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Running head: SMOKING CESSATION: THE EFFICACY OF A PATIENT PORTAL IN AN EHR 1

Smoking Cessation: The Efficacy of a Patient Portal in an EHR

Riana Santos

National University

HTM 692: Health Informatics Capstone

Dr. Barbara F. Piper

January 11, 2016

SMOKING CESSATION: THE EFFICACY OF A PATIENT PORTAL IN AN EHR 2

Abstract

According to the Centers for Disease Control and Prevention, 42.1 million people in the United

States are smokers. Cigarette smoking leads to the deaths of just under 500,000 Americans per

year. Every year the number of deaths from smoking dramatically increases. Cigarette smoking

is one of the largest preventable causes of death and disease in the United States. A deterioration

of a country’s overall health due to unhealthy habits, such as smoking, eventually leads to the

deterioration of a country’s economic growth. The American Recovery and Reinvestment Act

(ARRA) 2009 proposes the meaningful use of sophisticated Electronic Health Records (EHRs)

with an objective to stimulate and encourage technical infrastructure in United States’ health care

organizations. A patient portal, one of the components of a sophisticated EHR system, includes a

patients’ personal health records, which includes their smoking status. This technology can

provide health care professionals critical communication prompts to remind and encourage the

health staff of an organization to offer smoking cessation information to their patients. These

small interactions with the patient can lead to an overall improvement in health and survival rates

among patients who suffer from diseases associated with smoking behaviors, and can aid in

identifying the demographics of those patients most susceptible to the temptations of smoking.

Cessation and prevention are the end goals. Implementation of a patient portal can help with

both.

Keywords: Patient portal, EHR, smoking cessation, meaningful use, ARRA, HITECH


Table of Contents

Chapter 1: Introduction 4

Chapter 2: Background 4-6

Chapter 3: Literature Review 6-18

Chapter 4: Methodology 18

Chapter 5: Evaluation of Evidence 19-23

Chapter 6: Synthesis of Literature 23-24

Chapter 7: Recommendations 24-27

References 28-30

Appendices 31-35


According to the Centers for Disease Control and Prevention (CDC), 42.1 million people

in the United States are smokers. Cigarette smoking leads to the deaths of 480,000 Americans

per year. About 70% of patients who are smokers visit their physician annually for health check-

ups (Adsit et al., 2014). Due to time constraints primary care physicians focus on their task at

hand, their patient’s chief complaints and symptoms, instead of what is primarily causing their

symptoms. In the case of smokers, it would be tobacco use.

Based on current evidence, a patient portal, within the Electronic Health Record (EHR) is

crucial in identifying and creating a preventative care plan to help assist a patient combat

smoking and subsequently improve their health while streamlining medical procedures to quality

and cost. Utilizing this platform within a healthcare organization will aid in the likelihood of a

patients success in the cessation of smoking. This paper surveys how smokers can benefit from

the use of EHRs and their patient portals to promote better health outcomes, prevent disease and

its complications, and identify how primary care physicians can best promote the use of EHR

systems including their patient portals among their patients. Furthermore, it examines how

current health care organizations can utilize a patient portal. Upon conclusion, it postulates that

the wide use of EHR systems and their use of patient portals, along with a prevention strategy

can potentially enhance smoking cessation rates among smokers. The use of the patient portal

can help smokers improve their quality of life through evidence-based recommendations, and

possibly even enhance survival rates among chronic diseases associated with smoking behaviors.


Background

Approximately 480,000 deaths of Americans each year are due to smoking, and an

average of 41,000 of these deaths are related to second hand smoking. It was approximately the

end of the twentieth century when smoking was recognized as a contributor to premature death,

with smoking causing almost all lung cancer and 85 percent of chronic obstructive pulmonary

disease (COPD). In addition, smokers are at a high risk for diabetes and coronary heart disease

(Hivert et al., 2009). Cigarette smoking is one of the largest preventable causes of death and

disease in the United States. The US government spends more than $289 billion for medical care

related to smoking related illnesses (CDC, 2014). Smoking cessation, even as late as age 65, has

been shown to add as much as 2 years of life for men and 3.7 years for women. Ceasing smoking

at age 35 can increase an individual’s lifespan by close to 8.5 years for men and approximately

7.7 years for women (Taylor et al., 2002). Patient portals help support the identified measures

needed in a preventative care plan, and in the follow up care by reducing the amount of smokers

and preventing the younger ones from starting.

EHR are still in their infancy. As the cost of computing becomes cheaper, the amount of

sophisticated computerized healthcare systems will rise due to lower costs. Evidence-based

studies indicate implementing a smoking prevention platform, within the patient portal of the

EHR, has the potential to encourage prevention and cessation of smoking through the coding of

communication prompts, indicating to the medical staff, remediation should be offered, with

direction towards appropriate resources (and follow up prompts if patient denies remediation).

