ARTICLEPEDIATRICS Volume 137 , number 5 , May 2016 :e 20154185

Clinical Decision Support Tool for Parental Tobacco Treatment in Primary CareBrian P. Jenssen, MD, a, b, c Tyra Bryant-Stephens, MD, b Frank T. Leone, MD, MS, d Robert W. Grundmeier, MD, b, c Alexander G. Fiks, MD, MSCEb, c

abstractOBJECTIVES: We created a clinical decision support (CDS) tool and evaluated its feasibility,

acceptability, usability, and clinical impact within the electronic health record to help

primary care pediatricians provide smoking cessation treatment to parents/caregivers who

smoke.

METHODS: This prospective study of pediatric clinicians and parents was conducted at 1 urban

primary care site. Clinicians received training in smoking cessation counseling, nicotine

replacement therapy (NRT) prescribing, referral to an adult treatment program, and use

of the CDS tool. The tool prompted clinicians to ask about secondhand smoke exposure,

provide an electronic NRT prescription, and refer. Feasibility was measured by using

electronic health record utilization data, and acceptability and usability were assessed with

the use of clinician surveys. Parents reported clinical impact, including NRT accepted and

used.

RESULTS: From June to August 2015, clinicians used the tool to screen for secondhand smoke

exposure at 2286 (76%) of 3023 visits. Parent smokers were identified at 308 visits, and

165 parents (55% of smokers) were interested in and offered treatment. Twenty-four (80%)

of 30 eligible pediatric clinicians used the tool. Ninety-four percent of clinicians surveyed

(n = 17) were satisfied with the tool, and the average system usability scale score was

83 of 100 (good to excellent range). We reached 69 of 100 parents sampled who received

treatment; 44 (64%) received NRT, and 17 (25%) were currently using NRT.

CONCLUSIONS: A CDS tool to help urban primary care pediatric clinicians provide smoking

cessation treatment was feasible, acceptable, usable, and influenced clinical care. A larger

scale investigation in varied practice settings is warranted.

aRobert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia,

Pennsylvania; bDepartment of Pediatrics, University of Pennsylvania School of Medicine, and Children’s Hospital

of Philadelphia, Philadelphia, Pennsylvania; cDepartment of Biomedical and Health Informatics, Children's

Hospital of Philadelphia, Philadelphia, PA; and dPulmonary, Allergy, & Critical Care Division, University of

Pennsylvania, Presbyterian Medical Center, Philadelphia, Pennsylvania

Dr Jenssen conceptualized and designed the study, designed the data collection instruments,

conducted the initial analysis, and drafted the initial manuscript; Drs Bryant-Stephens and Leone

conceptualized and designed the study, supervised data collection, and reviewed and revised the

manuscript; Dr Grundmeier helped conceptualize and develop the intervention, supervised data

collection, and reviewed and revised the manuscript; and Dr Fiks designed the study, helped with

data analysis, and critically reviewed and revised the manuscript. All authors approved the fi nal

manuscript as submitted.

DOI: 10.1542/peds.2015-4185

Accepted for publication Feb 19, 2016

To cite: Jenssen BP, Bryant-Stephens T, Leone FT, et al. Clinical Decision

Support Tool for Parental Tobacco Treatment in Primary Care. Pediatrics.

2016;137(5):e20154185

WHAT’S KNOWN ON THIS SUBJECT: Secondhand

smoke exposure is a signifi cant public health problem

with clear negative effects on children’s health.

Pediatric primary care–based smoking cessation

interventions can be effective in helping parents quit,

but barriers have limited adoption and sustainability.

WHAT THIS STUDY ADDS: A clinical decision

support tool within the electronic health record to

help primary care pediatricians provide smoking

cessation counseling and prescribe nicotine

replacement therapy to parents who smoke was

feasible, acceptable, usable, and infl uenced clinical

care.

