligible providers and hospitals.
As mentioned above, in 2011 quitlines received over 117,000 referrals. We
expect that this number will increase dramatically as electronic quitline
referral becomes a possibility for a greater number of providers and health
systems. [add MA/JSI stats here about their experience]
Research demonstrates that by increasing the counseling time for those trying
to quit tobacco use we can increase the likelihood of successful quits.(2) Providers
can supplement the counseling time given to their patients by beginning the
tobacco cessation treatment process in-office and then referring patients to
quitlines. Such action will improve their patients’ outcomes.
4.As a community, the
network of state quitines is building capacity to implement electronic quitline
referral programs, and can definitively state that electronic quitline referral
is feasible by 2015. Currently, there are 15 organizations that
operate all 53 state quitlines (3). Three of these organizations (Alere
Wellbeing, John Snow International, Inc (JSI), and National Jewish Health
(NJH)) have begun implementing pilot electronic referral programs between state
quitlines and select health care partners’ EHRs. These three organizations
operate the quitlines for 41 states (3). As Alere, JSI and NJH complete their
pilot projects and prepare for full-scale implementation, 80 percent of the
state quitlines will have the technical capacity to conduct referrals with
EHRs. All three organizations are eager to share their learnings with other
state quitlines. [add text here.]
5.The quitline community
has a history of collaborative action and will take a standard approach to
developing electronic referral programs. In 2005, NAQC launched
a minimal data set (MDS) for evaluating quitlines that was comprised of
standard intake and follow-up questions for quitline clients. State quitlines
and researchers worked collaboratively to develop the standard data set. Within
6 months of finalizing the data set, all state quitlines had integrated the MDS
into their existing data systems. Over the years, state quitlines have worked
with researchers and external stakeholders to modify the MDS and to add
optional standard questions. The MDS has become a quality standard not only in
the U.S. and Canada, but also in the European Union and Asia.
NAQC plans to take a similar approach with electronic quitline referral.
Already, Alere, JSI and NJH are collaborating on standard data elements for
their pilot projects. NAQC is establishing a workgroup to build on their
collaboration and to develop standard tools that will be needed by quitlines
and EHRs, such as data elements that quitlines need to make a referral and the
type of acknowledgement and feedback that quitlines will provide to providers.
We also will be assessing various interfaces that can be utilized by quitlines
to be compliant with security requirements for personal health information.
By including electronic quitline referral as part of meaningful use stage 3,
ONC will support clinical decisions and tobacco cessation requirements (for
meaningful use) and will facilitate NAQC’s ability to collaborate with EHR
vendors and eligible providers and hospitals on behalf of state quitlines to
develop referral standards.
Vision for Electronic
NAQC believes that electronic quitline referral supports tobacco cessation
requirements for meaningful use stage 3 and supports clinical decisions to
treat tobacco dependence. Our vision extends to all patients age 18 and above
who are seen by primary care providers who meet the eligible provider
definition under the meaningful use rule or who are seen at eligible hospitals
and/or acute care hospitals under the meaningful use rule.
We recommend a requirement that a certified EHR system should have the
capability for fully electronic referrals to state quitlines. We also recommend
that all eligible providers and hospitals should be required to implement one
or more clinical decision support interventions related to tobacco use
cessation. The clinical decision support should guide providers to assess
tobacco use in all patients, advise all tobacco users to quit and to intervene
with tobacco users who are ready to quit in one or more of the following ways:
- Provide or refer to
- Refer patients ages 18 and
older to state quitlines; and
- Prescribe FDA-approved
cessation medications, as appropriate.
COMMENTS ON HITPC
PRELIMINARY SET OF RECOMMENDATIONS FOR STAGE 3
NAQC’s comments are limited to the preliminary recommendations that are related
to the use of EHRs for referral to tobacco cessation quitlines. These include
the proposed recommendations listed below:
- SGRP 109
- SGRP 113
- SGRP 130
- SGRP 103
- SGRP 303
- SGRP 304
- SGRP 305
- [May add 204A and 207]
SGRP 109 aims to record smoking status for patients 13
years old or older. The recommendation calls for more than 80% of patients to
have smoking status recorded within the EHR. The HITPC document proposes to
retire the measure because the threshold is being achieved.
Although we understand that performance is high and that the threshold has been
achieved, NAQC supports maintaining SGRP 109 as part of stage 3 meaningful use.
