Are Quitlines Ready for
the E-World?
Massachusetts Tobacco Cessation and Prevention
Program (MTCP)
Donna Warner, MBA, MA, Consultant
Tom Land, PhD, Director of Surveillance and Evaluation, MTCP
Anna Landau, MPH, Quitline Contract Manager, Cessation Program Director
Michael Stelmach, [Insert Degrees], Consultant to John Snow Inc. and MTCP
The QuitWorks E-Referral Team
 MTCP – QuitWorks Partnerships, Planning, and Evaluation
Tim Gorin, MPH, Database Analyst
Lois Keithly, PhD, MTCP Director
Thomas Land, PhD, Director of Surveillance and Evaluation
Anna Landau, MPH, Quitline Contract Manager and Cessation Program Manager
Donna Warner, MBA, QuitWorks Founder/Director, Consultant
 UMass Medical School – QuitWorks Detailing and Training
Elena List, MSW, LICSW, Project Director
Denise Jolicoeur, MPH, CHES, Special Projects Director
 JSI Research and Training Institute, Inc.- QuitWorks/Quitline Operations
Ann Marie Rakovic, MSW, Director, MA Smokers’ Helpline
Kristen Risley, MSW Operations Manager, MA Smokers‘ Helpline
Michael Stelmach, MBA, IT Consultant for E-Referrals; Privacy/Security and Consent
 Atrius/Harvard Vanguard Medical Associates – QuitWorks Electronic
Referrals
Thad Schilling, MD, Clinical Champion for Smoking Cessation
Elizabeth Hardy, Project Manager
Agenda






What do we mean by the e-world?
Why integrate quitlines into healthcare and
EMRs?
Can we agree on a common terminology?
How does it work? Electronic options, privacy
and security
Are quitlines ready: what capabilities do you
need?
What does the future hold? Next steps….
Question 1

Are quitlines ready for the e-world?
 Yes
 No
 Not sure
 Don’t know
What do we mean by the e-world?
EMR Adopters by State
DRAFT: DO NOT CIRCULATE
The Trend Line for Meaningful Use
2009
2011
2013
2015
Improved
outcomes
Advanced
clinical
processes
Data capture
and sharing
Source: Meaningful Use Workgroup Presentation, July 16, 2009
7
Integrating quitlines into healthcare:
Why do it?




Benefits to providers, patients, quitline and public
health
Increase reach and impact of quitlines
Alternative to costly media campaigns for programs
with limited media budgets
Availability of fax or e-referral program may
improve upstream interventions in healthcare
Integrating Quitlines into Healthcare:
Multiple Benefits
Self-Referred Callers and QuitWorks Referrals
July 2009 through December 2010
800
# of referrals
600
400
200
0
Jul-09 Aug- Sep09
09
Oct09
Nov09
Dec09
Jan10
Feb10
Total Referrals
Mar10
Apr10
May10
Jun- Jul-10 Aug- Sep10
10
10
Self-Referred Callers
Oct10
Nov- Dec10
10
Integrating Quitlines into Healthcare:
Multiple Benefits
Self-Referred Callers and QuitWorks Referrals
July 2009 through December 2010
800
# of referrals
600
400
200
0
Jul-09 Aug- Sep09
09
Oct09
Nov09
Dec09
Jan10
Feb10
Total Referrals
Mar10
Apr10
May10
Jun- Jul-10 Aug- Sep10
10
10
Self-Referred Callers
Oct10
Unique Providers
Nov- Dec10
10
Moving to e-referral options:
Why do it?
Make changes in program to keep pace with
changes in the healthcare delivery system
 Opportunity NOW with EMRs and meaningful
use


