EHR-Based and Fax-Based Referral to a Tobacco Quitline: A Comparative Study

Aim 1: To evaluate the rates of referral of tobacco users visiting primary care clinics to
the WTQL, comparing those who were referred via an EHR-based electronic referral system vs.
those referred via a manual paper fax referral system. Analyses will address the change in
rates of referrals from pre- to post-intervention and the trajectory of referral
post-intervention and will reflect per clinic rates.

Aim 2: To evaluate the rates of quality referrals of tobacco users visiting primary care
clinics to the WTQL, comparing those who were referred via an EHR-based electronic referral
system vs. those referred via a manual paper fax referral system (quality referrals are
defined as ones that result in individuals who enroll in and receive WTQL counseling and/or
medication treatment services). Analyses will address the change in referrals from pre- to
post-intervention and will reflect per clinic rates.

Aim 3: To examine variation in referral rates across clinics to test the hypothesis that the
eReferral system will result in greater consistency in referral in addition to higher rates
of referral. Qualitative methods will be used to understand the sources of variation.

Aim 4: To assess clinician and staff satisfaction with the eReferral and paper fax referral
systems via self-report questionnaires.

Aim 5: To evaluate smoking abstinence rates of tobacco users who were referred to and
accepted services from the WTQL, comparing those who were referred via an EHR-based referral
system vs. those referred via a manual paper fax referral system.

Clinic Eligibility:

Inclusion Criteria:

- The presence of discrete primary care clinical services within the clinic (defined as
general internal medicine or family medicine clinical services);

- At least three primary care clinician providers in the clinic (physicians or nurse
practitioners/physician assistants who see patients independently of a physician);

- A total primary care clinical volume of at least 60 patients each week;

- An existing EHR requirement for staff to document tobacco use status including smoking
status on all adult patients visiting the clinic at every visit;

- A capacity to enumerate patient visit information including adult patients/month and
adult tobacco users/month by clinician and by clinic;

- A willingness to participate in the proposed research;

- A lead physician or a clinic manager on site who agree to serve as a clinic champion
for the project;

- Prior use of the fax referral system to refer patients to the Wisconsin Tobacco Quit
Line with use data available for the 12 months prior to study launch;

- A willingness to accept random assignment to either of the two experimental
conditions.

Exclusion Criteria:

- Those clinics not meeting the above criteria (e.g. too small, limited EHR capacity).

(Note: In this study, the clinics are the "subjects" under study. The patients that will be
referred by the clinic to the Wisconsin Tobacco Quit Line will be least 18 years old and
Cigarette smokers)