The objectives and measures are an essential first step in assessing tobacco
use status of patients. Given the importance of helping patients quit tobacco
use, we recommend not retiring the objectives and measures.
Tobacco use screening and intervention is one of the most effective clinical
preventive services both in terms of cost and success.(2, 5) The health case
for maintaining SGRP 109 is strong. The health goals for the nation – Healthy
People 2020 – includes objectives on provider screening for tobacco status and
counseling, further demonstrating the importance of SGRP 109 and the importance
of measuring both screening and counseling. Clinical opportunities in this area
continue to be missed by some providers. Indeed, a recent article found that
only 21% of patients identified as current tobacco users received tobacco
cessation counseling and only 8% received tobacco cessation medications.(6) We
believe that meaningful use will drive health improvements in this area.
aims to use clinical decision support to improve performance on high priority
health conditions. The recommendations call for implementing 15 clinical
decision support interventions related to five or more clinical quality
measures for the entire EHR reporting period. Intervention areas include
preventative care, chronic disease management, lab and radiology measures and
advanced medication-related support.
NAQC supports SGRP 113 and encourages ONC to require that a certified EHR
system should have the capability for fully electronic referrals to state
quitlines. We also recommend that all eligible providers and hospitals should
be required to implement one or more clinical decision support interventions
related to tobacco use cessation. The clinical decision support should guide
providers to assess tobacco use in all patients, advise all tobacco users to
quit and to intervene with tobacco users who are ready to quit in one or more
of the following ways:
- Provide or refer to
- Refer patients ages 18 and
older to state quitlines; and
- Prescribe FDA-approved
cessation medications, as appropriate.
Incorporating electronic quitline referral under preventative care
will not be burdensome to eligible providers or hospitals. Many eligible
providers and hospitals already have established clinical decision support
interventions involving quitlines. As mentioned above, 50 state quitlines have
active fax-referral programs with in-state providers and hospitals. Through
these fax-referral programs, providers and hospitals have established procedures
for referring patients to the quitlines. These procedures can be used as a
model for electronic quitline referral. A handful of states have pilot projects
underway to establish electronic referrals with providers’ EHRs. As these pilot
projects are completed and move toward full-scale implementation, we expect
that the frequency of clinical decision support interventions on tobacco
dependence treatment through EHRs will increase significantly.
aims to use computerized provider order entry for referral/transition of care
orders directly entered by any licensed healthcare professional who can enter
order into the medical record per State, local and professional guidelines to
create the first record of the order. The recommendations call for more than
20% of referral/transition care orders to be recorded.
NAQC supports this recommendation and encourages ONC to include electronic
quitline referral as part of the scope of SGRP 130. Based on data from NAQC’s
most recent annual survey, 94% (i.e., 50) of the state quitlines receive fax
referrals from providers and hospitals, 34% receive referrals via email or
online and about 10% receive referrals from EHRs.(10) In 2011, approximately
1,000 referrals were made by EHR. Although this is under 1% of all referrals
(117,714), we expect the number to increase significantly once quitlines move
from pilot referral programs to full-scale implementation.
aims to generate and transmit permissible prescriptions, including discharge prescriptions,
electronically (eRx). The recommendations call for more than 50% of
prescriptions written by providers and more than 30% of hospital discharge
prescriptions to be transmitted electronically using certified EHR technology.
NAQC supports this recommendation. As we move forward with meaningful use,
electronic transmission of prescription will be important for high quality
patient care. About 83% of quitlines provide over-the-counter cessation
medications to their callers. Only 2 quitlines provide prescription cessation
medications to callers. It will be important for EHRs to have an ability to
transmit prescriptions electronically to quitlines so that quitlines can
follow-up with callers about their use of prescription cessation medications.
Quitlines also may want to request a prescription from a provider for his/her
patient. In such situations, eRx would be an efficient way to gain the
prescription for callers.
aims to have eligible providers and hospitals that transition their patient to
another setting of care or refer their patient to another provider of care
provide a summary of care record for each site transition or referral with
specific information. For referrals, the information includes a concise
narrative in support of the referral (free text that captures current care
synopsis and expectations). It recommends that a summary of care record be
available for 65% of referrals. Further, it recommends (as a certification
criteria) an ability to automatically populate a referral form for specific
purposes, including a referral to a smoking cessation quitline.