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JENSSEN et al

Secondhand smoke (SHS) exposure

is a significant public health problem,

with clear negative effects on

children’s health, including increased

risk of acute respiratory infections,

asthma exacerbations, sudden infant

death syndrome, and premature

death.1 Approximately 17% of US

adults smoke cigarettes, 2 but >40% of

US children have evidence of tobacco

smoke exposure.3 Pediatricians are

uniquely positioned to educate and

motivate parents toward protecting

their children from SHS.4 Parents

expect their pediatrician to ask

about their smoking status and

are interested in their pediatrician

providing smoking cessation

medication and connecting them

to additional resources.5, 6 Pediatric

clinicians, however, rarely provide

such treatment options to parents

who smoke.7 Nationally, of parents

who smoke who had accompanied

their child to the pediatric clinician

in the past year, only 38% were

advised to quit, and 15% had

pharmacotherapy recommended to

them.6

Pediatric primary care–based

smoking cessation interventions can

be effective in helping parents quit,

but barriers have prevented further

adoption and sustainability of such

practices.8–10 Time, recordkeeping

challenges, logistical issues, scope

of practice concerns, and lack of

insurance reimbursement are cited

as barriers to providing counseling

and prescribing nicotine replacement

therapy (NRT).11, 12 To address some

of these concerns, professional

organizations have adopted policy

statements and clinical guidelines

that underscore the importance of

all clinicians addressing tobacco

smoke exposure, including

recommendations that pediatricians

provide counseling and treatment to

adults who expose their children to

SHS.12–14

Electronic health records (EHRs)

and clinical decision support (CDS)

systems may improve the quality

and standardization of clinical

interventions for tobacco use.15–17

In pediatric settings, outpatient-

based multilevel interventions

are emerging to address these

barriers; the interventions combine

pediatric health care clinician

advice and behavioral counseling

with navigation to pharmacologic

cessation aids approved by the

US Food and Drug Administration

(FDA).18 No studies, however, have

made use of pediatrician counseling

combined with decision and

treatment guidance aided by health

information technology. We sought

to create a CDS tool and evaluate its

feasibility, acceptability, usability,

and clinical impact within the EHR

to help primary care pediatric

clinicians provide smoking cessation

treatment to parents who smoke. We

hypothesized that implementing CDS

would prompt pediatric clinicians to

provide such treatment.

METHODS

Study Design

This prospective study was

conducted in primary care clinicians

and parents, incorporating focus

groups, EHR utilization data, and

surveys. Surveys with closed- and

open-ended questions were used to

contextualize quantitative results.

The intervention, called the tobacco

treatment CDS tool, was developed

from April to May 2015. Once the

intervention was developed, the

single-armed, prospective portion of

the study was conducted from June to

August 2015.

Setting and Study Population

This study was conducted within The

Children’s Hospital of Philadelphia

(CHOP) Pediatric Research

Consortium, a primary care practice–

based research network that includes

31 practices in 2 states.19 One large

urban practice participated in the

study. This practice was selected

based on clinician willingness

to participate, practice size, and

proximity to CHOP. Eligible primary

subjects included all pediatric

primary care attending pediatricians

and nurse practitioners. Eligible

secondary subjects were parents/

caregivers (hereafter referred to

as “parents”), aged ≥18 years, who

were present for the child’s health

care (both well-child and acute)

visit, who smoke, and who were

interested in receiving treatment.

Exclusion criteria included those

clinicians who declined to participate

and, for secondary subjects, parents

who smoked but were not present

during the visit, who were <18

years of age, who did not speak

English, or who were not interested

in treatment. Only the first visit by

an individual child was included in

the final analysis. Age, demographic,

and insurance status information

was available for children. To ease

the burden of data collection, we

did not collect parent or clinician

demographic information.

Intervention

We created the parental tobacco

treatment CDS tool by using a

usability framework approach, 20

iteratively developing the tool while

incorporating input from future users

of that tool.21–24 The development

team included researchers, clinical

informaticians, clinical content

experts, and end-users. To further

inform tool development, we

performed focus groups and 1-on-1

interviews with clinicians and the

practice’s medical director in April

and May 2015. Questions focused

on barriers to current practice and

workable solutions to overcome

these barriers. End-users and

informatics experts emphasized a

reminder-type prompt that fit within

clinician workflows combined with

simple, easy-to-follow treatment

guidance steps.

The intervention was modeled off

the CEASE intervention, an evidence-

based system for implementing

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PEDIATRICS Volume 137 , number 5 , May 2016

smoking cessation treatment of

parents in the pediatric setting.9 The

parental tobacco treatment CDS tool,

which interfaced seamlessly within

the EHR (EpicCare; Epic Systems, Inc,

Verona, WI), included the following

basic capabilities (Fig 1A):

1. Prompt the clinician (in a

noninterruptive manner) to ask

the parent about smoking status

and assess interest in quitting, at

all well-child and acute visits. The

prompt (available for clinicians

only) would appear at the start of

the visit when the patient’s chart

was initially opened, and it would

remain available throughout the

visit until the clinician responded;

2. Select 1 of 4 responses to

assessment questions, either

parent: “interested, ” “not

interested, ” “not eligible” (ie, not a

smoker), or “defer decision” (Fig

1B).

