Systems Strategies to Address Tobacco Use: Utilizing EHRs to Improve Patient CareRyan Reikowsky, MA, MPHManager, Community DevelopmentArizona Smokers’ Helpline (ASHLine)

Why Address Tobacco Use?

Tobacco Use is EXPENSIVE.

• Tobacco use costs the U.S. $130 billion annually in health care costs and an additional $150 billion in lost productivity

• Comprehensive tobacco cessation programs reduce tobacco use and lower associated healthcare costs, providing a strong ROI

Efforts to reduce tobacco use, especially among the uninsured and underinsured, could significantly reduce healthcare spending.

Tobacco Use in Arizona: Quick Stats

• Adult smoking prevalence: 17.1%

• Annual health care costs directly attributable to smoking: $2.38 billion

• Portion covered by Medicaid: $316 million

• Smoking-attributable productivity losses: $1.65 billion

Tobacco Use as a Health Disparity

Low socioeconomic status (SES) is one of the single greatest predictors of tobacco use.

• Prevalence of current smoking is highest among adults with:

– Working class jobs

– Low education

– Low income

– No employment or underemployment

– Medicaid

– No health insurance

Tobacco Use as a Health Disparity

Approximately 21% of adults nationally are current tobacco users. However, relative to the general population:

• 34% of adult Medicaid recipients smoke

• 32% of uninsured adults smoke• Americans below the poverty line

are 40% more likely to smoke than those at or above the poverty line

Health Effects of Tobacco Use

• Smoking is the leading cause of preventable disease and death in the United States

• > 440,000 Americans die annually from smoking

• > 10 million Americans suffer from at least 1 disease caused by smoking

• Nearly 9 out of 10 cancers are caused by smoking

• 1 out of 3 cancer deaths are tobacco-related

Good News, Bad News

Bad News

Despite decades of evidence detailing the harmful effects of tobacco use and the health/economic costs associated with tobacco use:

• Current tobacco use is disproportionately concentrated among low SES individuals

• U.S. spends $22 billion annually in tobacco-related Medicaid costs (11% of all Medicaid costs)

• Only 23% of smokers on Medicaid receive practical assistance with quitting

This represents a lost opportunity.

Good News, Bad News

Good News

• Low SES smokers express significant interest in quitting and benefit from treatment

• Effective treatment is available

• Consistently providing treatment benefits both patients and providers

Community Health Centers in Arizona

Data from the National Association for Community Health Centers for 2011 suggest:

• Only 50% of community health centers in Arizona provide tobacco cessation counseling as a preventive service on site

Moreover, data from tobacco assessments completed by BTCD/HSAG in 2011 suggest:

• Although tobacco use screening rates are high, post-screening intervention rates are mixed and inconsistent

• Medication assistance is offered more consistently than behavioral support

Treating Tobacco Use & Dependence

The U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update recommends:

- Patients be consistently assessed for tobacco use at every clinical encounter and offered assistance and resources to quit

- Brief tobacco dependence treatment is effective

- Minimal interventions (≤3 min) are effective and should be offered to all tobacco users

Brief Interventions

• Interventions lasting <3 minutes increase overall tobacco abstinence rates

• Every tobacco user should be offered brief intervention, even if they are not referred to an intensive intervention

STRENGTH OF EVIDENCE: AUS PHS Clinical Practice Guideline: Treating Tobacco Use

and Dependence: 2008 Update

Brief Interventions

• Even when patients are not ready to make a quit attempt, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts

STRENGTH OF EVIDENCE: AUS PHS Clinical Practice Guideline: Treating Tobacco Use

and Dependence: 2008 Update

Intervention Models: 5A’s vs. AAR

ASK about

tobacco use

ADVISE to quit

ASSESS willingness to make a

quit attempt

ASSIST in quit

attempt

ARRANGE follow-up

ASK about

tobacco use

ADVISE to quit

REFER to

ASHLine

ASHLine’s Recommended Model

Follow 3 simple steps:

Ask,Advise,ReferWe’ll do the rest!

Integrating Tobacco Cessation Into EHRs

Ask, Advise, Refer (AAR) can be integrated into EHRs via templates designed to consistently prompt clinicians to:

- Screen for/assess tobacco use (including SHS exposure)- Assess cessation interest + past quit attempts- Encourage quitting- Advise about smokefree environments- Connect patients and families to cessation resources and

materials

Integrating Tobacco Cessation Into EHRs

The American Academy of Family Physicians (AAFP) recommends tobacco treatment templates be automated to appear during all well-patient exams, as well as when patients present with the following symptoms:

- Cough + upper respiratory problems- Diabetes- Ear infections- Hypertension- Depression + anxiety- Asthma

Ask

• Identify and document the tobacco use status of every patient at every visit

• Significantly increases rates of clinician Tx and patient cessation

STRENGTH OF EVIDENCE: AUS PHS Clinical Practice Guideline: Treating Tobacco Use

and Dependence: 2008 Update

Integrating Tobacco Cessation Into EHRs

Meet Meaningful Use Criteria

Objective: Record smoking status for patients 13 years old or older.

Measure: More than 50% of all unique patients 13 years or older seen by the EP have smoking status recorded.

EHR Requirement:

Must enable a user to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; and unknown if ever smoked.

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

What should be included in a tobacco cessation EHR template?

