1. Systems Strategies to Address Tobacco Use: Utilizing EHRs to Improve Patient Care Ryan Reikowsky, MA, MPH Manager, Community Development Arizona Smokers’ Helpline (ASHLine)

2. Why Address Tobacco Use? Tobacco Use is EXPENSIVE. Tobacco use costs the U.S. $130 billion annually in health care costs and an additional $150 billion in lost productivity Comprehensive tobacco cessation programs reduce tobacco use and lower associated healthcare costs, providing a strong ROI Efforts to reduce tobacco use, especially among the uninsured and underinsured, could significantly reduce healthcare spending.

3. Tobacco Use in Arizona: Quick Stats Adult smoking prevalence: 17.1% Annual health care costs directly attributable to smoking: $2.38 billion Portion covered by Medicaid: $316 million Smoking-attributable productivity losses: $1.65 billion

4. Tobacco Use as a Health Disparity Low socioeconomic status (SES) is one of the single greatest predictors of tobacco use. Prevalence of current smoking is highest among adults with: – Working class jobs – Low education – Low income – No employment or underemployment – Medicaid – No health insurance

5. Tobacco Use as a Health Disparity Approximately 21% of adults nationally are current tobacco users. However, relative to the general population: 34% of adult Medicaid recipients smoke 32% of uninsured adults smoke Americans below the poverty line are 40% more likely to smoke than those at or above the poverty line

6. Health Effects of Tobacco Use Smoking is the leading cause of preventable disease and death in the United States > 440,000 Americans die annually from smoking > 10 million Americans suffer from at least 1 disease caused by smoking Nearly 9 out of 10 cancers are caused by smoking 1 out of 3 cancer deaths are tobacco-related

7. Good News, Bad News Bad News Despite decades of evidence detailing the harmful effects of tobacco use and the health/economic costs associated with tobacco use: Current tobacco use is disproportionately concentrated among low SES individuals U.S. spends $22 billion annually in tobacco-related Medicaid costs (11% of all Medicaid costs) Only 23% of smokers on Medicaid receive practical assistance with quitting This represents a lost opportunity.

8. Good News, Bad News Good News Low SES smokers express significant interest in quitting and benefit from treatment Effective treatment is available Consistently providing treatment benefits both patients and providers

9. Community Health Centers in Arizona Data from the National Association for Community Health Centers for 2011 suggest: Only 50% of community health centers in Arizona provide tobacco cessation counseling as a preventive service on site Moreover, data from tobacco assessments completed by BTCD/HSAG in 2011 suggest: Although tobacco use screening rates are high, post-screening intervention rates are mixed and inconsistent Medication assistance is offered more consistently than behavioral support

10. Treating Tobacco Use & Dependence The U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update recommends: -Patients be consistently assessed for tobacco use at every clinical encounter and offered assistance and resources to quit -Brief tobacco dependence treatment is effective -Minimal interventions (≤3 min) are effective and should be offered to all tobacco users

11. Brief Interventions Interventions lasting <3 minutes increase overall tobacco abstinence rates Every tobacco user should be offered brief intervention, even if they are not referred to an intensive intervention STRENGTH OF EVIDENCE: A US PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

12. Brief Interventions Even when patients are not ready to make a quit attempt, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts STRENGTH OF EVIDENCE: A US PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

13. Intervention Models: 5A’s vs. AAR ASK about tobacco use ADVISE to quit ASSESS willingness to make a quit attempt ASSIST in quit attempt ARRANGE follow-up ASK about tobacco use ADVISE to quit REFER to ASHLine

14. ASHLine’s Recommended Model Follow 3 simple steps: Ask, Advise, Refer We’ll do the rest!

15. Integrating Tobacco Cessation Into EHRs Ask, Advise, Refer (AAR) can be integrated into EHRs via templates designed to consistently prompt clinicians to: -Screen for/assess tobacco use (including SHS exposure) -Assess cessation interest + past quit attempts -Encourage quitting -Advise about smokefree environments -Connect patients and families to cessation resources and materials

16. Integrating Tobacco Cessation Into EHRs The American Academy of Family Physicians (AAFP) recommends tobacco treatment templates be automated to appear during all well-patient exams, as well as when patients present with the following symptoms: -Cough + upper respiratory problems -Diabetes -Ear infections -Hypertension -Depression + anxiety -Asthma

17. Ask Identify and document the tobacco use status of every patient at every visit Significantly increases rates of clinician Tx and patient cessation STRENGTH OF EVIDENCE: A US PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

18. Integrating Tobacco Cessation Into EHRs Meet Meaningful Use Criteria Objective:Record smoking status for patients 13 years old or older. Measure:More than 50% of all unique patients 13 years or older seen by the EP have smoking status recorded. EHR Requirement: Must enable a user to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; and unknown if ever smoked. Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

19. Integrating Tobacco Cessation Into EHRs What should be included in a tobacco cessation EHR template? Tobacco use status can be documented as: -Current every day smoker -Current some day smoker -Former smoker -Never smoker -Smoker, current status unknown -Unknown if ever smoked Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

20. Integrating Tobacco Cessation Into EHRs Documenting Tobacco Use History Type of tobacco*: □ Cigarettes □ Pipe □ Cigars □ Smokeless How many years?_______ Packs per day: _______ Brand: _____________________ Approximate date of last quit attempt: ________ *□ Electronic cigarettes □ Other Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