If the parent was interested in

quitting (Fig 1C):

3. Link to an electronic NRT

prescription, with dosing guidance

(Fig 1D);

4. Prompt for clinicians to refer

interested parents to the adult

tobacco treatment program

(clinicians would enter the

parent’s name and contact

information, noting that the adult

program would contact the parent

to schedule an appointment within

2 weeks of the referral);

5. Finally, guidance to add

“Secondhand Smoke Exposure”

to the problem list, provide

additional resources to discharge

instructions, including the PA

Free Quitline, and document

that NRT was prescribed, if

appropriate.

Pediatric clinicians received a 1-hour

training session in prescribing NRT

and use of the tool, e-mails regarding

use of the tool for reference, and

additional training (as needed) in the

clinical setting.

Outcome Measures

Feasibility

Feasibility of the intervention was

evaluated by using EHR utilization

data. Available information included

the number of visits at which the

tool prompted a clinician to ask

about SHS exposure, as well as

clinician selection of 1 of the 4

assessment answers (ie, interested,

not interested, not eligible, defer

decision). Use of the tool to screen

for SHS exposure was defined as a

clinician selecting the “interested, ”

“not interested, ” or “not eligible”

selections. Information was also

available if the tool was “deferred”

to a later visit or not used at all (ie,

ignored by the clinician) (Fig 1A).

Pediatric Clinician Acceptability and Usability of Intervention

Pediatric clinician acceptability and

usability of the intervention were

measured by using a 20-question

survey developed by the study team.

Clinicians were surveyed at the end

of the study period. The survey,

which took ∼5 to 10 minutes to

complete, included questions about

advantages, disadvantages, and

suggested improvements for the

tool, as well as a computer system

usability scale.25, 26 This scale is a

reliable, low-cost, and effective tool

for assessing physician usability of

(and satisfaction with) a CDS tool.27

It is a questionnaire composed of

10 statements that uses a 5-point

Likert scale to measure strength of

agreement or disagreement with

the statement; the final score ranges

3

FIGURE 1AParental tobacco treatment CDS tool. Tool use workfl ow and utilization. The parental tobacco treatment CDS tool prompted clinicians to ask about SHS exposure at all visits during the study period (N = 3023). Boxes in the fi gure represent actions taken by clinicians within the tool. All actions are optional; clinicians could ignore the tool completely or select “defer decision” to use the tool another time. If there was no SHS exposure, the clinician would select the “not eligible, ” and the tool would close. If a parent smoker was identifi ed but not interested in quitting, the clinician would select “not interested.” If the parent smoker were interested in quitting, the clinician would select “interested, ” and the NRT prescription, referral program information, and additional guidance options would be shown. Numbers at branch points represent the number of offi ce visits at which the action occurred.

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from 0 to 100, with high scores

indicating increasing usability and

satisfaction.28

Parent Acceptability

Parent acceptability of smoking

cessation treatment was assessed

by using an 11-question survey

developed by the study team. The

first 100 parents who received

smoking cessation treatment in

primary care were contacted within

2 to 4 weeks of the office visit

to administer the survey. Three

attempts were made to contact

each parent. The survey, which took

∼5 minutes to complete, included

questions about satisfaction, barriers,

and suggested improvements for

primary care–based treatment and

referral. One member of the study

team (B.P.J.) administered the survey,

followed an established survey

script, and transcribed the survey

responses.

Clinical Impact

Measures of clinical impact included

counseling and advice received in

the pediatric clinic (NRT offered

by clinicians, NRT prescription

received by parents, and NRT used by

parents) and follow-up with the adult

treatment program. These measures

were collected via parent survey and

reports from the adult treatment

program back to the study team.

Baseline Data Collection

A retrospective chart review was

performed to obtain information on

baseline SHS exposure screening

and treatment rates for the study

clinic. A random sample of 200

patient charts was reviewed for all

patients (newborn to ≤18 years of

age) for all health care visits (both

well-child and acute) from June to

August 2014 (comparable period 1

year before the study period). SHS

exposure screening was defined

as the following: presence of, and

answer to, the question “Does

anyone smoke around the patient?”

found in the vitals section (asked

by the staff responsible for rooming

the patient during the clinical

visit); or any key words identifying

SHS exposure, such as “smoking, ”

“secondhand smoke, ” “smoker(s), ”

or “cigarettes” in the electronic

clinician note, including the Problem

List, Diagnoses, Social, or Counseling

sections. Tobacco treatment was

defined as documentation of

key words suggesting smoking

cessation counseling (eg, “smoking

counseling”), prescription of NRT,

or referral to the quitline or other

tobacco treatment programs.

