CS252963-A

 

Q&A with Harvard Vanguard Medical Associates and Atrius Health 


about Health Systems Change to Address Smoking
 

Background on Harvard Vanguard Medical Associates and Atrius Health 

Harvard Vanguard Medical Associates (Harvard Vanguard) is a nonprofit multi-specialty medical group 

providing care to 495,000 adult and pediatric patients at more than 21 offices across eastern Massachusetts. 

As an affiliate of Harvard Medical School, Harvard Vanguard physicians are on the staff of Boston’s academic 

medical centers and community hospitals. Harvard Vanguard’s 4,300 employees, including more than 600 

physicians and 1,000 health care professionals, are committed to making it easier for patients to be and stay 

healthy. 

Harvard Vanguard is an affiliate of Atrius Health (Atrius), an alliance of six nonprofit community-based 

medical groups and a home health care, private duty nursing and hospice agency in Massachusetts, 

representing more than 1,000 physicians and more than 1,700 other health professionals, with a total of 

10,000 employees serving more than one million patients across eastern and central Massachusetts. 

In the question and answer (Q&A) below, Harvard Vanguard and Atrius respond to questions about an 

extensive health systems change effort they undertook in 2007 to improve tobacco dependence treatment 

in their health care system. 

1. What was the impetus to improve how Harvard Vanguard addressed tobacco use? 

In 2007, our Chief Medical Officer identified smoking cessation as an important initiative to improve the 

overall health of our population. Accordingly, we launched a quality improvement initiative to improve rates of 

identification and intervention with our patients who smoke cigarettes. Our first step was to review data available 

from our electronic health record system (EHR) for tobacco cessation and establish a quality improvement goal. 

Before 2007, we had fields in our EHR to code for smoking and assessment, 

but the workflows and interventions that produced the data were unclear. 

Data from our EHR system showed that 84% of patients had a documented “Our Chief Medical Officer 

smoking status in the EHR, and 31% of smokers’ visits were coded for 

“tobacco assessment/counseling.” However, we could not determine how 

many smokers received prescriptions for cessation medications, nor was 

there a record of evidence-based interventions delivered (with the exception 

of the half of one percent of smokers who were referred to the state’s 

identified smoking cessation 

as an important initiative to 

improve the overall health of 

our population.”
 

quitline—the QuitWorks fax-referral program). We had no tools in place to 


support clinicians in conducting evidence-based, routine, tobacco cessation 

interventions with patients; we had no academic detailing programs, and we 


only had a loose affiliation with the Massachusetts quitline. In short, we did 


not have a system-level or system-wide intervention approach.
 

Based on this review and assessment, Harvard Vanguard set a quality goal to intervene with 25% of smokers across 

the organization. We began by designing a system to implement at four pilot sites. Clinic participation 

was voluntary; no monetary or other incentives were offered. Rather the focus was on doing “the right thing” (e.g., 

addressing tobacco use with patients). Within just a few years, our participating clinics greatly surpassed the 

initial goal. 

National Center for Chronic Disease Prevention and Health Promotion 

Office on Smoking and Health 
 

 

 

2. What kinds of changes did you have to make to create a system to support consistent 

clinical interventions? 

We made changes in four areas: clinical pharmacy, information technology, patient health education and 


marketing, and team training. These are described briefly below, and discussed in more detail in subsequent 


questions. 


•	 Medications Decision Support: We developed evidence-based decision support tools for clinicians with a goal 

to ensure that cigarette smokers were assisted and offered cessation medications. For example, a Smoking 

Cessation Drug Therapy guide was built into the EHR with information on first-line drug options, cost and 

insurance coverage for drugs, and a link to information on how to order a quitline referral. 

•	 Information Technology: We made changes to our EHR to support documentation of interventions with 

smokers, and we integrated decision support into the EHR as shown in Figure 1. We also worked to “close-theloop” on documentation of fax-referrals to the quitline. Now we receive patient-level Excel spreadsheet reports 

back from the quitline on all the patients we have referred and our tobacco cessation coordinator enters the 

outcomes (contact, services, quits) back into the patient record. Lastly, we developed a methodology to create 

reports in real-time to track the performance of our individual providers. 

•	 Team Training: We developed a team-based approach to perform the 5As, assigning specific roles to each of 

three team members—a medical assistant (MA), the visit clinician (usually an MD), and an advance practice 

clinician (APC), typically a nurse practitioner. To prepare clinicians to conduct this work, we created and offered 

mid-level provider (nurse) education and medical assistant training, tailored to each role. We also presented to 

the physician group at each site to inform them of the change in the MA role and to discuss the important role 

that physicians play in advising the patient to quit. 

•	 Health Education and Marketing: Patient education handouts were developed and included in the clinical 

workflow, which serves as a flow diagram of the steps or actions clinicians follow to perform routine tasks and 

generate results. 

