“The e-tobacco protocol allowed us to treat smoking status as a vital sign. We placed it in the EHR workflow where it made the most sense and couldn’t be overlooked.”
STERC received referrals for about
59 percent of the patients who were ready to quit. Participants in the Seton program attended six cessation classes held at various community sites in Aus- tin. Data show 66 percent of patients remained tobacco free six months after completing the Seton program. Dr. Angelocci says STERC reached 74
percent of the patients referred to the program. She explains STERC could not contact about one-quarter of patients be- cause they gave the clinic incorrect con- tact information or out-of-service phone numbers, or they may have moved. To help enrollment specialists reach more referred patients, the clinics added pa- tients’ preferred time of day to call and consent to leave detailed voicemails to the e-protocol. Moving forward, all con- tact numbers for patients (not just the preferred daytime number) will be add- ed to the protocol.
as a vital sign — a normal, expected aspect of every patient encounter. We placed it in the EHR workflow where it made the most sense and couldn’t be overlooked. We made it super simple to initiate a referral that required no print- ing, paperwork, or faxing. It’s just a few clicks in a template,” Dr. Angelocci said. “With the extensive amount of in-
formation a physician must process at every visit to provide the best care and reduce missed opportunities, it can’t all be left to memory and to one person. It is critical to use technology to automate prompts and offload some of that work- load to clinical support staff,” Dr. Ange- locci said.
Protocol in practice Dr. Angelocci describes learning to use the e-protocol workflow as “intuitive,” adding it requires minimal training. Cen- tex Systems Support Services — the in- formation technology services vendor for all three health systems — trained physi- cians, nurse practitioners, physician as- sistants, and behavioral health therapists to use the e-protocol. A tobacco cessa- tion counselor from the Seton Tobacco Education Resource Center (STERC) trained medical assistants (MAs). The
42 TEXAS MEDICINE March 2013
training included using motivational interviewing techniques to increase the number of patient referrals. MAs typically use the e-tobacco pro-
tocol to record a patient’s smoking status. If they don’t, a pop-up reminder alerts the MA, and he or she cannot complete the patient encounter form. The MAs in- quire about a smoker’s commitment to quitting by indicating whether the pa- tient is ready to quit in the next 30 days, thinking about quitting at some point, or not interested at all. If the patient is ready to quit within
the next month, the e-protocol allows a referral to the Quitline for phone-based tobacco cessation counseling or to STERC, a classroom-based, face-to-face cessation program. Both programs offer nicotine replacement therapy. The e-protocol requires users to make
a referral or to document that the pa- tient refused. “An automated backend business pro-
cess creates a nightly report listing all patients referred to cessation programs. The report is automatically sent via se- cure email server to enrollment special- ists at each of the two tobacco cessation programs. Specialists then contact the referred patients,” Dr. Angelocci said.
“It’s important to me that our organi- zation views the protocol as an active project that we continue to improve upon. Even when roles and workflows are studied upfront in an attempt to build a seamless process, there are al- ways lessons learned after implementa- tion,” Dr. Angelocci said. For a step-by-step guide to integrat- ing the e-tobacco protocol into a medi- cal practice EHR, visit
www.yesquit.org/ healthcare-providers. The site also fea- tures training videos that teach physi- cians to assess patients’ interest in quit- ting and guide them through tobacco cessation counseling. The Toolkit Mate- rials link directs physicians to download- able patient brochures in English and Spanish, a patient encounter checklist, Quitline business cards, guides to billing codes and pharmacotherapies, and more.
Meaningful use The e-tobacco protocol also can help physicians meet Medicare and Medicaid meaningful use EHR program require- ments. To date, the Lone Star Circle of Care has received $2 million in Medicaid meaningful use incentives.
Eligible non-hospital-based physi- cians with at least a 30-percent Med- icaid patient volume can receive up to $63,750 over six years in incentive pay-
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