Statistical Analysis

Quantitative analyses were

conducted by using Stata version 13.1

(Stata Corp, College Station, TX). The

population was described and data

reported with means and proportions

as appropriate. Categorical data were

compared by using a χ2 test (P < .05

was considered significant). Using a

content analysis approach, 29 NVivo

11 qualitative data analysis software

(QSR International, Melbourne,

Australia) was used to code and

identify themes for clinician and

parent survey responses. The CHOP

Institutional Review Board approved

this study. Clinicians provided

written informed consent, and

parents provided verbal informed

consent.

RESULTS

Baseline chart review (N = 200)

identified SHS exposure screening

at 82% (n = 163) of visits. When

screening occurred, 20% (n = 33)

of visits included a parent who

smoked. The staff (registered nurse

or medical assistant) responsible

for rooming the patient performed

the vast majority of SHS exposure

screening (n = 156 [96%]). Of the

smokers identified, 18% (n = 6)

were offered treatment. Treatment

involved counseling only. According

4

FIGURE 1B AND 1CParental tobacco treatment CDS tool. B, Opening screen for parental tobacco treatment CDS tool (©2015 The Children’s Hospital of Philadelphia; all rights reserved). C, Tobacco treatment CDS tool: interested in quitting selection (©2015 The Children’s Hospital of Philadelphia; all rights reserved).

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PEDIATRICS Volume 137 , number 5 , May 2016

to the medical record, no parents

were prescribed NRT or referred to

additional treatment options.

During the 3-month study period, of

3023 eligible child visits, pediatric

clinicians used the tool at 2286

(75.6%) child visits to screen

for SHS exposure resulting from

parental smoking. The clinic serves a

predominantly black, non-Hispanic,

and Medicaid insurance population.

Child characteristics of parents who

were screened compared with those

not screened are shown in Table 1.

Male gender (P = .03), white or Asian

race (P = .04), and having private

insurance (P = .02) were associated

with screening; patient age was not

(P = .2). Twenty-four (80%) of 30

eligible pediatric clinicians used

the tool at least once to provide

treatment (ie, they used the tool to

identify a parent who smoked who

was interested in quitting); 18 (of

24 total) were physicians and 6 (of 6

total) were nurse practitioners.

Feasibility

Of the 2286 visits at which the tool

was used, a parent who smoked was

present at 308 (13.5%) of the visits.

A total of 165 (54.6% of parents who

smoke) were interested in quitting

and were offered treatment. The tool

was deferred at 636 (21.0%) visits,

and it was ignored at only 101 (3.4%)

visits (Fig 1). There were substantial

differences in tool use according to

individual clinician, but >75% of

clinicians used the tool at >60% of

visits (median, 88%; 25th percentile,

60%; 75th percentile, 96%). One

clinician was responsible for the vast

majority of deferrals. Most clinicians

did not defer tool use at all (Fig 2).

Acceptability and Usability

Clinicians

Seventeen (71%) of 24 clinicians who

used the tool completed the survey.

Ninety-four percent of responding

clinicians were satisfied with the tool

and found it helpful. The average

system usability scale score was 83

of 100 (95% confidence interval,

78–88), which was in the good to

excellent range. Clinician responses

to open-ended questions generated

several clinically relevant themes.

Advantages of the tool included ease-

of-use (47%), a reminder to screen

all parents about smoking (29%),

and access to an electronic NRT

prescription (41%). A representative

clinician comment noted that the tool

“prompted me to address [smoking]

consistently and help provide NRT to

interested parents.” Disadvantages

included inability to reaccess the

tool once it was initially used (24%)

(eg, if NRT prescriptions need to be

reprinted). Participating clinicians

preferred more information on

contraindications for NRT use and

additional treatment options to help

guide care.

Parents

Of the parents interested in quitting

smoking, the first 100 were contacted

to complete a survey about their

experiences; 69 were successfully

surveyed, 9 parents declined, and 22

could not be reached. The majority

5

FIGURE 1DParental tobacco treatment CDS tool. NRT prescription link.