Tobacco use status can be documented as:- Current every day smoker- Current some day smoker- Former smoker- Never smoker- Smoker, current status unknown- Unknown if ever smoked

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

Documenting Tobacco Use History

Type of tobacco*:□ Cigarettes □ Pipe □ Cigars □ Smokeless

How many years?_______ Packs per day: _______

Brand: _____________________

Approximate date of last quit attempt: ________

*□ Electronic cigarettes □ Other

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

Documenting Tobacco Use History

Medication used in previous quit attempt:

□ Patch □ Bupropion

□ Gum □ Varenicline

□ Lozenge □ None

□ Inhaler □ Other: ______________

□ Nasal Spray

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Advise

• In a clear, strong, and personalized manner, urge every tobacco user to quit

• Capitalize on “teachable moments” with patients

STRENGTH OF EVIDENCE: AUS PHS Clinical Practice Guideline: Treating Tobacco Use

and Dependence: 2008 Update

Integrating Tobacco Cessation Into EHRs

Meet Meaningful Use Criteria

Objective: Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.

Measure: More than 10% of all unique patients seen by the EP have are provided patient-specific education resources.

EHR Requirement:

Must enable a user to electronically identify and provide patient-specific education resources according to, at a minimum, the data elements included in the patient’s: problem list; medication list; and laboratory test results; as well as provide such resources to the patient.

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

Documenting Advice

Counseled for:□ Three minutes or less □ 3 to 10 minutes □ 10+ minutes □ Counseled for secondhand smoke

Counseling notes: ____________________________________________________________________________________________________________________________________________

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

Readiness to Quit:

□ Not interested in quitting □ Thinking about quitting at some point □ Ready to Quit

Handouts/Education Provided:

□ Quitline card □ Quit Smoking Brochure□ Secondhand Smoke Brochure□ Other

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

Pharmacotherapy

Recommended OTC:

□ NRT Patch□ NRT Gum□ NRT Lozenge

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Integrating Tobacco Cessation Into EHRs

Pharmacotherapy

Rx Treatment:

□ NRT Nasal Spray Dosing: 1-2 doses/hour (8-40 doses/day); one dose = one spray in each nostril; each spray delivers 0.5mg nicotine

□ NRT Inhaler Dosing: 6-16 cartridges/day; initially use 1 cartridge q 1-2 hours

□ Bupropion SR Dosing: Begin 1-2 weeks prior to quit date; 150mg PO q AM x 3 days, then increase to 150mg PO bidContraindications: head injury, seizures

□ Varenicline Dosing: Begin 1 week prior to quit date; days 1-3: 0.5mg PO q AM; days 4-7: 0.5mg PO bid; weeks 2-12: 1mg PO bid.

Screen for: suicidal ideations

Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

Refer

• Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions

STRENGTH OF EVIDENCE: AUS PHS Clinical Practice Guideline: Treating Tobacco Use

and Dependence: 2008 Update

Referring to ASHLine

• A proactive referral to ASHLine ensures we will call your patient within 24 business hours

• ASHLine provides ongoing, intensive clinical intervention for you!

What is ASHLine?

Evidence-Based Service• Behavioral support

• Medication assistance

Long-Term Success• 7 Month Quit Rate (global): 30% (vs. 5% “cold turkey”)

• 7 Month Quit Rate (meds + coaching): 56%*

ASHLine Referral Program

Custom QuitFax (paper-based)

WebQuit Account (electronic)

EMR or EHR Template (hybrid)

Reporting Options

• Available by fax or e-mail• Confirmation report (within 24 hours)• Status report (within 10 days)

– First call within 24 business hours– Up to 5 call attempts over 10 business days– Notification of referral outcome (e.g. Enrolled,

Only Requested Information, Unable to Reach, Wrong Number, etc.)

Partnering to Achieve Systems Change Makes Sense!

A systems approach to tobacco assessment and intervention will ensure all patients receiving services are:

- Screened for tobacco use- Offered a brief intervention- Referred to services that can

help them quit successfully

Systematic provision of tobacco cessation services significantly improves health outcomes for all tobacco users, especially those with chronic disease and/or those who are members of “at risk” populations:

• Cancer• Chronic Obstructive Pulmonary Disorder (COPD)• Asthma• Diabetes• Hypertension• Ischemic Vascular Disease• Congestive Heart Failure• Coronary Artery Disease

Partnering to Achieve Systems Change Makes Sense!

Tobacco use assessment and intervention are key components of preventive health. Certified Electronic Health Records (EHRs) are built to help health care organizations provide better care.

EHRs are powerful tools that can help you:

• Ensure patients are systematically assessed for tobacco use• Consistently prompt clinicians to provide advice to quit (i.e. brief

interventions)• Consistent access and transmit referrals to community-based services

for intensive tobacco treatment (e.g. ASHLine)• Manage patient medication lists (e.g. tobacco cessation medications)• Monitor, prevent, and manage disease

Partnering to Achieve Systems Change Makes Sense!

ASHLine’s Community Development Team is available to partner with your organization to make tobacco systems change an achievable goal.

Things to consider:

- Systems change requires administrative support

- Identifying key players to lead and implement change is critical

- Who are the “key players” and/or decision-makers in your organization?

- Who should you be speaking with about partnering on systems change?

Partnering to Achieve Systems Change Makes Sense!

Potential Next Steps

• Evaluate tobacco use prevalence among service recipients to assess potential impact

• Consider policy development to address consistent provision of brief interventions + referral for tobacco users willing to make a quit attempt

Partnership opportunities:– Policy development, implementation, rollout– Audit ASHLine database (current locations)– Establish referral mechanism (EHR or paper)– Staff training, TA, ongoing support

Questions? Thank You!

Ryan Reikowsky, MA, MPHManager, Community DevelopmentArizona Smokers’ Helpline (ASHLine)1-800-556-6222 x208rcreikow@email.arizona.edu