NAQC supports this recommendation and is pleased that quitlines are
specifically mentioned in it. Examples of success in automatically populating a
referral form for quitline services have been documented. As mentioned under #3
above, three quitline operators (Alere Wellbeing, John Snow International, Inc
(JSI), and National Jewish Health (NJH)) have begun implementing pilot
electronic referral programs between state quitlines (IA, MA, NH, WI) and
select health care partners’ EHRs. The type of information needed from the EHRs
is minimal and includes:
[Ask for permission from service providers to include list of data elements]
Together, Alere, JSI and NJH operate the quitlines for 41 states (3). As Alere,
JSI and NJH complete their pilot projects and prepare for full-scale
implementation, 80 percent of the state quitlines will have the technical
capacity to conduct referrals with EHRs. All three organizations are eager to
share their learnings with other state quitlines.
is proposed for future stages of meaningful use. It recommends that eligible
providers and hospitals who transition patients to another site for care or
refers their patients to another provider of care include a number of specific
elements as applicable. HITPC poses a question about how we might advance the
concept of an electronic shared care planning and collaboration tool that
crosses care settings and providers, allows for and encourages team based care
and includes the patient and their non professional caregivers. A number of
priority use cases are identified, including the patient seeing multiple
ambulatory specialists needing care coordination with primary care, and a set
of questions are proposed (including how access may be managed).
NAQC will be launching a workgroup on electronic quitline referral in January
2013 and will ask members to consider HITPC’s question related to how we may
advance the concept of an electronic shared care planning and collaboration
tool. We will provide feedback to ONC as it becomes available.
aims to have eligible providers and hospitals to whom a patient is referred
acknowledge receipt of the referral and provide results from the referral to
the requesting provider. HITPC asks for comments on the return of test results
to the referring provider.
[Insert current practice from Alere, JSI and NJH].
In addition, NAQC will be launching a workgroup on electronic quitline referral
in January 2013 and will ask members to consider HITPC’s question related to
acknowledging receipt of the referral and providing results from the referral.
We will provide feedback to ONC as it becomes available.
Again, we thank ONC for the opportunity to comment and look forward to its
continuing dialogue and work on meaningful use of EHRs.
Linda A. Bailey, JD, MHS
President and CEO
NOTE: We may include a
comment on SGRP 204A and 207, shown below. Please let us know if you have any
comments for ONC on these recommendations:
aims to provide patients with the ability to view online, download and transmit
their health information within 4 business days of the information being
available to the eligible provider. The recommendations call for providing at
least 50% of patients with the ability to designate to whom and when a summary
of care document is sent to patient-designated recipients. It also proposes for
future stages that there be an ability for providers to review
patient-transmitted information and accept updates into EHR.
aims to use secure electronic messaging to communicate with patients on
relevant health information. It proposes for future stages to create the
capacity for electronic episodes of care and to do e-referrals and e-consults.
HITPC poses a question about the appropriate increase in threshold based upon
evidence and experience.
Zhu, SH (add reference)
Fiore MC, Jaen CR, Baker TB, et al. (May 2008). Treating Tobacco
Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD:
U.S. Department of Health and Human Services. Public Health Service.
North American Quitline Consortium. Online resources available at:
Fellows JL, Hollis J, Dickerson J et al. Return on Investment from
Tobacco Cessation (need full citation)
Maciosek MV, Coffield AB, Edwards NM, Flottemesc TJ, Goodman MJ,
Solberg LI. Priorities among effective clinical preventive services: results of
a systematic review and analysis. Am J Prev Med 2006; 31:52-61.
CDC. Tobacco use screening and counseling during physician office
visits among adults – national ambulatory medical care survey and national
health interview survey, United States, 2005-2009. MMWR 2012. 61(02); 38-45.
CDC. Smoking attributable mortality, years of potential life lost,
and productivitylosses – United States, 200-2004. MMWR 2008; 57:1226-8.
CDC. Vital signs: current cigarette smoking among adults aged >
18 years – United States, 2009. MMWR 2010; 59: 1135-40.
CDC. Quitting smoking among adults – United States, 2001-2010.
MMWR 2011; 60:1513-19.
NAQC. Annual survey of quitlines 2011. Available online at: http://c.ymcdn.com/sites/www.naquitline.org/resource/resmgr/2011_survey/naqc_2011_final_report_highl.pdf.
Viewed January 2, 2012.