Resources to Integrate Tobacco Treatment at the Point of Care

For inpatients, incorporating tobacco status flags in patient lists can prompt designated team members to provide advice, order medication, and provide counseling referrals. See Oklahoma best practice guide (pp. 4-5) and Trapskin et al., 2022 for examples.

• Sample Epic EHR form used to document tobacco treatment intervention delivery to adult inpatients.
• Sample Cerner form used to document tobacco use and automatically trigger orders for respiratory therapy tobacco cessation education.

• For Cerner users, consult the Cerner-specific guide for detailed instruction in how to build an alert to prompt a suggested plan of care for clinicians.
• For Epic users, there is an Epic Systems Corp. Setup and Support Guide (2015) that details steps to develop an EHR alert to prompt clinicians to offer tobacco treatment. The Epic-specific build guide (p. 32) developed for C3I also provides detailed guidance on alert development.
• New York City Health Epic EHR alert screenshot of their workflow for screening.

Clinical Inquiry (CLIQ) EHR prompt and order (p. 4) at Louisiana State University Health System Tobacco Control Initiative.

For outpatients, the Mayo Clinic implemented an EHR alert (Figure1) that prompts tobacco screening, an opt-out consult order for an in-house tobacco treatment program, and default visit diagnosis of nicotine dependence. The display logic for this alert is detailed in Appendix A of Jose et al., 2020.

The C3I Epic Build guide (p.39) provides screenshots of clinical decision support order sets that guide clinicians in the delivery of tobacco treatment at the point of care. This tool is designed to minimize clinician navigation, clicks, and time spent completing the form by defaulting diagnosis, counseling documentation, referral for follow-up care, and patient instructions. The four key components of the order set are:

1. Documentation of brief tobacco cessation counseling (this is the default unless unselected by the clinician) and setting a quit date, if applicable
2. Medication ordering (with guidance to start with first-line varenicline or combination nicotine patch and lozenge or gum treatment)
3. Referral to an internal Tobacco Treatment Specialist (this is the default unless unselected by the clinician) who will provide additional counseling (this may be replaced by an external referral to a treatment extender such as a quitline or SmokefreeTXT)
4. Provision of patient instructions that will appear on the patient-facing visit summary (these are auto-populated and modifiable).

Similar prompts to offer tobacco treatment and record patient response can be embedded as smart elements or drop-down menus in note templates to remind clinicians to offer or initiate treatment and record patient response.

1. Sample note template for tobacco quit plan (Epic).
2. Sample note template adapted from the C3I program.

Make note templates searchable to help clinicians quickly add the structured notes to their progress notes.

Patient instructions can be automatically added to visit summaries and other patient education materials by the EHR. Here are some samples of automated patient instructions regarding tobacco treatment.

In Epic, these instructions can be incorporated in order sets for clinic team members to review with patients at the point of care, as well. See Epic-specific guide (p. 39) for details.

Sample wallet cards with treatment options and patient instructions to give to patients at point of care.

Some health systems that are not able to quickly implement EHR changes have devised alternative, paper-based systems to prompt and guide clinician delivery of tobacco treatment. For example, one health system designed a sticker that providers completed to indicate if they delivered or patient refused the following:

1. Cessation counseling
2. Referral to internal cessation program
3. Prescribing medication
4. Giving education materials
5. Provider signature and pager #

These data were then entered into the EHR by other clinic team members.

Some health systems adopt delegation protocols to expand the workforce able to independently order nicotine medication without cosigners for each order. See a sample delegation protocol that enables pharmacists to order NRT.