Leveraging electronic medical record (EMR) changes and virtual care towards improving tobacco screening and referral rates.
Authors: Eng Lawson , Do Jennifer , Ku Monica , Quartey Naa Kwarley , Tymoshyk Iryna , Feng Anna , Liang Yunlong , Yang Anjie , Giuliani Meredith Elana , Dhanju Suman , Dunphy Colleen 
Published: September 2024

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Background:
Continued smoking after a cancer diagnosis is associated with poorer outcomes. Ontario Regional Cancer Centres are required to screen all new cancer patients for tobacco use and offer referrals for cessation support to patients using tobacco. At Princess Margaret Cancer Centre (Toronto, Canada), we leveraged an EMR change to Epic along with uptake in virtual care strategies from COVID-19, to improve both tobacco screening and referral rates for new patients.
Methods:
Following the EMR transition to Epic in June 2022, we piloted EMR and virtual care strategies from Jan 2023 to Mar 2024 to improve both tobacco screening and referral rates. Due to precautions during COVID-19, screening and referrals were completed using a hybrid pre-visit electronic tobacco use assessment questionnaire and in clinic paper-based referral system. Our interventions were co-developed by a team of hospital leadership, IT team members and clinicians. These included: 1) Collation of tobacco assessment data sources on Epic (Jan 2023); 2) Creation of an Epic referral inbox to track referrals (Aug 2023); 3) Assignment of electronic pre-visit tobacco assessments questionnaires to correct visit types (Sep 2023); 4) Creation of a half-day virtual nursing clinic to offer referrals for cessation support to patients initially declining support or those who were not offered using monthly reports from Epic (Nov 2023). Screening and referral rates were tracked monthly and quarterly during this period.
Results:
From Jan 2023 to March 2024, 15,063 new patients presented to our cancer centre. Baseline screening and referral rates before COVID-19 were 47% and 16%, respectively. Prior to this QI initiative, screening and referral rates were 18% and 1%, respectively. Post implementation, screening and referral rates improved to 42% and 25% (Table); rates of current tobacco use remained consistent from 12-16%. Collation of tobacco use assessments data on Epic had the greatest impact on improving screening rates from 18% to 39% (p<0.001), while the virtual nursing clinic helped to improve referral rates from 3% to 25% (p<0.001), with the greatest referral rate in Jan 2024 at 36%. Our virtual nursing clinic was feasible, where among patients contacted who initially declined or were not offered cessation support, 90% were contacted within 1-3 phone calls. Among patients contacted, 20% accepted a referral, while 41% of patients had already quit smoking by the time of contact.
Conclusions:
Both EMR and virtual care strategies helped to successfully improve both tobacco screening and referral rates for smoking cessation support; with the greatest impact from the collation of EMR data sources on tobacco use and development of a virtual nurse led clinic.

Quarterly tobacco screening and referral rates.

Jan-Mar 2023
Apr-Jun 2023
Jul-Sep 2023
Oct-Dec 2023
Jan-Mar 2024

Screening
33%
38%
39%
41%
42%

Referrals
0%
1%
3%
20%
25%