3. What guided the development of your new system of clinical interventions and EHR 

supports? 

First, we developed a set of principles to guide how we designed the system of interventions. We agreed that the 

intervention must: 

•	 Be evidence-based. 

•	 Be iterative. 

•	 Be consistent throughout the system. 

•	 Integrate into daily practice. 

•	 Support clinician intervention at point-of-care. 

•	 Involve all members of the clinical team. 

•	 Leverage community resources (like the QuitWorks— the state’s quitline referral program). 

•	 Include feedback on process measures to the clinical team (e.g., monthly rates of identification and intervention 

with cigarette smokers by site). 

We then developed a clinical workflow model that features a teaming approach (See Figure 1) with roles defined for 

medical assistants, visit clinicians (usually an MD), and advanced practice clinicians. The workflow includes scripts 

and prompts for each step in the intervention built into our EHR. Real-time data entry in the EHR is required; that is, 

the identification of smokers and interventions has to be recorded as they occurred during the patient visit. 

4. Putting it all together, what role does each member of the team play in the interventions, 

and what does your clinical and EHR workflow look like? 

The team-based intervention consists of the simple steps shown in Figure 1: identify tobacco users, deliver a 

brief intervention, and offer medications and refer patients to QuitWorks— the state’s quitline fax or electronic 

referral service for providers in Massachusetts, which links to the Mass Smokers Helpline. The steps are carried 

Page 2 of 5 
 

out by a three-person team, each with an assigned role: the Medical Assistant (MA), the Visit Clinician, and the 

Advance Practice Clinician (APC), shown in blue, yellow, and purple, respectively in Figure 1. In our systems, before 

the clinical visit, the medical assistant (MA) asks each patient about their smoking, documents smoking status, 

and verifies or determines readiness to quit (stage of change). The MA also orders the QuitWorks quitline referral 

for patients ready to quit and schedules a follow-up visit with an advance practice clinician, typically a nurse 

practitioner. The information recorded by the MA is available immediately in the EHR to the Visit Clinician (typically 

an MD), who is prompted by the EHR to deliver strong advice to quit during the patient visit. If the patient has 

indicated that they are ready to quit, the Visit Clinician delivers a congratulatory statement, confirms the QuitWorks 

referral, and offers the team’s support for a patient’s quit attempt. The advanced practice clinician (APC) then 

prescribes medications and provides counseling. 

Figure 1. Atrius and Harvard Vanguard Medical Associates Tobacco Intervention Workflow 

5. What was your implementation plan? How did you roll out the new system and how long 

did it take? 

Our project team, led by our physician-champion, developed a phased implementation plan, rolling out the new 

system to four clinics at a time, on a voluntary basis. We conducted academic detailing at the volunteer clinical sites 

and our project team (a physician champion and an assistant) trained the tobacco intervention teams. In May 2007, 

we recruited four Internal Medicine (IM) department pilot sites, and recruited a clinical champion at each site. In 

addition to training the clinical teams assigned to perform smoking interventions, we provided training materials 

for all clinic staff. In 2008–2009, we added six additional IM departments. By 2010, 12 of 17 Harvard Vanguard’s 

IM clinical sites were on board. Today, this system of tobacco interventions has been implemented in all Harvard 

Vanguard clinics. Through our common EHR, the workflow and decision support tools are also available to all five 

medical groups that operate within the Atrius organization. 

We also worked with Massachusetts Tobacco Control Program (MTCP) to close the referral loop to QuitWorks—the 

state’s quitline referral service for providers. Initially, we arranged with the quitline to send referring providers 

regular patient-level feedback data in Excel format, with our patient medical ID attached. We then encouraged 

Page 3 of 5 
 

 

MTCP and its quitline to offer a fully electronic referral option, because faxed referrals no longer fit within our fully 

electronic systems. Today, we send referrals to QuitWorks electronically from the EMR, but we decided to continue 

to receive patient feedback reports in Excel spreadsheet form. Our project assistant reviews the information and 

enters it manually into patient records. 

6. What makes your system work day-to-day and year-over-year? 

A number of things contribute to a functional and consistent system. First, we embedded decision-support tools 

in our EHR system—with prompts and scripts for each team member to follow. This makes the clinical workflow we 

agreed on easier for clinicians to remember and follow. 

Second, we monitor performance data monthly by clinic, by team, and by team member on the “ask,”“assess,” and 

“assist” steps. We provide each department, clinician, and medical assistant with monthly feedback reports and 

we review performance with each clinic team on each measure (supervisors conduct these reviews now). Some 

supervisors post the scores within the departments. They can also request detailed reports on each patient to 

review cases with missing assessments and identify staff for coaching to improve assessment and identification 

rates.a They also conduct periodic refreshers on the EHR screens that contain the smoking assessment and 

intervention prompts for staff with lower scores, and some supervisors incorporate the reports into performance 

reviews. It is this active review process with each team, not simply providing reports, that is critical to performance 

improvement. The Harvard Vanguard team that is responsible for implementing the systems reviews performance 

over time and compares progress and results across clinics. 

