Zehner Mark E, Kirsch Julie A, Adsit Robert T, Gorrilla Allison, Hayden Kristine, Skora Amy, Rosenblum Marika, Baker Timothy B, Fiore Michael C, McCarthy Danielle E
Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1930 Monroe Street, Suite 200, Madison, WI, 53711, USA.
Department of Family Medicine and Community Health, University of Wisconsin-Madison, 1100 Delaplaine Ct #1896, Madison, WI, 53715, USA.
Implement Sci Commun. 2022 Oct 8;3(1):107. doi: 10.1186/s43058-022-00357-4.
Health system change can increase the reach of evidence-based smoking cessation treatments. Proactive electronic health record (EHR)-enabled, closed-loop referral ("eReferral") to state tobacco quitlines increases the rates at which patients who smoke accept cessation treatment. Implementing such system change poses many challenges, however, and adaptations to system contexts are often required, but are understudied. This retrospective case study identified adaptations to eReferral EHR tools and implementation strategies in two healthcare systems.
In a large clustered randomized controlled trial (C-RCT; NCT02735382) conducted in 2016-2017, 11 primary care clinics in two healthcare systems implemented quitline eReferral, starting with 1 pilot clinic per system followed by 2 phases of implementation (an experimental phase in 5-6 test clinics per system and then a system-wide dissemination phase in both systems). Adaptations were informed by stakeholder input from live trainings, follow-up calls and meetings in the first month after eReferral launch, emails, direct observation by researchers, and clinic staff survey responses. Retrospective, descriptive analysis characterized implementation strategy modifications and adaptations using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). A pre- and post-implementation survey assessed staff ratings of eReferral acceptability and implementation barriers and facilitators.
Major modifications to closed-loop eReferral implementation strategies included aligning the eReferral initiative with other high-priority health system objectives, modifying eReferral user interfaces and training in their use, modifying eReferral workflows and associated training, and maintaining and enhancing interoperability and clinician feedback functions. The two health systems both used Epic EHRs but used different approaches to interfacing with the quitline vendor and integrating eReferral into clinician workflows. Both health systems engaged in iterative refinement of the EHR alert prompting eReferral, the eReferral order, trainings, and workflows. Staff survey comments suggested moderate acceptability of eReferral processes and identified possible targets for future modifications in eReferral, including reducing clinician burden related to EHR documentation and addressing clinicians' negative beliefs about patient receptivity to cessation treatment.
System-wide implementation of tobacco quitline eReferral in primary care outpatient clinics is feasible but requires extensive coordination across stakeholders, tailoring to local health system EHR configurations, and sensitivity to system- and clinic-specific workflows.
www.
gov, NCT02735382 . Registered on 12 August 2016.
卫生系统变革可扩大循证戒烟治疗的覆盖范围。通过主动启用电子健康记录（EHR）的闭环转诊（“电子转诊”）至州戒烟热线，可提高吸烟患者接受戒烟治疗的比例。然而，实施此类系统变革面临诸多挑战，通常需要根据系统环境进行调整，但这方面的研究较少。本回顾性案例研究确定了两个医疗系统对电子转诊EHR工具的调整及实施策略。
在2016 - 2017年进行的一项大型整群随机对照试验（C - RCT；NCT02735382）中，两个医疗系统的11家初级保健诊所实施了戒烟热线电子转诊，每个系统先从1家试点诊所开始，随后分两个实施阶段（每个系统在5 - 6家测试诊所进行实验阶段，然后在两个系统中进行全系统推广阶段）。调整依据的是利益相关者的意见，这些意见来自现场培训、电子转诊启动后第一个月的跟进电话和会议、电子邮件、研究人员的直接观察以及诊所工作人员的调查回复。回顾性描述性分析使用基于证据的实施策略调整与修改报告框架（FRAME - IS）对实施策略的修改和调整进行了描述。实施前后的调查评估了工作人员对电子转诊可接受性的评级以及实施障碍和促进因素。
对闭环电子转诊实施策略的主要修改包括使电子转诊计划与其他高优先级卫生系统目标保持一致、修改电子转诊用户界面及其使用培训、修改电子转诊工作流程及相关培训，以及维护和增强互操作性与临床医生反馈功能。两个医疗系统都使用Epic EHR，但在与戒烟热线供应商对接以及将电子转诊整合到临床医生工作流程方面采用了不同方法。两个医疗系统都对提示电子转诊的EHR警报、电子转诊订单、培训和工作流程进行了迭代优化。工作人员的调查评论表明电子转诊流程的可接受性一般，并确定了电子转诊未来可能的修改目标，包括减轻与EHR文档相关的临床医生负担以及解决临床医生对患者接受戒烟治疗的负面看法。
在初级保健门诊诊所全系统实施烟草戒烟热线电子转诊是可行的，但需要各利益相关者进行广泛协调，根据当地卫生系统EHR配置进行调整，并对系统和诊所特定的工作流程保持敏感。
www.
gov，NCT02735382。于2016年8月12日注册。