Patient portals help prevent and eliminate many of the costs incurred by our health care industry

for the care and treatment of diseases and deaths associated with smoking. The economic growth


of a country is directly related to the health status of its citizens. It’s common sense that good

health leads to a higher labor productivity.

Healthy People 2010 led to the development of the public health infrastructure, which

includes an organizational structure of official government health agencies, the public health

workforce and the information systems employed in public health practice (U.S. Department of

Health and Human Services, 2000). A Stimulus Act was passed in 2009 requiring “meaningful

use.” Meaningful use of a patient portal extends beyond the traditional bounds of healthcare.

Meaningful use is verified objectives that physicians and hospitals must meet, including

documentation and reports regarding their patients smoking status, in order to qualify for

incentive payments through the government funded, Medicare and Medicaid. Clinicians and

hospitals qualify when they utilize technology privately and securely and adopt meaningful use

of health information technology. Healthcare organizations must prove “meaningful”

improvements via their EHR systems and patient portals in order for their organization to receive

financial funds from the government.

Literature Review

I will commence the literature review by providing a relevant conceptual framework to

orient the reader to what’s known about the electronic EHR, patient portal, ARRA legislation and

meaningful use. I will follow this by briefly covering previous studies in order to clarify and

illuminate not only the knowledge learned from these studies, but additionally to identify some

of the gaps and weaknesses learned in previous studies (see Figures 5, 6 & 7). I will conclude by

expanding upon the need for further research and demonstrate how with the help of advanced

technologies, like an EHR, practitioners in their clinical setting can identify and refer more


tobacco users to cessation methods than is possible outside of a medical facility and without the

use of an EHR.

Electronic Health Records

According to the studies of Bentz, Bayley & Bonin (2007), assessment, documentation,

advising and assisting tobacco users, among healthcare providers, has improved due to the use of

EHR. EHRs are a digital version of patient charts which can be utilized in order to quickly and

smoothly share patient information among multiple health care providers. EHRs are a collection

of a patient demographics, medical history, allergies, prescribed medication, radiology images,

immunization dates and information, laboratory/test results, vital signs, progress notes, smoking

information and diagnosis and billing information (Health IT, 2015). These digital files can

easily be updated and modified and can be securely accessed by an authorized user. They are

very useful for the continuum planning of patient care and safety.

Electronic health records (EHRs) are known for their ability to save time Kruse et al

(2012). EHR provides provide current health information, improve communication from one

provider to another, as well as within a health care facility. As part of the EHR workflow during

a patient visit, the EHR can be enabled to prompt the health care provider to inquire about

tobacco use (Table 1). The healthcare provider is prompted to offer tobacco quit line services if

the patient is interested in quitting, and includes an option in the EHR to document if the patient

declined services.

The research of Adsit et al. (2014) reveals that the regulatory policy of healthcare

organizations increasingly includes utilizing an EHR system for treatment. EHR are currently

being implemented in large healthcare organizations as well as some small private practices

across the United States due to the revamping of healthcare. Using an EHR system helps support


patients while providing workflow advantages to hospitals and clinics. The patient record is

available anywhere there is internet access. It provides easy accessibility of medical health

information. It can be used concurrently by clinical staff and business staff. Each can access and

contribute to the patient’s needs. It permits instant communication by vastly speeding data input

and retrieval. It makes the checkout process and billing simpler, especially when the transfer of

patient medical information can be done safely from one provider to another provider (or from

one healthcare institution to another) instantaneously. Wider use of EHRs in the future is

expected because of their numerous advantages; however without a patient portal, an EHR can

only be utilized by providers. It cannot be accessed by patients. Thus, it is critical to differentiate

between the EHR and the patient portal.

Patient Portal

Riippa, Linna, Rönkkö, and Kröger (2014) observed that the electronic patient portal is

gradually becoming a popular avenue for health care providers to offer information to and

interact with their patients. Patient portals are one of the components of an EHR. The patient

portal has been defined by the US government as “a secure online website that gives patients

convenient 24-hour access to personal health information from anywhere with an Internet

connection using a secure username and password” (Health It, 2013). A patient portal provides

easy visibility of the patient record, patient data, discharge summaries, medications, lab results,

electronic prescription refills, appointment schedules, and facilitates organization wide,

expedient retrieval of accurate and timely patient information. It is available anywhere there is

internet access. It provides easy accessibility of medical health information. It allows patients

and doctors to plan their personal commitments, in turn reducing stress of both patient and

doctor, which benefits patient overall health. Furthermore, it increases patient satisfaction and


effective treatment because with a patient portal the patient is more likely to become involved

with the plan and care of their health treatment. Fewer medical errors occur; and time is saved

for both health care providers and patients by having immediate access to patient medical

information. These time savers include less phone calls for appointments and fewer phone calls

for medication refills.

