Electronic Referral - PowerPoint Presentation

Electronic Referral Scott McIntosh, PhDCenter for a Tobacco-Free Finger LakesUniversity of Rochester School of Medicine & DentistryDepartment of Public Health Sciences Electronic Referral for Tobacco Using Patients

Evidence-based Strategies in Tobacco Control Increases price of tobaccoClean Indoor Air (Smoking bans & restrictions, policies)Mass Media campaigns with interventions (i.e., part of comprehensive tobacco control programs)Reducing patient costs for treatment Availability of treatment for tobacco dependenceProvider reminder systems Telephone counseling and support Source: Guide to Community Preventive Services, Systematic Reviews & recommendations

Evidence-based Treatment Goals Very Brief Advice1 to 3 minutes is EFFECTIVE (40% increase)Clinician advice alone is EFFECTIVEMore counseling is even more effective e.g., 30 minutes can be 90% increaseSO: Time spent at point of care - PLUS -Multiple providers - PLUS -Telephone Quitline Counselors3 70% want to quit. 7% achieve long-term abstinence on their own. With physician assistance - every patient, every visit - this increases to > 30% .

4 In-Office Cessation InterventionsAt all patient / client contactsAsk whether client smokesAdvise client to stopAssess whether client wants to take actionAssist client in developing planArrange follow-up

Introduction to Center For a Tobacco-Free Finger Lakes Center For A Tobacco-Free Finger Lakes (formerly GRATCC) uses evidence-based resources and programs to assist organizations in the design and implementation of policy and office based systems to identify and effectively treat tobacco dependence, according to the Department of Health and Human Services Clinical Practice Guidelines.Electronic Referral from large medical and mental health systems is a primary goal with a large anticipated impact on Population Health

Ideal Quitline e-Referral Example Source: http://www.naquitline.org NAQC. (2013). Quitline Referral Systems. (A. Wendling, MD, MPH and R. Daigh, MBA). Phoenix, AZ.

Steps Taken So Far STEPS TAKEN SO FARComprehensive policy (established 2013)Recommended Minimal Data Set for EHRState subcommittee (Disseminated Feb, 2014) Refer to QuitElectronic referral capability established, Summer, 2017Opt to Quit (ultimate goal, identified in SMH Policy)Inpatient vs. Outpatient / AmbulatoryHealth Maintenance Navigator for OutpatientsSocial HistoryClinician training toolkit and materials (CTFFL website, 2017)

Examples of Ambulatory Order Set to NYS Quitline

Three Areas or “Silos” that need to be collaborators

Justification Medical Directors and clinicians have to be involved from the top down to justify a new “build” (software programming in EPIC). E-referral must make clinician’s job easier not harder.New EMR builds have to benefit the medical system financially. A strong case needs to be made for why the build is beneficial for reducing hospital admissions, saving on health care costs, etc.

Physicians identify implementation challenges Excessive physician and staff time to implement Disruption to practice Concern with the time it will take to implement and be eligible for meaningful use Concern with staff skills and ability to implement Unexpected costs for associated hardware Unexpected costs to implement the basic system Concern of system quality Concern with vendor quality and support Unexpected costs to customize the system to a practice’s needs and requirements Unexpected costs to maintain the system and keep it functionSource: Medical Economics EHR Best Practices Study October, 25 2017“Eliminate the number of clicks. It’s too many…..Compare that to going on Amazon. In three clicks I have bought a book” –(Local Physician)

Technical/Legal Concerns Concerns and questions at the institutional levelHIPAAWill transmission of data violate any possible HIPPA rules?Data TransmissionWhat pr0cess for transmitting data will be used?Data SecurityWhat security concerns or policies are in place from prospective client?LegalHealth Care Providers are sometimes required to obtain a Business Associate Agreement (BAA) if a third party vendor is performing a function or service for a facility & Affiliates that requires the vendor to have access to health information to create, receive, maintain, or transmit protected health Information (PHI) in order to perform their functions.

Technology Acceptance Model Ronis S, Baldwin C, McConnochie K, McIntosh S, Szilagyi PG, Dolan JG (2015). Caregiver Preferences Regarding Personal Health Records (PHR) in the Management of Attention Deficit Hyperactivity Disorder (ADHD). Clinical Pediatrics, 54(8): 765-74. PMCID: PMC4474750. doi: 10.1177/0009922814565883. Davis FD, Bagozzi RP, Warshaw PR. User acceptance of computer technology: a comparison of two theoretical models. Management science 1989;35:982-1003.Venkatesh V, Davis FD. A theoretical extension of the technology acceptance model: four longitudinal field studies. Management science 2000;46:186-204.Azjen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes 1991;50:179-211.