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JENSSEN et al

of parents surveyed (89%) reported

being satisfied or very satisfied with

clinician treatment. Parents were

receptive to pediatricians offering

services to help them quit smoking,

and 28% of surveyed parents

specifically noted that they became

motived to use treatment because

quitting smoking was framed around

helping their child. Reflecting

the sentiments of many, 1 parent

explained “Usually my doctor talks

to me about it, but it makes sense

for my baby’s doctor to talk with me

because me smoking affects not just

my health but the health of the baby

as well. Now actually trying to help

parents is great.”

Clinical Impact

Of parents surveyed (69 of 100

contacted), 66 (96% of those

surveyed) received advice on

quitting, 52 (75%) were offered an

NRT prescription, 44 (64%) received

a prescription, and 17 (25%) had

filled the prescription and were

currently using NRT. Many parents

emphasized that the pediatrician

offering NRT helped connect them

to this treatment, with 1 parent

noting they were “surprised that the

pediatrician talked about smoking

and offered the prescription. I

didn’t know patches were covered

[by insurance]. It’s been 10 years.

Excited about quitting.” Although

165 parents were referred to the

adult treatment program, no parents

successfully followed up for an

in-person session. Parent-reported

barriers to program follow-up

included general stress (20%), work

(16%) and child care (10%) conflicts,

cost (8%), referral issues with

current insurance (6%), and lack of

insurance coverage (4%). Although

the majority of parents (51%) did

not think any improvements to the

intervention were needed, those

who had suggestions recommended

more office-based smoking cessation

counseling (ideally provided while

they were waiting with their child

or immediately after the visit) with

follow-up by telephone for continued

support.

DISCUSSION

We conducted the present study to

determine if effectively leveraging

CDS would prompt pediatric

clinicians to provide smoking

cessation treatment of parents who

smoke. Compared with baseline, our

intervention resulted in comparable

rates of SHS screening; it also

more than doubled the rates of

smoking cessation counseling and

led to clinicians providing NRT for

interested parents. In addition, the

majority of pediatric clinicians used

6

TABLE 1 Child Characteristics

Characteristic Total Screened (n = 2286

[75.6%])

Not Screened (n = 737

[24.3%])

Pa

Age, y

<1 423 (18.5) 130 (17.6) .2

1–5 856 (37.4) 292 (39.6)

6–12 689 (30.2) 196 (26.6)

13–19 318 (13.9) 119 (16.2)

Gender

Female 1070 (46.8) 379 (51.4) .03

Male 1216 (53.2) 358 (48.6)

Race

Black 1911 (83.6) 639 (86.7) .04

White 126 (5.5) 23 (3.1)

Asian 51 (2.2) 11 (1.5)

Other 198 (8.7) 64 (8.7)

Ethnicity

Hispanic or Latino 111 (4.9) 31 (4.2) .5

Not Hispanic or Latino 2175 (95.1) 706 (95.8)

Insurance category

Medicaid 1713 (74.9) 586 (79.5) .02

Private 558 (24.4) 144 (19.5)

Self-pay 15 (0.7) 7 (1.0)

Data are presented as n (%).a Via χ2 analysis.

FIGURE 2Tool use according to individual clinician (n = 30).

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PEDIATRICS Volume 137 , number 5 , May 2016

the tool at most of the visits. Before

the intervention, when treatment

was provided, it only involved

counseling, rather than prescription

of FDA-approved medications.

Our adherence to informatics

consensus guidelines in CDS system

development helped create a tool

that was feasible, acceptable, and

usable. We emphasized usability in

tool development30 and ensured that

it fit within clinical workflows31, 32 and

complemented physician–patient/

family communication around SHS

exposure and tobacco treatment.33

In addition, the effectiveness of this

intervention likely depended on the

tool’s seamless integration into the

EHR. These approaches ensured that

the tool met the standards of effective

CDS systems: appear at the point of

care, offer a specific recommendation,

and then enable compliance with

that recommendation.31, 34 Finally,

we engineered the tool to match

an existing workflow for CDS for

other aspects of pediatric care

already successfully in use by the

practice.35–38

Parents accepted pediatric primary

care–based smoking cessation

treatment and reported a clinical

impact on smoking cessation. Parents

who received counseling and NRT

explained that they were using

these medications with the intent of

quitting smoking. Although simple

clinician advice can lead to a small

but meaningful increase in quit

rates, 39 use of NRT is 1 of the most

effective strategies to help increase

an individual’s likelihood of quitting.