The major factor that identifies it as a patient portal is ownership, observes Kruse,

Bolton, & Freriks (2015). It is accessed by the patient, but owned by the physician or health care

establishment, and the organization manages it describes Kruse et al. (2015). The patient portal

acts as an intermediary between the patient and the organization. It can be used concurrently by

clinical staff, business staff and patients to integrate and promotes effective use of data.

Furthermore, a patient portal includes patients’ personal health records including smoking status

(Adsit et al., 2014). The innovative technology of the patient portal empowers doctors and their

staff with the tools needed to utilize and sustain a reliable smoking cessation intervention

platform. A patient portal allows the patient to feel and become empowered by their own active

role in their personal health. This increases patient satisfaction and effective treatment. The

patient portal is increasingly being used by health care providers to offer information and to

interact with their patients (Riippa et al., 2014). Implementation of a patient portal can aid in the

prevention and reduction of smokers while boosting the overall culmination of an organizations

economic security without jeopardizing its quality. According to Byczkowski et al. (2014) almost

seventy percent of parents of critically ill children agreed that the patient portal improved their

ability to manage and to understand their child’s condition.


ARRA

In response to the recession, 800 billion dollars was allocated as a stimulus to offset

further economic drain to our nation’s economy in The American Recovery and Reinvestment

Act (ARRA). The legislation in ARRA 2009 includes many measures to modernize, improve,

and promote technology innovation in our nation`s infrastructure. Nineteen billion of the over

800 billion was allocated with the goal that by the end of the second decade in the twenty first

century nine tenths of our health care data infrastructure will be stored within the patient portal

within the EHR, with an estimated date of 2020 to have more than ninety percent of a patient’s

info housed within an EHR (Lindholm et al., 2010). A main advantage of the patient portal is that

it is owned and managed by the health care organization, allowing the patient access to the data.

The Centers for Medicare & Medicaid Services (CMS) grant an incentive payment with

premiums paid over a five year period for eligible providers or hospitals that can demonstrate

and document the adoption of an EHR once the criteria requirement has been met. Eligible

professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to

$63,750 through the Medicaid System (CMS, 2015).

Health Information Technology for Economic and Clinical Health (HITECH) was signed

into law as part of ARRA. The HITECH Act supports the concept of EHR Meaningful Use and

proposes the meaningful use of interoperable EHRs as a critical national goal in US Health care

delivery systems to promote innovation while decreasing the excessive financial burden to health

care providers (Health IT, 2013).

Meaningful use is a set of standards defined by the Centers for Medicare & Medicaid

Services (CMS) to provide incentive payments of $40,000 to $60,000 to eligible physicians and

hospitals who adopt, implement, and upgrade or demonstrate meaningful use of certified


electronic health records (Health IT, 2015). Furthermore, some physicians and hospitals who do

not meet deadlines can be charged a penalty fee. The department of health and human services

has developed an inclusive process to develop the criteria or objectives (which were published

allowing feedback which resulted in 23 objectives for hospitals and 25 for clinicians and thus

resulted in providing a broader range of in freedom for providers to devise their own strategy

toward meaningful use (U.S. Department of Health and Human Services). These objectives

specifically state there needs to be “meaningful use” exhibited every calendar year by providers

to achieve increased patient-controlled data as it relates to patient portals to achieve significant

advances in health care processes and outcomes. Some of the benefits of meaningful use include

complete and accurate information, better access to information, and self-management.

Benefits of Meaningful Use

Complete and accurate information.

Meaningful use allows physicians and the staff to have all the information they need

regarding the patient and their health history even before they see them for their appointments.

The EHR is a system organized to ensure quick, secure and accurate electronic access to

information permitting rapid retrieval of data for patients as well as health care providers.

Beyond the obvious abilities of the EHR, such as its ability to allow more detail, the large

amount of information contained in an EHR, allows for complex, analytically structured analysis

and comprehensive clinical reports. In addition, this frees up the researcher’s time. Benefits of

these reports are broad and include, but are not limited to: the planning and monitoring of

performance that allow the practitioners to improve staffing needs while particularly addressing

integration and condensing of many differing jobs into fewer, more comprehensively defined,

jobs. Historically, analyzing such complex research was a very cumbersome, labor-intensive


activity of data abstracts which required a great deal of complex insight, a great deal of subtasks

and maximum involvement often leading to delayed, ambivalent or missing data (from literally

physical files) while imposing a very high cost on the healthcare organization and could possibly

be linked to business failure.