21. Integrating Tobacco Cessation Into EHRs Documenting Tobacco Use History Medication used in previous quit attempt: □ Patch□ Bupropion □ Gum□ Varenicline □ Lozenge□ None □ Inhaler□ Other: ______________ □ Nasal Spray Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

22. Advise In a clear, strong, and personalized manner, urge every tobacco user to quit Capitalize on “teachable moments” with patients STRENGTH OF EVIDENCE: A US PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

23. Integrating Tobacco Cessation Into EHRs Meet Meaningful Use Criteria Objective:Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. Measure:More than 10% of all unique patients seen by the EP have are provided patient-specific education resources. EHR Requirement: Must enable a user to electronically identify and provide patient-specific education resources according to, at a minimum, the data elements included in the patient’s: problem list; medication list; and laboratory test results; as well as provide such resources to the patient. Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

24. Integrating Tobacco Cessation Into EHRs Documenting Advice Counseled for: □ Three minutes or less □ 3 to 10 minutes □ 10+ minutes □ Counseled for secondhand smoke Counseling notes: ______________________________________________________________________ ______________________________________________________________________ Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

25. Integrating Tobacco Cessation Into EHRs Readiness to Quit: □ Not interested in quitting □ Thinking about quitting at some point □ Ready to Quit Handouts/Education Provided: □ Quitline card □ Quit Smoking Brochure □ Secondhand Smoke Brochure □ Other Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

26. Integrating Tobacco Cessation Into EHRs Pharmacotherapy Recommended OTC: □ NRT Patch □ NRT Gum □ NRT Lozenge Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

27. Integrating Tobacco Cessation Into EHRs Pharmacotherapy Rx Treatment: □ NRT Nasal Spray Dosing: 1-2 doses/hour (8-40 doses/day); one dose = one spray in each nostril; each spray delivers 0.5mg nicotine □ NRT Inhaler Dosing: 6-16 cartridges/day; initially use 1 cartridge q 1-2 hours □ Bupropion SR Dosing: Begin 1-2 weeks prior to quit date; 150mg PO q AM x 3 days, then increase to 150mg PO bid Contraindications: head injury, seizures □ Varenicline Dosing: Begin 1 week prior to quit date; days 1-3: 0.5mg PO q AM; days 4-7: 0.5mg PO bid; weeks 2-12: 1mg PO bid. Screen for: suicidal ideations Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.

28. Refer Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions STRENGTH OF EVIDENCE: A US PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

29. Referring to ASHLine A proactive referral to ASHLine ensures we will call your patient within 24 business hours ASHLine provides ongoing, intensive clinical intervention for you!

30. What is ASHLine? Evidence-Based Service Behavioral support Medication assistance Long-Term Success 7 Month Quit Rate (global): 30% (vs. 5% “cold turkey”) 7 Month Quit Rate (meds + coaching): 56% *

31. ASHLine Referral Program Custom QuitFax (paper-based) WebQuit Account (electronic) EMR or EHR Template (hybrid)

32. Reporting Options Available by fax or e-mail Confirmation report (within 24 hours) Status report (within 10 days) – First call within 24 business hours – Up to 5 call attempts over 10 business days – Notification of referral outcome (e.g. Enrolled, Only Requested Information, Unable to Reach, Wrong Number, etc.)

33. Partnering to Achieve Systems Change Makes Sense! A systems approach to tobacco assessment and intervention will ensure all patients receiving services are: -Screened for tobacco use -Offered a brief intervention -Referred to services that can help them quit successfully

34. Systematic provision of tobacco cessation services significantly improves health outcomes for all tobacco users, especially those with chronic disease and/or those who are members of “at risk” populations: Cancer Chronic Obstructive Pulmonary Disorder (COPD) Asthma Diabetes Hypertension Ischemic Vascular Disease Congestive Heart Failure Coronary Artery Disease Partnering to Achieve Systems Change Makes Sense!

35. Tobacco use assessment and intervention are key components of preventive health. Certified Electronic Health Records (EHRs) are built to help health care organizations provide better care. EHRs are powerful tools that can help you: Ensure patients are systematically assessed for tobacco use Consistently prompt clinicians to provide advice to quit (i.e. brief interventions) Consistent access and transmit referrals to community-based services for intensive tobacco treatment (e.g. ASHLine) Manage patient medication lists (e.g. tobacco cessation medications) Monitor, prevent, and manage disease Partnering to Achieve Systems Change Makes Sense!

36. ASHLine’s Community Development Team is available to partner with your organization to make tobacco systems change an achievable goal. Things to consider: -Systems change requires administrative support -Identifying key players to lead and implement change is critical -Who are the “key players” and/or decision-makers in your organization? -Who should you be speaking with about partnering on systems change? Partnering to Achieve Systems Change Makes Sense!

37. Potential Next Steps Evaluate tobacco use prevalence among service recipients to assess potential impact Consider policy development to address consistent provision of brief interventions + referral for tobacco users willing to make a quit attempt Partnership opportunities: – Policy development, implementation, rollout – Audit ASHLine database (current locations) – Establish referral mechanism (EHR or paper) – Staff training, TA, ongoing support

38. Questions? Thank You! Ryan Reikowsky, MA, MPH Manager, Community Development Arizona Smokers’ Helpline (ASHLine) 1-800-556-6222 x208 rcreikow@email.arizona.edu