RESEARCH ARTICLE

Implementation of an Inpatient Electronic ReferralSystem (Opt-to-Quit) From the Electronic HealthRecord to the New York State Smokers’ Quitline:First StepsRachel Boykan, MD,a Carolyn Milana, MD,a Grace Propper, MS, RN, CPNP, NNP-BC,a Patricia Bax, RN, MS,b Paula Celestino, MPHb

A B S T R A C T OBJECTIVES: (1) To implement a new policy-driven referral program, Opt-to-Quit, using electronic datatransfer from the electronic health record (EHR) to the New York State Smokers’ Quitline (NYSSQL) and(2) to improve referrals to the NYSSQL for smoking caregivers of children admitted to a children’s hospital.

METHODS: Smoking caregivers of pediatric patients were referred to the NYSSQL through astandardized template built into the EHR, during the child’s hospitalization or emergencydepartment encounter. Direct data exchange was based on a point-to-point protocol, withoutdependence on any external centralized processing service. Input and oversight were provided by amultidisciplinary task force, which included physician and nursing leadership, informationtechnology specialists, Health Insurance Portability and Accountability Act compliance personneland legal counsel, and NYSSQL staff. The process was refined through several iterative plan-do-study-act cycles, using a single-armed, prospective cohort study design, including surveys of nursingstaff and continued input of information technology experts on both hospital and Quitline sides.

RESULTS: In 2013, 193 smokers were identified in 2 pilot units; 62% (n5 119) accepted referral tothe NYSSQL. In 2014, after expansion to all inpatient units and the emergency department,745 smokers were identified, and 36% (n 5 266) accepted referral. Over the 2 years, overall increasein referrals was 124%; as of the first quarter of 2015, referral rate was sustained at 34%.

CONCLUSIONS: Hospital-wide implementation of the Opt-to-Quit program through our EHRwas feasible and sustainable and has significantly improved referrals to the NYSSQL.

aStony Brook Children’sHospital, Stony Brook,

New York; and bRoswellPark Cessation Services,

Department of HealthBehavior, Roswell Park

Cancer Institute, Buffalo,New York

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2016-0004Copyright © 2016 by the American Academy of Pediatrics

Address correspondence to Rachel Boykan, MD, Department of Pediatrics, HSC T 11-060; Stony Brook University, Stony Brook, NY 11794.E-mail: rachel.boykan@stonybrookmedicine.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

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

FUNDING: A portion (nurses’ surveys) of this study was supported through a New Investigator Award (Dr Boykan) from the AmericanAcademy of Pediatrics Julius B. Richmond Center of Excellence through a grant from the Flight Attendant Medical Research Institute.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Boykan initiated the implementation of the Opt-to-Quit program at Stony Brook Children’s Hospital, oversaw data collection and analyses, andcontributed to, reviewed, and revised the manuscript; Dr Milana oversaw data collection and analyses and contributed to, reviewed, and revised themanuscript; Ms Propper oversaw data collection and analyses, directed process change at Stony Brook Children’s at all stages of this initiative, andcontributed to, reviewed, and revised the manuscript; Ms Bax and Ms Celestino directed the implementation and all process changes at the NewYork State Smoker’s Quitline and contributed to, reviewed, and revised the manuscript; and all authors approved the manuscript as submitted.

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Smoking rates have significantly decreasedover the past 20 years. Despite advances,14.5% of adults in New York State aresmokers, and more than 1 000 000 childrenare exposed to secondhand smoke (SHS)each year.1,2 Physicians and other healthcare workers play an important role inpromoting evidence-based smokingcessation treatments, such as motivationalinterviewing, counseling, nicotinereplacement therapy, and referrals to asmoking cessation quitline. Several studieshave demonstrated that hospitalizationprovides a “teachable moment” for smokingparents of hospitalized children.3–6 Moregenerally, the inpatient setting provides anopportunity to address smoking cessationand SHS by incorporating interventionsinto hospital admission or discharge planswith all hospitalized smokers or families.7