Better access to information.

Meaningful use allows for greater access to information and ability to easily share

information among doctors, clinics, hospitals and across health care institutions, which results in

better coordination of care, overall improvement in patient health, and a decrease in financial

burdens. Sophisticated access to information in hospitals permits more beds filled to capacity and

greater use of resources, which results in staff volume requirements being easier to predict while

simultaneously reducing the amount of redundant procedures and unnecessary staff activities

performed. Generally speaking, the meaningful and wide use of patient portals within the EHR

has the potential of contributing to knowledge in a variety of multivariate medical situations.

This knowledge can lend support to improved managerial decisions, more pertinent audits of

compliance, accounting/monetary gains. Furthermore, it allows for a widespread, broad range of

scientific analysis of archived clinical data, reducing the amount of discrepancies and historical

researchers necessary.

Self-Management.

Few patients are literally dying when they seek care and few are cured after they depart

their doctor’s office. In the interim there needs to self-management. Self-management

encourages health. Meaningful use within a patient portal allows patients to be more in control of

their own health which makes them more involved and active in their own and their family’s

healthcare. A patient portal empowers the patient. As technology improves healthcare has


gradually moved into the hands of the patient. Patients, throughout history have been viewed as

uneducated, inept receivers of health care. And for good reason, most did not possess much

medical knowledge and thus could not cure or prevent their ailments. However, with the vast

amount of information available over the Internet, patients have emerged as an integral part of

healthcare. Patient portals allows the patient to advocate their thoughts and opinions, pushing

them to a more symbiotic role in their health. If the patient feels like he/she is in a subservient

role, he/she will be more apathetic to their natural ability to improve their health. Patients will be

more active in preventative health. Contrary to medical opinion, clients are more appropriate

judges of their level of pain than previously believed and can in fact accurately assess their

medical issues. Studies show that a patient’s investment in their personal healthcare dramatically

affects the outcome. Caretakers have been shown to have a bias toward pain perception and

treatment, and commonly underestimate pain severity and thus may under treat it (Hamill-Ruth

et al., 1999).

Prevention is health care self-managed.

If we want patients which suffer from tobacco related diseases to live longer and

experience a better quality of life, then we need to change the standards that neglect prevention,

diagnosis, and supportive care, otherwise known as the triple-neglect situation emphasizes Hong

et al. (2015). As a well-known proverb states, an ounce of prevention is worth a pound of cure.

Prevention is a necessary ingredient in protecting life. Prevention of a disease is cheaper and

more effective than managing an acquired condition which could have been prevented. Chronic

lung disease is more commonly treated than a sudden collapsed lung. The most effective way to

prevent chronic lung disease is to cease smoking. It’s well-known to most Americans that

patients who have a chronic disease caused by smoking, can improve their health by ceasing to


smoke. And, surprisingly an estimated 70% of all U.S. smokers desire to stop smoking (CDC,

2005a). Some headway has been made in eliminating smoking and thus reducing chronic health

problems. However, there is still a large percent of the population who smokes or, who may

begin smoking.

Support for prevention often requires continuing assistance, follow-up and periodic

support for the changes made in lifestyle and health-related behaviors as deemed appropriate.

The most effectual way to get people to stop smoking and prevent recurrence involves multiple

interventions and prolonged reinforcement. For this reason, general practitioners, nurses, health

professionals (or nonprofessional lay health workers such as administrative positions) can

educate clients personally through the aid of a patient portal, one of the components of a

sophisticated EHR system. The patient portal includes a patients’ personal health records, which

includes their smoking status. This technology can provide health care professionals, such as

general practitioners and nurses the critical communication prompts to remind and encourage

them and the other health staff of an organization to offer smoking cessation information to their

patients.

The eReferral Quitline Referral System

Wisconsin’s healthcare system has demonstrated the possibility as well as the success of

incorporating a smoking cessation intervention through their use of a modified EHR system,

explains Adsit et al. (2014); concluding, the patient portal in the EHR helps increase the

participation of patients who are smokers to cease smoking. Epic System Corporation (Epic) is

one of the largest EHR systems in the nation. Wisconsin`s healthcare system is using the Epic

system (Dean Health System) which is one of the largest telephone tobacco quitlines. The State

of Wisconsin uses the service of Alere Wellbeing, Incorporated (Alere) as the Wisconsin`s


Tobacco Quitline (WTQL). With the help of a modified EHR system, EPIC designed an

eReferral system for more efficient and faster ways to deliver treatments to patients who are

smokers.

