RE: Tobacco Cessation Champions: Recognizing Physicians Who Ask, Advise, and Refer

Thank you for your eLetter.

Our project started with the development of a Clinical Decision Support (CDS) triggered by completion of the tobacco history in the Past History section of the EHR. The CDS was designed to be a two-way communication with the Maryland Tobacco Quitline, with the Quitline's outreach results populating patient’s medical charts for physician review. This was accompanied by multimedia tools to disseminate the innovation and to teach physicians and practitioners how to use and refer. We recognized major barriers to be time, comfort with tobacco cessation medications, billing, and other clinical competing priorities. Additionally, our e-referral system is opt-in. If a physician does not have time to complete the e-referral, it is not sent. To mitigate the barriers, our team provided training in tobacco treatment and billing and coding for tobacco cessation counseling. We saw some improvement, and with a new source of funding, the NCI Cancer Moonshot Cancer Center Cessation Initiative (C3I) grant, we were able to develop a new staff pathway in Epic for tobacco use assessment and treatment. This included the development of a fifth vital sign that staff was to complete to start the conversation on tobacco. Adjacent to the fifth vital sign was a hot link to the history section where tobacco history could be documented. Additionally, referrals to the Quitline and to the in-person Tobacco Health Practice (THP). was triggered. Lastly, we developed a vaping tool in Epic EHR accompanied by training to complete the history of all tobacco and nicotine products. Some of these newer innovations were reactive changes in response to physician barriers and challenges, and others were proactive and part of our long-term plan. The THP, for example, was developed as part of our C3I plan and has become a focal point for all patients who do not wish to engage with telephone counseling.

In addition to the EHR changes, we also tweaked our presentations to all physicians and staff to accommodate their challenges and barriers. We were guided by colleagues and their observations to add a podcast and Epic tip sheets to allow asynchronous learning. We planned a positive reinforcement strategy to provide Champion certificates to those individuals who had e-referred 10 or more times and Advocate certificates to others. Data is slowly accruing, and we anticipate that the impact of these certificates, which will be provided annually, will become evident soon.

As mentioned above, we are planning to continue to review referral data to look for trends and total numbers. In our data, we have noted that physician referral from attending physicians is more likely to lead to engagement with the Maryland Quitline, and resident physician referral is less likely to lead to engagement. A possible challenge may be that Epic EHR captures tobacco use data in a moment of time rather than longitudinally. Therefore, currently, we are unable to track longitudinal changes in tobacco use, to determine the effectiveness of the initiative. In the future, we plan to develop a grant-funded approach to track all patients who are touched by any of the Epic EHR innovations.

The years of clinical experience impacting referral patterns is noted above. Attending physicians are more likely to refer and have their patients engage with the Maryland Quitline. Referrals tend to be higher among primary care physicians when compared to specialists but competing priorities and reduced patient interaction time impact the number of referrals. Since the inclusion of staff participating actively in recording tobacco history and initiating the counseling referral process, we anticipate that physician burdens will be reduced. However, we have not studied this assumption.

1. Dark M, Klyushnenkova E, Gaynor A, Kernan C, Khanna N. Tobacco Cessation Champions: Recognizing Physicians Who Ask, Advise, and Refer. Ann Fam Med. 2022 Nov-Dec;20(6):579. doi: 10.1370/afm.2891. PMID: 36443068; PMCID: PMC9705038.
2. Khanna N, Klyushnenkova E, Quinn D, Wolfe S. Patient Engagement by the Tobacco Quitline after Electronic Referrals. Nicotine & Tobacco Research, 2022;, DOI: 10.1093/ntr/ntac190.
3. Khanna N, Klyushnenkova E, Dark M, Melamed J, Gaynor A, Bennett M, Deepak J. Integrating a Systematic, Comprehensive E-cigarette and Vaping Assessment Tool into the Electronic Health Records at the University of Maryland Medical System. Journal of the American Board of Family Medicine. Submitted on December 6th 2022. Accepted February 13th, 2023. Published abstract at: https://www.jabfm.org/content/integrating