Using nursing staff has been shown to befeasible and effective in both adult andpediatric inpatient settings.7–11

Quitlines are a key component of tobaccocontrol by providing telephone counseling,nicotine replacement therapy, and Web-based resources and support. Quitlineshave been shown to be a highly cost-effective intervention, delivering highvalue relative to cost when comparedwith other common disease preventioninterventions and medical treatments.12

A “fax to quit” model for referrals has beenshown to improve referral rates toquitlines13–15 by providing a proactiveapproach. However, the task of faxing mayrequire significantly more time for staff.16

The emergence of the electronic healthrecord (EHR) presents unique opportunitiesfor streamlining the process of referral to aquitline. One recent study showed increasedreferral rates when prompts for referralswere built into the EHR.17 In a randomizedcontrolled trial of 10 adult clinics in Texas,electronic referral facilitated by licensedvocational nurses showed a 13-fold increasein the percentage of smokers referred tothe quitline, compared with standard(paper) referral.18 In another pilot program,a built-in “eReferral” to a quitline within theEHR increased referrals from 0.3% to 14%.19

Stony Brook Children’s Hospital is anacademic, tertiary care hospital located in

Suffolk County, NY, with a county populationof 1.5 million people. Twenty-four percent ofthe population is under age 18 years. Thesmoking prevalence of adults within thecounty is 12%.20 Before 2012 educationalmaterials were provided to smokers, but noreferrals were received by the New YorkState Smokers’ Quitline (NYSSQL) from ourhospital.

METHODS

In 2012, Stony Brook Children’s partneredwith the NYSSQL, administered by RoswellPark Cancer Institute in Buffalo, New York,to implement a new policy-driven quitlinereferral program, Opt-to-Quit (OTQ). In achildren’s hospital, OTQ supports healthcare providers’ cessation interventions bythe adoption of a system-wide proactiveapproach to identifying all tobacco-usingcaregivers and, unless consent isspecifically denied, referring them to theNYSSQL, ideally using direct electronictransfer of contact information from theEHR. Implementation of OTQ was piloted inour newborn nursery and NICU and thenapplied to all units within the Stony BrookChildren’s Hospital with the goal ofimproving referrals for NYSSQL services.Surveys and Strengths, Weaknesses,Opportunities, and Threats (SWOT)analyses of nursing staff were conductedas part of another related research study21

and were approved by our institutionalreview board.

Planning the Intervention

As the first step of this initiative, weidentified key stakeholders and created amultidisciplinary task force includingphysicians, nurses, information technology(IT) specialists, Health Insurance Portabilityand Accountability Act compliancepersonnel, and legal counsel. This task forceworked with NYSSQL staff to design aprocess to identify caregivers who smokeand electronically make referrals to theNYSSQL through Cerner, our EHR (CernerCorporation, North Kansas City, MO, USA). Astatement was created for caregivers togive consent for referral to the NYSSQL. Asingle-armed, prospective cohort study wasdesigned to evaluate how we incorporatereferrals into daily workflow. All caregivers

of admitted children (mothers, fathers,family members/caregivers) over age18 years, who were identified as smokers,were eligible for enrollment for quitlineservices. Data were collected viacompliance reports that were requestedand run from Cerner by our IT departmentto help identify additional opportunities toimprove the process. Data were collected inmonthly time periods using Excel software(Microsoft, Redmond, WA) and includeddocumentation of task completion andreferral information sent to the NYSSQL.Two multiple-choice surveys (at beginningand 9 months) and SWOT analyses (at21 months) were performed with nursingstaff to assess attitudes and workflow issues.