Consistent with the Public Health

Service Clinical Practice Guideline, it is

essential that clinicians and the health

care delivery system consistently

identify and document tobacco use

status and treat every tobacco user

with cessation counseling and FDA-

approved medications, except when

medically contraindicated.40

Although parents interested in

quitting smoking were receptive to

treatment through a pediatric setting,

referral to an adult tobacco treatment

program did not help parents receive

more intensive treatment. Additional

treatment remains important

because more intense counseling

sessions improve cessation rates.40

Promoting adult treatment through

pediatric office settings has been

shown to be effective for increasing

adult vaccination, 41, 42 treating

postpartum depression, 43 and

reducing intimate partner violence

in mothers.44, 45 Future research is

needed to investigate additional

models, such as co-locating services

or embedding experts in pediatric

settings, to help enhance receipt of

smoking treatment of parents.

Our study has several limitations.

First, the study was a single-armed

trial of pediatric clinicians at 1

outpatient urban academic practice.

We did not have a comparison

group to know the rates of smoking

cessation counseling and treatment

offered by clinicians who did not use

the tool. Nonetheless, for parents

who smoke, tool use by clinicians

led to substantially higher rates of

counseling and treatment offered

compared with baseline data. Second,

although we found that families of

white and Asian race or who had

a private insurance status were

more likely to be screened for SHS

exposure, explaining differences in

screening based on race or insurance

status was beyond the scope of this

project and could be an area for

future study. Third, further study

is needed to determine how results

will generalize to other settings.

Fourth, there were limitations to the

CDS tool itself. Tool use may have

been negatively affected because

clinicians could not re-access the

tool. Development of the CDS tool

targeted the initial conversation

with parents on smoking cessation.

We do not have information about

how the tool affected subsequent

office follow-up. Fifth, we evaluated

process measures of counseling,

treatment, and referral as the

outcomes of this study. We could

not verify the accuracy of parent

self-report of other outcomes. Sixth,

we did not offer all FDA-approved

cessation medications, including

additional NRT options, bupropion,

or varenicline. This absence may

have affected parent willingness

to receive a prescription and/or

their use of cessation medications.

Finally, despite achieving a 69%

response rate for the parent surveys,

our findings could be susceptible to

nonresponse bias.

CONCLUSIONS

A CDS tool to help primary care

pediatric clinicians provide smoking

cessation treatment was feasible,

acceptable, and usable. More than

three-quarters of parents were

screened, and many accepted

pediatric primary care–based smoking

cessation treatment. These promising

results suggest that a randomized

trial of this approach, including

varied practice settings and with

additional measures of effectiveness

such as biologically confirmed parent

quit rates, is warranted.

ACKNOWLEDGMENTS

We thank the network of primary

care clinicians, their patients, and

families for their contribution to

this project and clinical research

facilitated through the Pediatric

Research Consortium at CHOP. We

also thank Chris Wirtalla for his help

with data analysis.

7

ABBREVIATIONS

CDS:  clinical decision support

CHOP:  Children’s Hospital of

Philadelphia

EHR:  electronic health record

FDA:  US Food and Drug

Administration

NRT:  nicotine replacement

therapy

SHS:  secondhand smoke

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8

Address correspondence to Brian P. Jenssen, MD, Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, 1310 Blockley Hall, 423

Guardian Dr, Philadelphia, PA 19104. E-mail: jenssenb@email.chop.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

POTENTIAL CONFLICT OF INTEREST: Drs Fiks and Grundmeier are co-inventors of the Care Assistant software that was used to provide clinical decision support

in this study; and Drs Jenssen, Bryant-Stephens, and Leone have indicated they have no potential confl icts of interest to disclose.

FUNDING: Supported by the John M. Eisenberg Scholar Research Award from the University of Pennsylvania, Division of General Internal Medicine, and the 2015

Implementation Science Working Group Pilot Grant from the University of Pennsylvania’s Perelman School of Medicine, Department of Medical Ethics and Health

Policy.

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PEDIATRICS Volume 137 , number 5 , May 2016

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DOI: 10.1542/peds.2015-4185 originally published online April 14, 2016; 2016;137;Pediatrics 

Alexander G. FiksBrian P. Jenssen, Tyra Bryant-Stephens, Frank T. Leone, Robert W. Grundmeier and

Clinical Decision Support Tool for Parental Tobacco Treatment in Primary Care

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Alexander G. FiksBrian P. Jenssen, Tyra Bryant-Stephens, Frank T. Leone, Robert W. Grundmeier and

Clinical Decision Support Tool for Parental Tobacco Treatment in Primary Care

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