Figure 2 is an example of how we review our performance across the whole organization and for the long haul—as 

shown here, over three years. In 2009, we worked with the state’s largest commercial insurance company, with 

whom we have a global payments contract, to include a tobacco metric. 

Figure 2. Atrius Harvard Vanguard Identification and Intervention Rates

 (3 months prior to roll out – 3.5 years post rollout) 

System sustainability is also a function of Atrius organizational commitment to quality care and our high 

performance culture. Chief among success factors are personnel dedicated to oversee the system of tobacco 

interventions, including an MD champion and a department supervisor. They were charged to design and 

implement the interventions, train clinical teams, and monitor performance continuously, reporting back 

periodically on both process and outcome measures to the Atrius CEO and Executive Team. Monthly reports 

detailing Medical Assistant performance are also shared with IM Supervisors and Managers, IM Chiefs and Site 

Administrators; high level data from all of the sites are posted so sites may view each other’s performance. 

In January 2014, a “best practice alert” was added to our EMR with logic built in that triggers an alert when 

smokers are identified as “ready to quit” by automatically providing the visit clinician with an order screen to place 

a Quitline referral. This has made it easier for clinicians to remember to refer and has subsequently increased the 

volume of referrals. 

Page 4 of 5 
 

 

 

7. What outcomes were achieved within Harvard Vanguard Medical Associates sites that 

implemented and sustained a systems-level change? 

As shown in the feedback report above, the Harvard Vanguard sites that implemented the new tobacco cessation 

systems change program rapidly reached high performance levels of “ask” and “assist.” In 2009–2010, Harvard 

Vanguard partnered with the Massachusetts Tobacco Control Program to analyze more than 4,000,000 encounter 

records from their EPIC system for the period January 1, 2005, to November 30, 2010.1 The results, published in 

2010, report the following: 

•	 Among Harvard Vanguard clinics implementing the new systems changes,b

 a clinical intervention occurred 

during 82.5% of visits where patients were identified as smokers, compared with 59.4% at sites with no systems 

change. 

•	 Quitline electronic referrals were implemented and referrals doubled within 3 months. 

•	 Quits increased in clinics that had made systems changes, compared with sites that did not. In particular 

-	 Smoking rates were reduced by 10% in participating clinic sites. 

- Decreases in self-reported smoking prevalence were 40% greater at clinics that achieved systems change 

(13.6% vs. 9.7%, p< .01). 

•	 On average, the likelihood of quitting increased by 2.6% (p< 0.05, 95% CI: 0.1%–4.6%) per occurrence of brief 

intervention; after 3 years, a patient with a history of smoking who had 3 visits per year would be as much as 

26% more likely to have quit smoking.1 

8. How has the partnership between Atrius and the MA Tobacco Control Program evolved? 

What is the status today? 

The Massachusetts Tobacco Control Program has had a longstanding partnership with Harvard Vanguard, initiated 

in 2000, when the QuitWorks fax-referral program was first launched. Over time, Harvard Vanguard became one 

of the largest and most consistent sources of quitline referrals, and Quit Works became increasingly integrated 

into both the Atrius clinical workflow and the Atrius EHR system. As a longtime user, Harvard Vanguard worked 

frequently with Quit Works to recommend improvements—including feedback reports—to align QuitWorks more 

closely with Harvard Vanguard’s workflow. Harvard Vanguard’s request for MTCP to develop a fully-electronic 

referral capability moved MTCP forward in its ultimate development of this capability. We were the first large health 

care delivery system in MA to adopt fully electronic referrals—doubling our referrals to QuitWorks within 3 months. 

Today, all medical groups and clinical sites within the Atrius organization can make fully electronic referrals from 

our common EPIC EHR. 

Footnotes 

a.	 Currently the QuitWorks disposition on each patient is faxed to the secure Atrius Medical Record server (we call it e-faxing) . The Medical Records staff 

retrieve them electronically and attach the disposition to the referral in the EMR which then routes thru the provider’s EMR for review. This also allows for it 

to be stored permanently in the EMR. 

b.	 Land et al. (2012) defined ‘‘health systems change’’ as first month when more than half of all office visits at a given site included an identification for 

cigarette smoking. In all months following that date, the rate of cigarette smoker identifications could never drop below 50%. Furthermore, there had to be 

at least 12 consecutive months with rates above 50%. By this definition, 12 of the 17 Harvard Vanguard sites had achieved ‘‘systems change.’’1 

References 

1.	 Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, et al. The effect of systematic clinical interventions with cigarette smokers on quit status and the rates of 

smoking-related primary care office visits. PLoS ONE. 2012; 7(7):e41649.doi:10.1371/journal.pone. 

Page 5 of 5