Electronic health record closed-loop referral (“eReferral”) to a state tobacco quitline: a retrospective case study of primary care implementation challenges and adaptations
Authors: Zehner Mark E. , Kirsch Julie A. , Adsit Robert T. , Gorrilla Allison , Hayden Kristine , Skora Amy , Rosenblum Marika , Baker Timothy B. , Fiore Michael C. , McCarthy Danielle E. 
Published: October 2022

Abstract
Background
Health system change can increase the reach of evidence-based smoking cessation treatments. Proactive electronic health record (EHR)-enabled, closed-loop referral (“eReferral”) to state tobacco quitlines increases the rates at which patients who smoke accept cessation treatment. Implementing such system change poses many challenges, however, and adaptations to system contexts are often required, but are understudied. This retrospective case study identified adaptations to eReferral EHR tools and implementation strategies in two healthcare systems.

Methods
In a large clustered randomized controlled trial (C-RCT; NCT02735382) conducted in 2016–2017, 11 primary care clinics in two healthcare systems implemented quitline eReferral, starting with 1 pilot clinic per system followed by 2 phases of implementation (an experimental phase in 5–6 test clinics per system and then a system-wide dissemination phase in both systems). Adaptations were informed by stakeholder input from live trainings, follow-up calls and meetings in the first month after eReferral launch, emails, direct observation by researchers, and clinic staff survey responses. Retrospective, descriptive analysis characterized implementation strategy modifications and adaptations using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). A pre- and post-implementation survey assessed staff ratings of eReferral acceptability and implementation barriers and facilitators.

Findings
Major modifications to closed-loop eReferral implementation strategies included aligning the eReferral initiative with other high-priority health system objectives, modifying eReferral user interfaces and training in their use, modifying eReferral workflows and associated training, and maintaining and enhancing interoperability and clinician feedback functions. The two health systems both used Epic EHRs but used different approaches to interfacing with the quitline vendor and integrating eReferral into clinician workflows. Both health systems engaged in iterative refinement of the EHR alert prompting eReferral, the eReferral order, trainings, and workflows. Staff survey comments suggested moderate acceptability of eReferral processes and identified possible targets for future modifications in eReferral, including reducing clinician burden related to EHR documentation and addressing clinicians’ negative beliefs about patient receptivity to cessation treatment.

Conclusions
System-wide implementation of tobacco quitline eReferral in primary care outpatient clinics is feasible but requires extensive coordination across stakeholders, tailoring to local health system EHR configurations, and sensitivity to system- and clinic-specific workflows.

Trial registration
www.clinicaltrials.gov, NCT02735382. Registered on 12 August 2016.