The problem with paper…
 Can’t file a paper feedback report in an EMR
RI and MA
QuitWorks
E-Referrals
Featured on
Health IT.gov
Home > Beacon Communities > An Innovative, Community-based Approach to Smoking Cessation
An Innovative, Community-based Approach to Smoking
Cessation
March 10, 2011, 5:27 pm / Jason Kunzman and Aaron McKethan / Beacon Communities Project Officer and Beacon Communities
Program Director
One of the criteria set forth in Stage One Meaningful Use guidelines pertains to capturing information at the point of care about
patients’ smoking status, and as relevant, offering counseling to help patients quit smoking. While attending the Rhode Island
Statewide Patient Centered Medical Home Learning Collaborative on February 5, we learned about the kinds of innovations that
this aspect of meaningful use may inspire and make more widespread in the future.
Terri Mrozak of Quality Partners of Rhode Island introduced us to a comprehensive smoking cessation strategy that makes the
best available use of health information technology (health IT) to support patients seeking to quit smoking across three states. She
explained that quitting smoking is often the single most important thing one can do to improve their health, and that it takes most
1
smokers as many as eight quit attempts before they are able to quit permanently.
Terri then told us about QuitWorks – RI , a free stop-smoking service sponsored by the Rhode Island Department of Health and
based on a program created by the Massachusetts Tobacco Control Program in 2002. Since its inception, providers in three states
(Massachusetts, New Hampshire, and Rhode Island) have referred more than 30,000 patients to QuitWorks, and nearly one in
2
every five
patients contacted
quit smoking within six months after enrolling in the program. More than a telephonic quit line,
While
QuitWorks
itselfhas
pre-dates
which
are widely available
across the
the country, QuitWorks combines traditional telephonic care management with a health ITthe
meaningful
use rule,
enabled referral management system.
combination of well-established
tobacco counseling approaches
According to Donna Warner, QuitWorks founder in Massachusetts, patients interested in smoking cessation resources can be
with
healthreferred
IT linking
patients’
electronically
to the QuitWorks
program through their physicians’ electronic health records (EHRs) with the patient’s
data
back
into referring
medical
ID attached.
This automatically triggers a follow-up telephonic referral to a trained quitline counselor who will reach out to
the patients and
offer targeted
education
and coaching. Importantly, status reports can be provided back to physicians directly into
physicians’
EHRs
represents
the
theirof
EHR
system, whichthat
allows physicians to follow up with patients and monitor their progress as they seek to quit. As part of the
kind
innovation
program, Quality
Partners
Rhode Island also helps physician practices develop the workflow changes needed in their office to
meaningful
use
mayofsupport
support approaches to tobacco-dependence treatment. While QuitWorks itself pre-dates the meaningful use rule, the combination
more
broadly. tobacco counseling approaches with health IT linking patients’ data back into referring physicians’ EHRs
of well-established
represents the kind of innovation that meaningful use may support more broadly.
1
Massachusetts Office of Health and Human Services
2
Dr. Thomas Land, Massachusetts Tobacco Control Program, Director of Surveillance and Evaluation
The Manual Process
1. Complete Referral Form
Tobacco user fills in their
information
3. Give Patient A
Brochure
Specifies language preference
Gives signed consent to be
called
Provider fills in their
information or it is pre-filled
2. Fax to 1-866-560-9113
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Defining Terms
 What do
we mean by e-referrals?
 Five stages in a quitline referral with feedback



Manual or electronic?
Paper or electronic?
Multiple electronic modes
What do we mean by electronic?
In the Provider’s Office
Step 1
In Hyperspace
Step 2
Initiating the Referral
Transmitting the Referral
• Manual: Form filled out on
paper
• Hybrid: Form downloaded,
some fields pre-populated
• Fully Electronic: Form in
EMR, completion automatic
• Manual: Paper forms are
Step 5
transmitted by FAX
• Hybrid: Referral by FAX,
email or internet
• Fully Electronic: One click
referral to Quitline
Step 4
Interfacing with EMR
Transmitting the Feedback
• Manual: File paper feedback
reports
• Hybrid: File/scan paper feedback
reports or manual data entry
• Fully Electronic: EMR record
automatically updated
• Manual: Paper forms are
Arriving At the Quitline
Step 3
Interfacing with Database
• Manual: Paper based, manual
data entry into database
• Hybrid: Manual data entry
into database
• Fully Electronic: Automatic
entry into Quitline database
transmitted by FAX
• Hybrid: Transmission by FAX
or email
• Fully Electronic: Daily or realtime transmission
Leaving the Quitline
In the Provider’s Office
And
In the Medical Record
Back In Hyperspace
Health-e-link Supports
Quitline eReferrals
Information Exchange
Network
EPIC
eClinical Works
Quitline
Referral
Data
Items
AllScripts
NextGen
GE Centricity
Other EMRs
Quitline
Feedback
Data
Public
Health-e-link
Domain-e-link
Massachusetts
Database
Quitline
Referral
Data
Items
State 1
Database
State 2
-Secure transmission
-HIPAA compliant
-Standardizes data
-Path to full integration
Database
Quitline
Feedback
Data
State 3
Database
State 4
Database
Other States
How It Works: Referral Options