Improvement Activities

Nurses were tasked with completing the OTQreferral because of their presence at thebedside during all shifts. Informationregarding the OTQ program was provided tonursing staff, and educational sessionswere conducted for staff beforeimplementation. Caregivers who weresmokers were identified by the admittingnurse as part of the standard questionnaireasked of all caregivers on admission. If asmoker was identified, the nurse wasgranted access to a referral windowfunctioning directly within the EHR. Thenurse read a short statement within thewindow to the smoker, which explainedthe referral process and NYSSQL services.The statement served as consent forcollection and electronic transmission ofinformation to be sent to the NYSSQL. TheNYSSQL contacted caregivers by phonewithin 24 to 72 hours to completeenrollment.

A major step in the implementation processwas the coordination of informationprocessing, both at the hospital and atNYSSQL. Web services were developed toenable our EHR to send data to the NYSSQLon a 24/7 basis using a self-definedstandard format. The minimum necessaryinformation for electronic transmission wasdirectly entered into the referral window:first and last name, date of birth, address,phone number, and best time to call. Datawere transmitted from the Stony Brookpatient data system to a secure Web service

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Roswell Park Cessation Service created forthe NYSSQL, where it was securely storedand managed by the NYSSQL. The data wereformatted in an XML file to meet the NYSSQLOTQ data format requirements. The NYSSQLalso provided a secure password-protectedWeb site where outcome data on all patients(eg, medications mailed, number ofcounseling sessions) was made available inreal time to designated Stony Brookpersonnel. This data exchange is based on apoint-to-point protocol without dependenceon any external centralized processingservice, requiring little additional cost tosustain this process in the future. The ITstaff at Stony Brook Children’s Hospital andthe NYSSQL worked together to set up thisprocess and clean up the initial issues overa period of a few months. With the referralwindow in place caregivers were referreddirectly through the child’s chart withoutthe need for a separate encounter for thecaregiver within Cerner.

Because all caregivers are not necessarilypresent or receptive to smoking cessationrecommendations on admission, the optionfor referral through the EHR was madeavailable to staff as an ad hoc function to becompleted at any time during the hospitalstay. After admission, if a smoker wished toenroll in quitline services, any physician ornurse was able to access the referralwindow and transmit the information to the

NYSSQL, allowing for enrollment at any timeduring a child’s hospitalization.

Measurement Plans and Analysis

Compliance with referral to the NYSSQL,based on Cerner reports, was assessed onan ongoing basis by our Quitline Task Force,comprising inpatient unit nursingchampions, nurse and physician leadership,and IT specialists. On the basis of nursingfeedback and information on referral ratesfrom the NYSSQL, changes were made to theprocess through several iterative plan-do-study-act cycles.

Surveys at the beginning and 9 months afterimplementation and SWOT analyses at21 months after implementation wereadministered and collected for a 2-weekperiod by a research assistant. For themultiple-choice surveys, relationships wereexamined using the x2 test of independence.All tests of significance were done using a2-tailed a at the level of P, .05. Analyses wereconducted using the SPSS software (version21; IBM SPSS Statistics, IBM Corporation,Armonk, NY). For the SWOT surveys, themeswere identified using qualitative analysis.

Histograms were created to represent datacollected during the initial implementationperiod, the roll out throughout theChildren’s Hospital, and after finalization ofthe process in the EHR. The data pointsrepresented are the total number of

children identified as exposed to SHS andthe number of smokers who acceptedreferral to the NYSSQL.

RESULTS

In the 20 months before our implementationof the OTQ referral process, the NYSSQLreceived a total of 263 referrals from allof Suffolk County, with zero referrals fromthe Stony Brook area (zip code 11794). In2013, we saw an absolute and immediateincrease with 193 smokers identified in thepilot units and 119 referrals made to theNYSSQL (62%). We attribute this success, inpart, to the daily presence of a researchassistant on our pilot units. This presenceserved as a reminder to nursing tocomplete the referral and for parents torequest quitline services. Compliance wasstrong for the first 12 months of the project.

