Health System Implementation of a Tobacco Quitline eReferral.

Electronic referrals (eReferrals) can be an effective way to connect patients with tobacco quitlines, but there is still a need to investigate their real-world implementation. This study examines the implementation of a health system tobacco eReferral to a state quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system. The study found that a quitline eReferral order can be successfully implemented and sustained in a health system with minimal promotion, without provider alerts and in conjunction with group classes, while maintaining reach and effectiveness similar to other studies.

The bidirectional eReferral with the Helpline is the first in California. Primary care, specialty care, and hospital care all adopted the eReferral, demonstrating that the utility is not specific to primary care. Automation enhancements that were minimally intrusive to the provider likely enhanced adoption, implementation, and maintenance. Almost two-thirds of ordering providers used it at least twice, and automation into the hospital discharge order set doubled monthly orders.

For reach, the study found a contact rate of 52%, which is consistent with rates found in other studies. Incorporating complementary technology, such as texting or mobile apps, may enhance smoker engagement in cessation. The difference in the rate of accepting services between clinic and hospital patients is not surprising, since hospital patients may be recovering from an acute illness. The Helpline treatment reach of 61% is comparable or higher than others reported in the clinical trials.

For effectiveness, the “missing = smoking” quit rate of 12.2% is comparable to 6 month quit rates seen in other studies of eReferrals to tobacco quitlines. Even the “complete case” quit rate of 21.9% may reflect an underestimate of the higher range, as only half of the patients who had an eReferral had a follow-up clinic visit within the year. The study did not measure the utilisation of medications, which may improve quit rates. Smokers may take multiple attempts to quit, which may be reflected in the ongoing success of the second eReferrals. The low number of third and fourth eReferrals limited interpretation.

The study suggests that eReferrals with minimal promotion and automation enhancements that are minimally intrusive to the provider can be effective in promoting smoking cessation. Additionally, the study highlights the importance of the adoption of technology and its potential to help healthcare professionals promote tobacco cessation.

Hood-Medland EA, Stewart SL, Nguyen H, Avdalovic M, MacDonald S, Zhu SH, Mayoral A, Tong EK. Health System Implementation of a Tobacco Quitline eReferral. Appl Clin Inform. 2019 Aug;10(4):735-742. doi: 10.1055/s-0039-1697593. Epub 2019 Oct 2. PMID: 31578046; PMCID: PMC6774758.