Designing for Sustainability: An Approach to Integrating Staff Role Changes and Electronic Health Record Functionality Within Safety-Net Clinics to Address Provision of Tobacco Cessation Care

Background Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics. Methods Changes to the electronic health record (EHR) facilitated staff to document when they ask about tobacco use, advise the patient to quit, offer to connect the patient to a quitline(QL) counselor, and refer interested patients to receive a call from a QL. Medical assistants (MAs) were trained to use the new sections of the EHR, and their roles were expanded to include the provision of brief cessation advice and activation of the QL referral. Primary outcomes were change in tobacco cessation processes preimplementation vs. one, three, and six months postimplementation of the strategy. Results The increase in performance of tobacco cessation care was significant and sustained at six months postimplementation for assessing smoking status (50.9% vs. 76.3%; odds ratio [OR] = 3.04; 95% confidence interval [CI] = 2.80–3.31), providing advice (15.1% vs. 92.7%; OR = 69.3; 95% CI = 51.88–92.60), assessing readiness to quit (22.8% vs. 76.6%; OR = 10.80; 95% CI = 8.92–13.08), and accepting a referral to the QL (1.3% vs. 21.7%; OR = 20.31; 95% CI = 4.91–84.05). Conclusion Key stakeholder engagementinformed a system change intervention that includes an EHR–supported role expansion of MAs for QL referrals; these changes substantially increased the provision of tobacco cessation care.