In May 2013, the OTQ referral function wasexpanded to all inpatient pediatric units.Two anonymous self-report surveys weregiven to nursing staff, the first at the time ofhospital-wide initiation of the program (T1)and the second at 9 months (T2). Of212 total nurses employed at that time, 44(21%) completed the survey at T1, and 39(18%) completed the survey at T2. Questionsfocused on attitudes toward smoking,counseling of patients, referral of patientsand families to OTQ, and workflow. At bothtimes, 97% of respondents believed it wastheir responsibility to advocate for theirpatients, and almost all respondentsreported that they asked about parental orpatient smoking. There was an upwardtrend in asking about other relatives’smoking over the survey periods (T1, 34% vsT2, 47%; P . .05). From T1 to T2, theproportion of respondents reporting

TABLE 1 SWOT Analysis: Nurses’ Feedback on the OTQ Program

Strengths of OTQ Weakness/Threats Opportunities (Suggestions)

Offered to all smokers Discussing smoking is perceived as uncomfortable Involve other personnel (social worker, dedicatedcounselors)

As part of EHR, referral is streamlined Referral to NYSSQL inadequate (need to do on-sitecounseling as well)

Start process prenatally (involve obstetrician)

Cost-effective and convenient Lack of buy-in to referral process Improve understanding of the program among staffand patients; better promotional materials,include videos

Lack of understanding of quitline services Provide nicotine replacement therapy for referredindividuals

Dedicated self-referral stations

TABLE 2 Compliance With Referral Tasks Completion

Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15

Pediatrics overall referral tasks 1892 2209 2263 2024 2304 2268

Referral tasks completed 982 1005 1009 895 1000 923

Referral tasks completion rate (%) 51.9 45.5 44.6 44.2 43.4 40.7

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referring for smoking cessation servicesincreased (T1, 57% vs T2, 80%; P 5 .024).There were also trends towardimprovement in referring other relatives forsmoking cessation services (ie, OTQ) andoffering nicotine replacement therapy(T1 34% vs T2, 42%; P . .05). Nursesreported no change in their ability tocomplete all tasks during a shift.

In October, 2014, nurses were askedto participate in a SWOT analysis bycompleting an open-ended questionnaire.Responses (n 5 26) elucidated continuedissues and opportunities for improvement,specifically tailoring the timing of referralcompletion to minimize redundancy inworkflow, the need for continued educationof staff regarding SHS and third-handsmoke, and the programs offered by theNYSSQL (Table 1).

Initial compliance data from the EHRreviewed for a 6-month period (August2014–January 2015) revealed that only∼40% to 50% of the referral tasks werecompleted each month (Table 2). To increasecompliance, work was done in the EHR toimprove the process and eliminateworkarounds. It was noted that there were2 ways within the EHR to refer smokers tothe NYSSQL, and the compliance reportneeded to be modified to reflect bothmethods. Additionally, staff members wereable to bypass the process by exiting thereferral screen before completing all of thenecessary steps for transmission ofinformation to the quitline.

After a review of the workflow with front-line staff, the OTQ section of the PediatricNursing History was changed to mandatedfields as appropriate, which increased

compliance with screening completion to100%. Despite an apparent drop in OTQacceptance rates, our identification ofappropriate referrals increased nearlythreefold over the 2 years (2013–2014),correlating with an overall increase in OTQreferrals of 124% (Fig 1).

Data were not collected during the firstquarter of 2015 because of ongoingchanges to the EHR. Data collected in2015 for the second and third quarters(April 15–September 15) supported ourcontinued improvement after a brief rolloutperiod. After modifications to the EHR (firstquarter 2015), we maintained a 34%acceptance rate (Fig 2). Follow-up data fromthe NYSSQL showed that of those referred,44% were reached. Twenty-two percent of allreferred (49% of those reached) wereenrolled in quitline services (Fig 3).

FIGURE 1 OTQ: total identified in 2013–2014. ED, emergency department.