Technology Acceptance Model Pre-Contemplation/Contemplation Preparation Action/MaintenanceWhat are the decision-making variables representing the pros and cons of changing at the Institutional level?As we do with patients in pre-contemplation, we aid the institutional decision-making process with education, meeting them where they are at, finding their motivation, “making it easy” for behavior change.

Assessing “Actual Use” “Have you used eRecord for your patients who use tobacco?”“Which of the referral order features have you used?”“What is the main way you access referral orders?” For offices/institutions: “Are your clinicians aware/trained?” “How many use it?” “What documentation do you have?” Ongoing evaluation of actual use is vital to decision making, development, implementation, and improvements.

Barriers “If you (clinician) have not used electronic referral for tobacco users, what are the main reasons?” Barriers “If you (institution) have not created electronic referral for tobacco users, what are the main reasons?”

Behavioral Intentions “I intend to use electronic referral more frequently in the future”

Perceived Usefulness process management (7b-f, 8, 9f, 10) record keeping 7a, 9a-e ) “I find the electronic referral easy to use” “For each of the following features, please indicate how useful you think it might be…. …for treating patients’ Nicotine Dependence …for prevention of CVD, Caner, other diseases …for caring for your patients in general Process Management Record Keeping

External Variables “When you have concerns about patient tobacco use, how do you proceed in your setting (what is the workflow)?““How often do you get the specific information you need?”“How easy are referrals using your EHR?” Work Flows Record Keeping

Barriers Barriers “If you (institution) have not created electronic referral for tobacco users, what are the main reasons?” _ Not a priority _ Not reimbursed _ No policy _ Patients do not want this _ Programming cost _ Legal barriers _ It’s up to the patients Policy Cost

Barriers ADDRESSING INSITUTIONAL BARRIERS_ Not a priority Joint Commission, CVD, DSRIP_ Not reimbursed Increasingly being reimbursed_ No policy Policy 10.03 since 2013_ Patients do not want this 70% of patients expect/rapport is increased_ Programming cost Other diseases lack outside funding _ Legal barriers Business Partner Agreement _ It’s up to the patients No. Addiction is a Chronic Disease As patients in pre-contemplation, we aid the institutional decision-making process with education, meeting them where they are at, finding their motivation, “making it easy” for behavior change.

Where We Are At Where we are at:Policy in place, and it is clear: address with each patient, every visit, use Opt-to-Quit, etc.Legal barriers addressed (BPA, HIPAA)Programming finished for basic referral to the QuitlineDisposition data workflow still in development, reliant on CTFFL funding for consultant to receive and report on patient outcomesOne announcement by PR departmentUptake still similar to baseline (i.e., same “champions” are using electronic referral, need to expand adoptors)

Lessons Learned Lessons LearnedCTFFL and CCH facilitated progressPolicy, high level buy-in, initial programmingEach mid-level system at their own “Stage of Change”Necessitates multiple engagement, education, movitvationOverall progress only as strong as weakest linkClinical Counsel, Programmers, PR, Uptake still similar to baseline (i.e., same “champions” are using electronic referral, need to expand adopters)The evidence-base and data do not reliably influence decision-making. Why not? Public Health isn’t “real science” or “real medicine”It’s patient “behavior” not “addiction” There are too many other, more important, priorities

Next Steps Next stepsIncrease PR, messaging, etc. that the referral existsKeep working to make progress with disposition dataDesignate someone to take over from CTFFLProgramming improvements to provide seamless data flow to and from the Quitline, and in-and-out of each patient’s electronic health record (where evaluative data are all housed, including clinician behavior, tobacco use, related health variables, number of hospitalizations, co-morbidity, etc.Evaluation (REDCap survey, interviews)What else?

Expected Results Clinicians who have already used the electronic referral will be more likely to have favorable opinions about usefulness and functionality.They will also be more likely to report high intentions to use the referral in the futureAnticipate low to moderate uptake of use, with steady increases over time per: PR buy-in, CTFFL messaging, word-of-mouth, and Data, Data, Data.

Additional Resources Online CME / treatment information www.nysmokefree.com (Click to Quit)www.smokefree.gov (includes chat)www.Talktoyourpatients.org (clinician resources)Treating Tobacco Dependence - Clinical Practice Guidelineswww.surgeongeneral.gov Center for a Tobacco-Free Finger Lakes Training & Materials Website:www.smokingresearch.urmc.edu

Wrap Up Please fill out evaluation: http://j.mp/2Eddd1m Or: Thank you!For more information:Center for A Tobacco-Free Finger LakesScott McIntosh, PhD, Directoremail: scott_mcintosh@urmc.Rochester.edu phone: (585) 275-0511