Paper-based Referrals
 Providers fax referrals to QuitLine and receive paper-
based updates via fax.

eForms-based Referrals
 Providers securely email electronic forms (pdf, word
documents) and receive electronic updates (Health-elink).

eReferrals
 Referrals are made directly from EMRs. Updates are
returned directly to patient charts in EMRs (Health-elink).
How It Works: Privacy & Security

Paper-based Referrals
 HIPAA allows providers to fax patient information for
treatment purposes.

eForms Referrals
 More secure and accountable. Documents are
exchanged over a secure network with restricted access.

eReferrals
 Most secure and accountable system-to-system data
exchange. Removes majority of manual intervention.

Regardless of approach, HIPAA must be addressed.
Atrius / HVMA Case Study

5 medical groups with 800 physicians in 30+ sites use a shared
EPIC/EMR platform.

Atrius used hybrid e-referral model (form in EMR / FAX
transmission) for 5 years.

EMR supports eReferrals from the point-of-care.

Health-e-link accepts eReferrals, translates data and routes to
TobaccoWeb.

Benefits include increased referrals and reduced burden.

Planned next steps include Referral Updates directly into EMR
patient charts.
Atrius System Referrals 2009 vs. 2010
Quitline Referrals Before and After e-Referral Launch
(21 Atrius Health Sites -- 2009 vs 2010)
125
# of referrals
100
75
50
25
0
October
November
2009
December
2010
January
Capabilities Needed
Are you ready?




Operations performance standards
Real-time access to referral data
Flexible feedback reporting capability
Knowledge of:
 EMR products
 Meaningful Use tobacco measures
 Joint Commission proposed measures
 Knowledge of privacy, security, and consent

Detailing and training with clinical workflow and
EMR fields
Question 2

Does your quitline referral program have the
capacity to generate feedback reports to
providers on every patient referred?
 Yes
 No
 Don’t Know
Question 3

Does your fax referral program offer on-site
detailing service for institutional users (e.g.
hospitals, CHCs, larger provider practices)
 Yes
 No
 Don’t know
Question 4

Does your quitline have performance
standards that are monitored at least monthly
(e.g. time from referral receipt to first contact attempt,
contact rates, time within which feedback reports must be
sent)
 Yes
 No
 Don’t Know
Question 5

Does your quitline have the capability to
transmit referral data from an EMR to quitline
and back to an EMR electronically?
 Yes
 No
 Under development
 Don’t Know
What Does the Future Hold?



Meaningful use will continue to incent providers
to adopt “certified” EMR systems which support
electronic data exchange.
States will continue to develop health
information exchanges (HIEs).
State and federal agencies will seek to leverage
the above efforts to improve public health
program management and healthcare oversight.
Next Steps



Understand the overall eReferral process and
how it may benefit your program and
participating practices.
Consider a phased approach for implementation
(paper-based, eForms, eReferrals).
Understand the broader “meaningful use”
context.
 Stage 1, 2, 3
 Clinical Quality Measures
Next Steps - continued

Understand the capabilities of your systems.
 EMR, HIE, QuitLine

Consider long term implications of IT choices.
 (3rd party, open source, custom, hosted solutions)

Engage local resources that can help.
 Regional extension centers
 Health information exchanges
 EMR vendors
 Public health program leaders
Notes of Caution

eReferrals must fit into clinical workflow.

“Certified” EMRs offer different levels of support for
public health programs (understand how EMR vendors
interpret and support meaningful use).

HIEs don’t automatically resolve all data exchange issues.
Understand your local HIE priorities and capabilities.
Thank you!
www.quitworks.org
info@quitworks.org
thomas.land@state.ma.us
anna.landau@state.ma.us
michael_stelmach@jsi.com
donna.warner@state.ma.us
Join the MultiState Collaborative on upcoming webinars:
1) Meaningful Use 4/26/2011, 12:30pm-2:00pm
2) Drill-down on technical e-Referral questions and answers (May-TBA)
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