The eReferral quitline is a referral system that is being used in Wisconsin’s healthcare to

document the Best Practice Advisory (BPA). BPA is an EHR tool to use for evidence-based

clinical intervention. BPA automatically generates a prompt in the system for clinicians to offer

the quitline services (See Figure 2). The main goal is to refer all adult patients in the system who

are willing to quit smoking to the WTQL for cessation services (Adsit et al., 2014).

There are two Dean Clinics in Wisconsin implementing these two Quitline processes. One

process involves sending a Fax-to-Quit referral form by fax manually. The other process involves

using an electronic eReferral method (Adsit et al., 2014). Studies show that eReferral helps

increase the participation of patients who are smokers in the quit line service compared to the

paper-based quit line service. Figure 3 is the patient portal under the eReferral smoking status

section of an EHR and shows the healthcare provider`s responsibilities to ensure that this is

completed.

Need for further research

Disparity between users.

National surveys in the US show that a majority of Americans are interested in electronic

access to their health related information, however the results, according to Byczkowski, Munafo

and Britto (2014) show there is a disparity between interest and the actual behavior of using the

patient portal. The Byczkowski et al. (2014) study determined the amount of people indicating

interest is much higher than those that are using the portal. In addition, the Goldzweig et al.

(2013) study determined disparities. The Goldzweig et al. (2013) study discovered disparities


between the interrelated factors of income, education and vocation of portal users; and

concluded, by urging efforts be made in reducing socioeconomic disparities. The instruments

used in the Goldzweig et al. (2013) study included a modified EHR. The data retrieved from this

study was then analyzed and interpreted. The data indicated blacks, Latinos and Filipinos were

less likely to use the portal than whites. It also indicated that than those with an education at or

below a high school level education were less likely to utilize the patient portal than those with

college level education. Byczkowski et al. (2014) also noted that there is evidence of disparities

in patient portal enrollment and use by race and insurance status.

Furthermore, Goldzweig et al. (2010) addressed usability issues, noting in their research,

some human factors which negatively impacted usage of the patient portal. Byczkowski et al.

(2014) also noted some human factors which created a barrier to usage, such as users being

unable to recall their password. The Byczkowski et al. (2014) study stated the most common

reason that parents didn’t use the portal was never receiving or losing their password and

The socioeconomic disparities found among users, as well as the human factors, both warrant

further research to determine which area of the portal may impair or hinder the user. In addition,

it might be useful to not only look at the race of the user, but the language. If English is not the

user’s first language, this fact alone, would definitely cause a barrier to use of the patient portal.

Thus, further studies would be beneficial to determine whether different language options

programmed into the patient portal would enable more use among patients who have a primary

language other than English.

Goldzweig et al. (2013) also noted there was a slightly higher amount of females than

males that utilized the patient portal. Goldzweig et al. (2013) expounded on this, noting that not

only females used the portal more often but those in a more dire health status, such as patients


with more diagnoses utilized the patient portal more often than those with fewer and less severe

health prognoses. Furthermore, patients with many prescribed medications were more likely to

use the patient portal than those with less health issues. As mentioned above those patients in a

more dire health status utilized the patient portal more frequently; and, I believe it’s worth noting

that parents of children suffering from life threatening illnesses did in fact use the portal the most

(with parents of children in need of cardiac surgery ranking the highest of diagnoses that

instigated the parents to more avidly utilize the portal, suggesting it is worth implementing a

brief and comprehensive patient portal training for those families whose children are victims of

extraordinary difficult health challenges).

Lessons Learned

The literature reviewed on the efficacy of utilizing a patient portal and an EHR helps

illuminate the lessons learned in previous studies. Fraser, Christiansen, Adsit, Baker & Fiore

(2013) addressed the lessons learned in their study which utilized a modified EHR for linking

recruitment of tobacco users while propagating and identifying an effective cessation

intervention for all smokers seen in primary care settings. Fraser et al. (2013) described five

lessons learned during their research which they felt would be useful to other researchers. The

first lesson identified by Fraser et al. (2013) is the need for a flexible design process. Fraser et al.

(2013) elaborates that there are limited options for determining how and where the study

invitation becomes visible and whether or not a mandatory pop-up response window is

important. The second lesson learned in the Fraser et al. (2013) research is the need to

understand the IT work process. Fraser et al. (2013) emphasized the importance of estimating IT

staff work requirements separately for each participating health care system. The third lesson (as

cited in Fraser et al., 2013) is language and communication, Fraser et al. (2013) discussed how it


is common for researchers to “speak a different language” than computer programmers. The

fourth lesson of Fraser et al. (2013) is need for adaptation to EHR differences due to the

differences and dissimilarities between vendor platforms which they suggested can lead to the

need for more vigilant training and follow up for the medical assistants or users. Fraser et al.

