Agenda

1. Seizing the Electronic Health Record to Enhance the Delivery of Tobacco Dependence Treatment in Primary Care SettingsRob Adsit, MEdMichael Fiore, MD, MPH, MBAUW-CTRIJuly 28, 2010Madison, Wisconsin

2. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? • Health systems change • Applying the evidence in a real-world health system • Outcomes • Summary

3. Agenda • Introduction - UW-CTRI (Called out) • Why treat tobacco dependence? • Why focus on primary care? • Health systems change • Applying the evidence in a real-world health system • Outcomes • Summary

4. UW-CTRI University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and Intervention (UW-CTRI) Founded in 1992

5. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? • Health systems change • Applying the evidence in a real-world health system • Outcomes • Summary

6. Annual deaths from smoking compared with selected other causes in the United States

7. Smoking Prevalence Among U.S. Adults, 1955-2008 Source: CDC TIPS

8. U.S. Smoking in Perspective • Kills more than 430,000 Americans each year. • Approximately 20% of adult Americans smoke. • 3000 children and adolescents become regular tobacco users every day. • Causes cancer, heart disease, stroke, pulmonary disease, and adverse pregnancy outcomes. • $75 billion in health care costs annually • $82 billion in lost productivity each year

9. U.S. Smokers in Perspective • 70% of smokers want to quit • 70 - 80% try to quit “cold turkey” • Cold turkey quit rates are < 5% • The challenge – linking smokers who want to quit with evidence-based treatments which have long-term quit rates of 20 - 40%

10. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? (Called out) • Health systems change • Applying the evidence in a real-world health system • Outcomes • Summary

11. Treating Tobacco Use and Dependence: The Clinician’s Role • 80% of smokers see a clinician each year • 60% of smokers are asked if they smoke • Only 25% of those seeing a clinician leave that visit with evidence-based counseling and/or medication

12. The New Vital Sign

13. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? • Health systems change (Called out) • Applying the evidence in a real-world health system • Outcomes • Summary

14. Health Systems Change • Challenges • Asking about and documenting tobacco use • Seizing clinic visit to treat tobacco addiction • Building the brief intervention model (5A’s) into the electronic health record (EHR) • EHR is a tool, not a solution • Brief intervention built into clinic workflow • Making evidence-based tobacco dependence treatment the standard of care

15. Systems Interventions:Clinician Training and Chart Reminders Effectiveness of clinician training combined with charting on asking about smoking status (“Ask”) (n = 3 studies)* • Intervention • Number of arms • Odds Ratio (95% C.I.) • Estimated rate (95% C.I.) • No intervention • 3 • 1.0 • 58.8 • Training and charting • 3 • 2.1 • (1.9, 2.4) • 75.2 • (72.7, 77.6) • *US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008 *US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008

16. Systems Interventions:Clinician Training and Chart Reminders Effectiveness of training combined with charting on setting a quit date (“Assist”) (n = 2 studies)* • Intervention • Number of arms • Odds Ratio (95% C.I.) • Estimated rate (95% C.I.) • No intervention • 2 • 1.0 • 11.4 • Training and charting • 2 • 5.5 • (4.1, 7.4) • 41.4 • (34.4, 48.8) *US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008 *US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008

17. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? • Health systems change • Applying the evidence in a real-world health system (called out) • Outcomes • Summary

18. How does this work in a real health system? • Dean Health System, large healthcare system in south central Wisconsin • Medical Director, doctors, quality improvement staff, training staff, information technology staff • UW-CTRI • Outreach Specialist, Outreach Program Manager, Center Director (physician)

19. Goals • Adapt/Modify electronic health record (EHR) to identify and intervene with tobacco users • EHR is a tool, not the solution • Consistent, time efficient clinical workflow modifications • Tobacco dependence treatment incorporated into existing clinical workflow and clinician roles

20. Existing environment for tobacco dependence treatment • Identifying and documenting majority of tobacco users • Not all identified tobacco users were receiving evidence-based treatment • Few treatment interventions being documented

21. Process • Multi-year process • Succinct verbiage, smartsets, drop-down menus • ID tobacco users; tobacco use history; ready/not ready to quit; counseling; medications; referral to quitline • Clinic workflow, clinic staff roles • Pilot testing at physician champion clinic • Training and roll-out in family medicine, internal medicine, OB/GYN across system • Emphasized briefness (1-3 minutes) of effective intervention

22. Tobacco Dependence Treatment Brief Intervention 5 A’s Model* • Ask – Do you currently use tobacco? • Yes  Advise to quit  Assess, Are you willing to quit now?  • Yes  Assist, Provide appropriate tobacco dependence treatment  Arrange Follow-up • No  Assist, Intervene to increase motivation to quit  Arrange Follow Up • No  Ask, Have you ever used tobacco? • Yes  Assess, Have you recently quit? Any changes? • Yes Assist, Provide relapse prevention  Arrange follow-up • No  Assist, Encourage continued abstinence  Arrange follow up • No  Arrange Follow Up *US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008 *US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008

23. Vitals

24. Patient Instructions

25. Smoking Cessation DHS AMB

26. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? • Health systems change • Applying the evidence in a real-world health system • Outcomes (Called out) • Summary

27. Outcomes • Change implemented in18 Dean Health general internal medicine and family practice clinics • One year pre- and one year post-implementation data from 250,000 adult patient visits

28. Outcomes

29. Outcomes

30. Additional Post-Intervention DataAdult Smokers • Prescribed Medication – 6.3% • Smart Set Used – 2.5% • Counseling Documented – 1.5%

31. Agenda • Introduction - UW-CTRI • Why treat tobacco dependence? • Why focus on primary care? • Health systems change • Applying the evidence in a real-world health system • Outcomes • Summary (Called out)

32. Summary/Lessons Learned • Healthcare system can effectively use EHR to treat tobacco dependence • Evidence-based, BRIEF tobacco dependence treatment can be built into the EHR and the clinic workflow • Increased rate of tobacco users identified, documented and treated • Smoking rates decline

33. Funder Funding provided by: National Cancer Institute Contract Number HHSN261200900453P

34. www.ctri.wisc.edu www.ctri.wisc.edu

35. Contact Information Rob Adsit, MEd 608-262-7557 ra1@ctri.medicine.wisc.edu Michael Fiore, MD, MPH, MBA 608-262-7539 mcf@ctri.medicine.wisc.edu