Closed-loop referral to external resources such as state tobacco quitlines, the NCI-sponsored SmokefreeTXT program, and automated interactive voice response telephone support is feasible to implement.
Many C3I programs incorporated such referrals in their tobacco treatment programs. Most state quitlines now accept electronic referrals from EHRs. Detailed build guides are available to guide efforts to build interfaces with external programs that can receive referrals from the EHR and return results back to the EHR automatically.
- C3I build guides for Cerner and Epic detail considerations and steps in building closed-loop eReferral to varied resources (e.g., quitlines, texting programs, interactive voice response programs).
Additional eReferral Resources
- The North American Quitline Consortium (NAQC) guide for implementing eReferral to quitlines
- The HIPxChange protocol and toolkit to support quitline referral in specialty clinics (following free registration). This excellent resource provides in-depth build specifications and implementation strategies to support quitline eReferral.
- Information from vendors that operate your state quitline and Smokefree.gov resources about eReferral requirements, options, and setup:
- You can look up who operates your state quitline at the bottom of the profile for your state program in the NAQC directory.
- You can also contact ICF International, the operator of SmokefreeTXT and other Smokefree.gov resources sponsored by NCI.
- Contacting the operators of these services regarding their interface capabilities is important, as the interfaces used among healthcare entities continue to evolve (e.g., from HL7 v2 to v3 and FHIR).
- Information from operators of interactive voice response programs (such as TelASK) that you can use to program automatic outbound calls to patients to facilitate interface and interoperability development.
eReferral Design Considerations
- Referral to other programs (e.g., a tobacco treatment program offered by an affiliated but separate health system or department of health) via eReferral is also possible with some level of interoperability.
- Closed-loop eReferral to external tobacco treatment can occur on an opt-out basis, in which referrals are placed for all patients currently using tobacco unless they actively decline such referral, if both parties (referring cancer program and the program receiving referrals) agree to this.
- Even if eReferral occurs automatically and by default, without requiring action from cancer care teams, cancer program teams play important roles in promoting the external program to patients.
Fax or Manual Referral
Programs that cannot quickly customize their EHR to implement eReferral can still implement closed-loop referral to quitlines via fax. Results returned by fax can be scanned in or manually entered into the EHR. However, fax referral methods tend to reach fewer patients than eReferral (Fiore et al., 2019), so eReferral is a preferred method that both prompts and facilitates referrals.