(2013) discussed the fifth lesson is to minimize modifications after the initial launch as post

launch modifications can be timely as well as costly. The sixth lesson of the Fraser et al. (2013)

research is privacy, which is critical in today’s hacking environment. Lesson seven of the Fraser

et al. (2013) research is extraction and knowledge of EHR data. The last lesson of Fraser et al.

(2013), lesson eight, is the fast-paced and time sensitivity of a medical staff and their day to day

hectic, and sometimes unfathomable work load. The interaction and documentation process

needs to be very brief. Fraser et al. (2013) documented in their study that two minutes is optimal,

which totaled six to eight minutes with a smoking rate of their patients at approximately fifteen

to twenty-five percent of all of their patients.

Due to the recentness of the legislation, it was difficult to locate studies which evaluated

patient satisfaction with their patient portal. The more health care organizations which offer a

patient portal will impact the success of future reviews. Future investigation would be helpful.

Methodology

In order for me to gather all the information needed for the literature review, my

professor, Barbara Piper, guided me towards discovering a topic. I was given an opportunity to

work with our National University librarian, Zemirah Lee, a very supportive librarian. She

ensured I was able to independently use National University’s online library and search engine. I

utilized the vast amount of information on the CDC.Gov website and HealthIT.gov website,


specifically searching for the terms: “meaningful use,” “ARRA,” and “HITECH.” They provided

me with useful information regarding legislation, meaningful use and the benefits and incentive

program (respectively). I queried the keywords: “patient portal,” “EHR,” in the following search

engines: Johanna Briggs Institute, google scholar, Centers for Medicaid and Medicare, Cochrane

library, PUBMED (MEDLINE), OVID, as well as hand-searching to find peer-reviewed,

scholarly articles. Differences in syntax led to different articles based on the search engine. If

there was more than 25 results, I utilized other applicable search strings to narrow the results.

The term “patient portal” is slow to transcend across different platforms, and thus the results

varied. In databases which used Boolean search operators, I searched for the combination of the

following key terms: smoking, smokers, tobacco users, cessation, ARRA, and patient portal.

Most search engines used Boolean search operators, which produced more relevant literature. I

tried to circumvent bias however found this somewhat difficult. The higher grade research

journals are well funded and likewise have a larger base of readers; thus, articles from these

journals tend to be cited more often than studies with a lower percentage of readers. In addition, I

utilized ProQuest, DOAJ Directory of Open Access Journals, and Academic on file to further my

research. Over 200 articles were screened and analyzed. Of the 200, 25 were deemed acceptable

and analyzed further.

Evaluation of Evidence

Author and Date

Methods Sample/Setting

Design Intervention Measures

Major Findings

Recommendations/Gaps

Adsit et al. (2014)

Two Dean Clinics in Madison, WI. One a

family medicine

Targeted smokers visiting a physician via the eReferral

Measuring and tracking the referral rate of smokers utilizing an

EHR integrated e-Referral Quitline use is effective in boosting rate of smoking

Increase quitline exposure because only one percent of smokers in the USA use a quitline. However those that

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primary care clinic with 7 physicians and one a pulmonary speciality

with 6 physicians.

(electronic) in comparison to the paper fax to quit referral system

EHR integrated quitline

cessation utilize a quitline show increased cessation rates

Bentz et al. (2007)

Nineteen primary care clinics in Oregon.

Clustered randomized clinical trial

Determine whether EHR generated provider performance feedback increases tobacco cessation efforts in primary care clinics

Providers had higher rates of EHR documentation of asking about tobacco use with almost double documentation of assistance with quitting.

More focus on lead nurses. Lead nurses appear to be the most active vehicle to encourage medical assistants to ask and assist patients with quitting, thus should be the staff targeted

Boyle et al. (2014)

EHR’s to prompt tobacco use in healthcare settings.

Randomized studies and non- randomized studies

Access the effectiveness of electronic health record facilitated interventions on smoking cessation support and outcome.

Modest improvement in providing a smoking cessation intervention when EHR facilitated

Conduct a meta-analysis to provide a precise estimate of smoking cessation when prompted by an EHR

Byczkowski et al. (2014)

A tertiary children’s hospital

Cross sectional telephone survey with semi structured interviews

Understand perceptions of the usability Understand the value of patient portals of parents of children with a chronic disease

Most parents agreed the patient portal was timely, accurate and useful in managing their child’s condition

Increase awareness of the patient portals existence


Fraser et al. (2013)

Primary care settings in southern Wisconsin. Patients recruited from 10 -12 family practice clinics.

Compare multiple smoking cessation interventions

The use of the EHR for linking recruitment and intervention in identifying effective cessation interventions for all smokers seen in primary care settings

The EHR is a powerful tool to facilitate a team science approach. The interaction and documentation process required less than two minutes for each smoker or 6-10 minutes for each MA over a full clinic day.

