Electronic Health Record Closed-loop Referral ("eReferral") to a State Tobacco Quitline: a Retrospec
Tuesday, October 25, 2022
Posted by: Natalia Gromov
Zehner ME, Kirsch JA, Adsit
RT, et al.
Electronic Health Record
Closed-loop Referral ("eReferral") to a State Tobacco Quitline: a
Retrospective Case Study of Primary Care Implementation Challenges and
Adaptations.
Implement Sci Commun.
2022;3(1):107. Published 2022 Oct 8. doi:10.1186/s43058-022-00357-4
Background. Health
system change can increase the reach of evidence-based smoking cessation
treatments. Proactive electronic health record (EHR)-enabled, closed-loop
referral ("eReferral") to state tobacco quitlines increases the rates
at which patients who smoke accept cessation treatment. Implementing such
system change poses many challenges, however, and adaptations to system
contexts are often required, but are understudied. This retrospective case
study identified adaptations to eReferral EHR tools and implementation
strategies in two healthcare systems.
Methods. In
a large clustered randomized controlled trial (C-RCT; NCT02735382) conducted in 2016-2017, 11
primary care clinics in two healthcare systems implemented quitline eReferral,
starting with 1 pilot clinic per system followed by 2 phases of implementation
(an experimental phase in 5-6 test clinics per system and then a system-wide
dissemination phase in both systems). Adaptations were informed by stakeholder
input from live trainings, follow-up calls and meetings in the first month
after eReferral launch, emails, direct observation by researchers, and clinic
staff survey responses. Retrospective, descriptive analysis characterized
implementation strategy modifications and adaptations using the Framework for
Reporting Adaptations and Modifications to Evidence-based Implementation
Strategies (FRAME-IS). A pre- and post-implementation survey assessed staff
ratings of eReferral acceptability and implementation barriers and
facilitators.
Findings. Major
modifications to closed-loop eReferral implementation strategies included
aligning the eReferral initiative with other high-priority health system
objectives, modifying eReferral user interfaces and training in their use,
modifying eReferral workflows and associated training, and maintaining and
enhancing interoperability and clinician feedback functions. The two health
systems both used Epic EHRs but used different approaches to interfacing with
the quitline vendor and integrating eReferral into clinician workflows. Both
health systems engaged in iterative refinement of the EHR alert prompting
eReferral, the eReferral order, trainings, and workflows. Staff survey comments
suggested moderate acceptability of eReferral processes and identified possible
targets for future modifications in eReferral, including reducing clinician
burden related to EHR documentation and addressing clinicians' negative beliefs
about patient receptivity to cessation treatment.
Conclusions. System-wide
implementation of tobacco quitline eReferral in primary care outpatient clinics
is feasible but requires extensive coordination across stakeholders, tailoring
to local health system EHR configurations, and sensitivity to system- and
clinic-specific workflows.
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