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DISCUSSION

Hospital-wide implementation of theOTQ program through our EHR hassignificantly improved referrals to theNYSSQL. The program’s success can beattributed to many factors. Systematizingthe process removed the variabilityinherent in a provider-dependent model,in which referrals are made by thosepractitioners with more interest orexperience in smoking cessation.Incorporation of the referral withinnursing workflow with mandatedcompletion of required fields helped tostreamline the process and maximizeefficiency. Continued input from staff andeducational modules rolled outthroughout the process improved buy-in.

Adopting a systems-based approach tooffering quitline referrals to all smokers is

not a new concept. The fax-to-quit model hasbeen widely used and has demonstratedsuccess in several studies, especially whenadequate education and training areprovided. Bernstein et al showed a markedincrease in health care providers’ faxedreferrals with a program emphasizing“systems change” through training andtechnical assistance.14 In Wisconsin, thenumber of faxed referrals increased by afactor of 5 when training and on-sitetechnical assistance and performancefeedback were provided.16 The advent of theEHR provides opportunities to standardizesmoking cessation efforts by improveddocumentation of tobacco status and byproviding prompts for referrals orcounseling services.22 In Massachusetts,QuitWorks is a robust program thatfacilitates the linking of health care

organizations, health care providers, andtheir patients to the quitline throughmultiple approaches, including education,program promotion, provision of nicotinereplacement therapy, and electronicreferral options.23

In implementing this novel program, wefaced several challenges. Although we hadbuy-in from a core group of early adopters,consistent compliance with referralcompletion required oversight, continuededucation, and a culture shift on the part ofthe staff. Workarounds had to be identifiedand corrected. Reported widely in theliterature, workarounds have beendescribed as “clever methods for gettingdone what the system does not let you doeasily.” In hospitals, they are often viewed asblocks that prevent the accomplishment oftasks, which may be temporary but if

FIGURE 2 OTQ: total identified in 2015.

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sustained have the potential to be adoptedas routine practices.24,25

In our process, correct completion of allrequired fields was hard to enforce throughsystems change. For example, if a telephonenumber was not entered with the correctconfiguration of numbers and spaces, thedata were not transferred, and within ourEHR, there was no way to enforce this withan error message or hard stop. Ideally,required information, such as name andcontact information, would auto-populatefrom the patient’s chart, saving time andpreventing transcription errors. This wouldbe possible if the smoker being referredwere the patient; however, in our case, wewere referring caregivers whose contactinformation might differ from that in thechart. Furthermore, because of the potentialdifference between caregiver contact

information and the patient’s information,generating compliance reports waschallenging. Electronic transmissionsneeded to be consistently monitored at thesite of transmission and receipt requiringregular communication with NYSSQL staff.

CONCLUSIONS

To our knowledge, we are the first children’shospital to establish an electronic referralsystem in collaboration with a quitline.Although we did not have a fax-to-quit modelat our institution for comparison, one canassume that streamlining the processthrough the EHR would compare favorablybecause fewer steps are required totransmit information. Our success isevidenced by the continued increase inreferrals to the NYSSQL. With theinfrastructure and IT support in place on

both ends, this program is sustainable. Nextsteps include the incorporation of on-sitecessation counseling and provision ofnicotine replacement therapy to improvereferral rates and promote cessation fromthe time of hospitalization.

Acknowledgments

The authors acknowledge the invaluablecontribution of Srinivasa G. Seshadri, PhD,(Sesha) (deceased) to the design andimplementation of the Opt-to-Quit Programand to the collaboration between StonyBrook Children’s Hospital and the NewYork States Smokers’ Quitline. We alsothank James Koutsky, Cessation ServicesData Manager for Roswell Park CancerInstitute, and Dennis Pietraszewski,Assistant IT Director, Roswell ParkCessation Services

FIGURE 3 OTQ: NYSSQL Stony Brook referrals in 2015.

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