Studies to determine how and where the pop-up prompt alerts the medical assistants / nurse would be helpful. Studies to determine if documentation of smoking status should be mandatory.

Goldzweig et al. (2013)

Group Health network of clinics and Partners HealthCare network of clinics.

Two reviewers extracted the data of randomized controlled trials. No meta_analysis.

Measuring the satisfaction level of clinical care & patient outcomes from tethered patient portals to an EHR

Patient attitudes are positive. However, they may be more effective when used w/ case mgmt. Evidence is insufficient. Socioeconomic disparities.

Reduce socioeconomic disparities by addressing usability issues.Gap in reporting- difficult to determine if it was failure of portal intervention or failure of reporting

Hivert et al. (2009)

78,293 patients from twelve primary care practices receiving regular care over a three year period

Defined patients with risk factor clustering using MetS characteristic.

Measuring whether the use of EHR data is beneficial to identify at-risk patients

EHR data is useful to target lifestyle interventions for primary prevention of CHD and reduce health care cost

Developers of future guidelines should require EHR data and metabolic syndrome combined to identify patients and populations at risk

Kruse et al. (2015)

Peer-reviewed observational studies which evaluated patient

There were no human subjects in this study. All information was

Measuring the success of the patient portal in regards to its effect on quality of

More health care organizations offer features of a patient portal than 4 years ago. There is an

Increase the amount of training and quantity of technical support and increase internet access. These both


portals between the dates from Jan 1, 2011 to August 24, 2014.

retrieved from secondary data sources

care, medical outcomes and patient satisfaction

increase in customer satisfaction and retention but weakness on medical outcomes.

contributed to identified adaptation barriers.

Kruse et al. (2012)

Two community health centers serving low income patients in Boston, Massachusetts

Mixed method design calculated the average number of referrals per PCP

Measured the benefit of a one click functionality added to an EHR to improve delivery of tobacco cessation treatment

Functionality added to an EHR allowed PCPs to refer smokers to a centralized tobacco treatment coordinator who called smokers, provided brief counseling and provided an opportunity for feedback

Sending monthly performance reports to the PCPs. Peer pressure may encourage PCPs to refer their patients to evidence-based tobacco cessation treatment.

Lindholm et al. (2010)

Dean Health System and the University of Wisconsin School of Medicine and Public Health modified 18 primary care clinic’s

Cross-sectional study focused on a single health care system. One year before implementation and one year after intervention implementation.

Measuring the success of EHR to identify and treat tobacco users. EHR to include tobacco intervention prompts

A large health care system can increase the identification of smokers. Brief tobacco dependence interventions can be built into primary care when an EHR is used.

Develop more EHR stratification tools that better define which components and categories can be built into health care systems to identify smokers.

Piper et al. (2013)

Two primary care clinics, Aurora Health Care and Dean Health

Targeted Smokers in the motivation phase while visiting a primary care

Measuring the success of a chronic care model in treating tobacco dependence

Smokers offered cessation interventions at a primary care clinic visit, versus mass mailing are

Need newer more effective models to increase percentage of smokers who receive advice to quit. One third of patients were not


System. Wisconsin, US.

clinic for regular care.

integrated into EHR of PHP to identify and treat tobacco users. prompted through the use of a chronic care model

more likely to participate in treatment and quit smoking.

invited. Mandatory documentation section may have caused MA’s to fail to invite due to time constraints. Providing MA’s feedback would be beneficial. Needs alternate approaches to better compare research.

Synthesis and Summary

The literature reviewed indicates health organizations using an EHR with a patient portal

for identifying tobacco users who are willing to quit will have a broader success rate than those

health organizations not utilizing a patient portal. The literature reviewed emphasizes the active

role patient portals play in identifying and following up with patients who have tried to quit

smoking but have not been successful in the past; and, elaborates on this point by demonstrating

that smokers whom have access to a patient portal have a more positive outcome than those that

do not utilize a patient portal. The literature assessed demonstrates that with the help of advanced

technologies like an EHR, practitioners can reduce medical expenses. The literature describes

how a sophisticated EHR provides the backbone for a more reliable smoking cessation

procedure, accords fewer errors, and ensures a better overall patient success and satisfaction

guarantee than word of mouth prompted by sheer memory of the medical staff assessing the

patient. The evidence demonstrates that an industry wide use of a patient portal within the EHR

will increase the likelihood of smokers successfully quitting.


The lack of evidence evaluating tobacco cessation rates amongst the medical institutions

which have implemented a patient portal, in comparison with those which have not implemented

a patient portal, warrants a widespread analysis of the association between smoking cessation of

those medical organizations using a patient portal as opposed to those medical institutions not

using a patient portal.

