1. Technological Innovations to Improve Tobacco Cessation In Health Systems Charles J. Bentz MD Medical Director: Tobacco Cessation and Prevention Providence Health System: Oregon

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

3. 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

4. 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 )

5. Smoking Prevalence in PHP vs. Oregon

6. 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

7. Paper- Based Tracking Codes

8. 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)

9. 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)

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

11. 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

12. 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

13. Using Logician™ (EMR)

15. Paper Quit Line Fax Form

16. Electronic Quit Line Fax Form

17. Providence Health System Inpatient Smoking Cessation

18. Systematic vs. Non-Systematic: PHS Inpatient Cessation Program Data: HBOC

19. Inpatient Program Database

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

21. “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