Technological Innovations to Improve Tobacco Cessation

In Health Systems

Charles J. Bentz MDMedical Director: Tobacco Cessation and Prevention

Providence Health System: Oregon

Providence Health System: OregonEmployees: 11,954Active Medical Staff: 1,967Providence Health Plan (HMO): 321,621Providence Preferred (PPO): 362,979Licensed Beds (acute & long-term): 1,474Admissions: 59,188Births: 8,965Outpatient visits: 2,054,612

Providence Health System Task Force on Tobacco Cessation and Prevention

• Physician Leader• Access Services• Respiratory Care• Health Services Integration• Long Term Care• Human Resources• Behavioral Health• Employer Health• Prov-RN

• Health Education• Research Analyst• Home Care • Quality Management• Women & Children’s Program• Diabetes Disease Management• Pharmacy• C.O.R.E• Community Health Worker

SMOKING CESSATION AND PREVENTION: 2002

Providers•5 A’s Training/Education•Reimbursement •Physician Leadership

Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN

Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN

Health System•AAHP Awards •Funded Research•NCQA Accreditation

Target Groups•Women & Children•HRA, High Risk•Disease Management•PHS employees •Web-Based

Community•TOFCO•Oregon Quit Line•Legislation

Hospital-Based•Inpatient Program•Behavioral Health/CD

Evaluation•C.O.R.E.•Programs•CQI

SMOKER(who wants to quit)

Smoking Prevalence in PHP vs. Oregon

15%16%17%18%19%20%21%22%23%24%

'88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000

State of Oregon (BRFS) Providence Health Plan: Oregon

HEDIS Tracking Code Pilot Project• Develop codes to track prevention and disease management• Implement Tracking Codes in Two Offices

– Paper Chart Based office• Paper “CPT-like” billing codes for tobacco cessation

– Smoker: Current, Recent Quit, Remote Quit, Never, Advice to quit

– Electronic Medical Record (EMR) Based office: • Same measurements as in paper-clinic

– Observation Headings in EMR database and encounter forms• CQI process evaluation of implementation• External Validation of TR Codes: Chart Review

Paper-Based

Tracking Codes

Immunizations TR700 DtaP (DTP ACELL) TR711 DTP w/Polio TR701 DTP TR712 OPV TR702 DT TR713 Polio (inj) TR703 Tetanus TR716 Varicella TR704 Mumps TR718 Tetanus & DT (adult) TR705 Measles TR019 Diphtheria TR706 Rubella TR720 DTP/HIB TR707 MMR TR724 Influenza TR708 Measles & Rubella TR732 Pneumococcal TR709 Rubella & Mumps TR737 HIB TR710 MMRV TR724 Influenza TR732 Pneumococcal TR021 Prior Hx Varicella Diabetic Indicators Hemoglobin A1c Level TR800 Dilated retinal exam TR203 > 9.0 TR801 Foot exam TR202 >8<9.0 TR220 Negative both micro & macroalbuminuria TR201 >7<8.0 TR221 Positive either micro & macroalbuminuria TR200 <7.0 Smoking Indicators Counseling TR001 Smoker TR100 Smoking cessation TR002 Non-smoker/remote quitter (>6 months) TR101 Substance abuse TR003 Recent quitter (<6 months) TR102 Sexually transmitted disease Disease management/prevention LDL Cholesterol Level TR600 Cholesterol and lipid drug management TR232 >160 TR601 Beta Blocker after MI TR231 >130<160 TR602 Aspirin use TR230 >100<130 TR603 ACE Inhibitor Use TR229 <100 TR301 Lead Screening Questionnaire Women’s health TR520 Mammography TR521 PAP Smear TR010 Prior total hysterectomy TR011 Bilateral mastectomy TR500 Prenatal visit TR510 Postnatal visit

Preventive care (Medical Office)

Office billing dept

Claims processing

(Health Plan)

(Feedback on preventive care)

Paper Chart Environment: Flow of preventive care data

(Tracking Codes)

Financial Incentive (quality bonus)

Preventive Care (Medical office)

Fee ticket(billing service)

Claims processing

(Health Plan)

HEDIS/Quality Bonus incentive

(Feedback on preventive care)

Electronic Medical Record (EMR) Environment: Flow of preventive care data

EMR (Direct reporting to Health Plan)

Percent of Patients with Documentation about Tobacco Use in the Paper-Based and EMR Clinics

45% 42% 42%

79% 80%88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-99 Jul-99 Aug-99

Perc

ent o

f Pat

ient

s w

ith D

ocum

enta

tion

Paper Clinic EMR Clinic

Summary: Paper-Based Record

• Paper Tracking Codes CAN WORK• Data loss was an issue• MCO delay (feedback vs. reporting)• Physician memory: Double documentation • Time intensive, wide practice variation• Single Health Plan Only

Summary: Electronic Medical Record • Much easier data collection• Measurement built right into practice• Entire clinic population vs. one health plan• 50% provider turnover during study period• Issues of data ownership (private practice)• Return on investment (ROI) of EMR

Using Logician™ (EMR)

Using Logician™ (EMR)

Paper Quit Line

Fax Form

Electronic Quit Line Fax Form

Providence Health SystemInpatient Smoking Cessation

Referra lQ u it L in eC lasses

Surviva l K itR esou rces

D is trac t ion A id s

Pharm a cotherapyP h arm ac is t-B ased

G u id e lin e

Notific a tion of PC PP erson a l L e tte r

R esou rces

INTERVENTIONAssessm ent by Trained Therapist

"D o you n eed help w h ile in H ospital? ""A re you in teres ted in rem ain in g Sm oke-F ree?"

RESPIRATO RY CAREDaily Census of Inpatient Sm okers

ACCESS SERVICESSystem atic Identification of Current Sm okers

Systematic vs. Non-Systematic: PHS Inpatient Cessation Program

0

2000

4000

6000

8000

10000

1994 1995 1996 1997 1998 1999 2000 2001 2002

Face to Face Interventions with Hospitalized Smokers

Data: HBOC

Inpatient Program Database

Percent of Inpatient Admissions who have Tobacco Status Ascertainment: PSA Hospitals

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Jun-00

Jul-00 Aug-00

Sep-00

Oct-00

Nov-00

Dec-00

Jan-01

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01 Aug-01

PMH PPMC PSVMC

“You can’t improve… what you can’t measure”

• Seek usefulness (not perfection) in measurement• Balance process and outcome measures• Keep the measurement simple• Use qualitative and quantitative data• Operational definitions of the measures• Measure small, representative samples• Build the measurement into daily work• Develop a measurement team Nelson EC, Annals Int Med. 1998, 128:460-466