Recommendation

Future investigation would be helpful to better understand the most efficient, effective

time-sensitive modified EHR to help medical assistants identify and aid in smoking cessation. It

is critical that there needs to be a friendlier user-interface design. It would be beneficial for the

programmers of the software to physically go out into the medical environment and take a walk

in the life of the “roomers” or nurses (the primary user of the software) so they are able to

understand their time constraints as well as their needs, and incorporate these needs into the EHR

portal design. The programming of the software is central to its utilization.

Not only do the programmers need to create user-friendly systems monitoring the use to

determine which screens cause confusion and what enhancements or changes they can

incorporate into the patient portal so that it is simpler to use for the less computer literate medical

staff, but they also need to design the portal so that all patients have equal opportunities to

successfully utilize it. As stated previously, it is suggested the EHR programmers need to create

user-friendly systems monitoring the use to determine which screens cause confusion and what

enhancements or changes they can incorporate into the patient portal so that it is simpler to use

for the less computer literate individuals. A sophisticated EHR system is only as good as those

trained to use it. If there is poor training, there will be poor results. One suggestion would be to


designate an IT member to meet up with the medical staff of the organization that will primarily

be using the tobacco cessation intervention software platform, and equally important, there needs

to be a designated staff member of the medical facility that is trained to meet one on one with

any of the patients to ensure that each patient is comfortable setting up, navigating, and

comprehending how to access all the patient portal’s sites features.

Some headway has been made in eliminating smoking and thus reducing chronic health

problems. However, there is still a large percent of the population who smokes or, who may

begin smoking. Prevention cannot be emphasized enough. Persuading our nation’s youth not to

smoke before they begin smoking is fundamental. A social media advertisement campaign

(Facebook, Twitter and Instagram) about tobacco cessation would increase awareness on how

tobacco use inevitably damage the health of the smoker`s (especially young adults). An efficient

way to prevent young people from smoking is stopping their older family members from

smoking. I conclude with an urge for other researchers to delve further into this investigation. A

deterioration of a country’s overall health eventually leads to a deterioration in its economic

growth. Society reaps the benefits of a healthy population and a healthier labor pool.

Many people with nicotine addiction become lost in the healthcare system. If support to

cease smoking is not provided, the victim of the addiction may give up rather than stop smoking.

The physician who knows their patients background can be more adept at offering solutions to

the most profound case of nicotine addiction. Advice and help, along with routine follow-up by

healthcare professionals can be effective in nicotine addicts change their risky behavior. It is

recommended that there be a set of standardized policies so that all clinics and hospitals will

have an interoperable cessation application. This will enable each patient`s healthcare provider to

follow up regarding the smoking status of the patient, while having better access on patients


health information. A thorough assessment of the patient whom uses tobacco, as well as a

commitment to quit, and a follow up clinical visit scheduled.

It’s well-known to most Americans that patients who have a chronic disease caused by

smoking, can improve their health by ceasing to smoke. Overall, an estimated 70% of U.S.

smokers desire to stop smoking (CDC, 2005a). The most effectual way to get people to stop

smoking and prevent recurrence involves multiple interventions and prolonged reinforcement

utilizing meaningful use of a patient portal within an EHR.

The prevention of disease is one of the most rapidly evolving and is an issue growing in

importance in the United States and the rest of the world. As I have explored, the main function

of the healthcare organization is the protection of the health of its community. A major activity in

protection of a community’s health is management and prevention of life threatening illnesses.

Aggregate data demonstrates we need protocols to support the prevention of disease. Technology

allows the healthcare industry the successful protocols to be instituted; one specific protocol, a

cessation protocol allowing prompts to alert the medical staff to suggest a plan of action for

patients, whom are smokers, whom may have not been successful in the past at ceasing to

smoke. Furthermore, it can flag future health care providers to their patients’ progress in the

addiction cycle and allow the provider to individually offer support and suggestions or even a

specific plan, which in the past was not possible. The possibilities of this EHR technology and

the patient portal is still in its infancy and therefore, although there is not yet a straightforward

path to follow, there are theoretically sound examples of how effective this cessation approach

will be toward putting a halt to the unfortunate series of diseases caused by smoking.


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APPENDIX

Table 1 (Adsit et al., 2014)

http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=4167898_13142_2014_259_Fig1_HTML.jpg


Figure 2 (Lindholm et al., 2010)

http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=3587763_nihms-433854-f0003.jpg


Figure 3 (Kruse et al., 2012)

http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=3509313_11606_2012_2174_Fig1_HTML.jpg


Figure 4 Comparison Studies


Figure 5, 6 Comparison of Studies

smoking cessation: the efficacy of a patient portal in an ehr · web viewaccording to the centers...

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