Electronic health record closed-loop referral ("eReferral") to a state tobacco quitline: a retrospective case study of primary care implementation challenges and adaptations.
Electronic health record closed-loop referral ("eReferral") to a state tobacco quitline: a retrospective case study of primary care implementation challenges and adaptations.
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DOI：
10.1186/s43058-022-00357-4
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发表时间：
2022-10-08
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卫生系统的改变可以增加循证戒烟治疗的覆盖面。主动电子健康记录（EHR）启用，闭环转诊（“电子转诊”），以国家戒烟热线增加吸烟患者接受戒烟治疗的比率。实施这样的系统变化带来了许多挑战，但是，和适应系统的情况下，往往需要，但研究不足。这项回顾性案例研究确定了两个医疗保健系统中的电子转诊EHR工具和实施策略的适应性。在2016-2017年进行的一项大型群集随机对照试验（C-RCT; NCT 02735382）中，两个医疗保健系统的11个初级保健诊所实施了退出线电子转诊，从每个系统的1个试点诊所开始，然后是2个实施阶段（每个系统5-6个测试诊所的实验阶段，然后是两个系统的全系统传播阶段）。调整是通过利益相关者的实时培训、电子转诊启动后第一个月的随访电话和会议、电子邮件、研究人员的直接观察和诊所工作人员的调查答复来了解的。回顾性、描述性分析采用循证实施战略调整和修改报告框架（FRAME-IS）描述了实施战略的修改和调整。实施前和实施后的调查评估了工作人员对电子转介的可接受性以及实施障碍和促进因素的评级。对闭环电子转诊实施战略的主要修改包括使电子转诊倡议与其他高度优先的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和相关培训，以及维护和加强互操作性和临床医生反馈功能。这两个卫生系统都使用Epic EHR，但使用不同的方法与退出线供应商进行交互，并将电子转诊集成到临床医生工作流程中。这两个卫生系统都参与了对电子健康记录警报的反复改进，以提示电子转诊、电子转诊令、培训和工作流程。工作人员调查意见表明，电子转诊流程的可接受性中等，并确定了电子转诊未来修改的可能目标，包括减少与EHR文件相关的临床医生负担，并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戒烟热线电子转诊是可行的，但需要利益相关者之间的广泛协调，根据当地卫生系统的电子健康记录配置进行调整，并对系统和诊所特定的工作流程保持敏感。www.clinicaltrials.gov，NCT02735382。于2016年8月12日注册。 在线版本包含补充材料，可通过10.1186/s43058-022-00357-4获得。
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.clinicaltrials.gov, NCT02735382. Registered on 12 August 2016. The online version contains supplementary material available at 10.1186/s43058-022-00357-4.
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影响因子：
5.5
作者：
Baker TB;Berg KM;Adsit RT;Skora AD;Swedlund MP;Zehner ME;McCarthy DE;Glasgow RE;Fiore MC
通讯作者：
Fiore MC
影响因子：
2.1
作者：
Gibson B;Kramer H;Weir C;Fiol G;Borbolla D;Schlechter CR;Lam C;Nelson M;Bohner C;Schulthies S;Sieperas T;Pruhs A;Nahum-Shani I;Fernandez ME;Wetter DW
通讯作者：
Wetter DW
影响因子：
3.6
作者：
Adsit, Robert T.;Fox, Bradley M.;Fiore, Michael C.
通讯作者：
Fiore, Michael C.
影响因子：
7.2
作者：
Kirk, M. Alexis;Moore, Julia E.;Birken, Sarah A.
通讯作者：
Birken, Sarah A.
影响因子：
5.7
作者：
Jolles, Monica Perez;Lengnick-Hall, Rebecca;Mittman, Brian S.
通讯作者：
Mittman, Brian S.