Decision support (see Table )
MAs and physicians reported consistent use of the chart stamp for screening and counseling, and as a reminder to refer and prescribe. MAs documented the "ask" portion of the stamp at all visits with new and continuing patients, which occurred before patients saw the physician or a nurse. Physicians reported using the stamp primarily as a support tool to remind them of the patient's smoking status and to prompt further assessment and services for smokers. Of note, providers agreed that the chart stamp did not interrupt workflow or add time to the visit.
The Fax-to Quit referral was also viewed as a valuable resource for busy clinicians. In contrast to the chart stamp, however, the Fax-to-Quit referral form was not as easily integrated into the patient encounter. A barrier to using this system included the unanticipated lengthy process involved in explaining the program, which could take up to 15 minutes. Staff and physicians described the form as too complicated, particularly for the literacy level of the patient population, and they reported language barriers in explaining the Fax-to-Quit program to patients who did not speak English as their first language.
The emphasis on faxing also presented technological challenges, as clinics did not always have a reliable fax machine and the faxing process added staff time to the patient encounter. In addition to simplifying the form, staff suggested streamlining the faxing process within the clinic to save time and improve integration.
Themes related to decision support and delivery system design
Delivery system design (Table )
The goal of creating a team approach, in which all staff were knowledgeable about tobacco cessation policies and procedures and responsibility for tobacco treatment would be spread across multiple staff, was not completely realized. According to providers and staff, the chart stamp was better integrated into staff workflow than the Fax-to-Quit program because it was embedded in the encounter form and, therefore, easy to access. There was also clear role definition related to this system change: MAs were tasked to screen all patients using the chart stamp prompt and physicians to follow-up on the remaining items on the chart stamp.
The interviews did uncover an unanticipated gap in using the chart stamp to reach patients who may have bypassed the MA prior to seeing the physician or who were at the clinic to see a social worker. Nurses and social workers reported that forms they used with patients, such as for triage or patient education, did not include the stamp. As a result, patients who came in for a nurse or social worker visit and did not see a MA or doctor were not consistently screened, counseled, and referred.
In contrast to a team approach between the MA and physician in completing the chart stamp, the physician had primary responsibility for the Fax-to-Quit referrals. MAs and nurses were trained to make the Quitline referrals, but they did not consistently perform this task. Physicians explained the program to patients, filled out the form and often faxed it. At times they also had to leave the room to locate forms as they were not in the chart and not always in the exam rooms. Physicians felt this limited the long-term sustainability of the program.
The majority of physicians expressed a desire for more teamwork in providing tobacco treatment and referring smokers; however, they were reluctant to ask staff to do more due to concerns about overburdening staff and staff resistance. Physicians also believed that smoking cessation assistance fell well within the responsibilities of nursing staff as they were already providing education on other health issues.
One of the barriers to staff engagement was the perception that more training was needed to increase staff confidence and expertise in delivering tobacco use treatment. Once the topics of tobacco use and the availability of telephone counseling were raised, patients often asked questions that the MAs and nurses did not feel they could answer. Both staff and physicians felt that they could use more training on the motivational aspects of helping smokers quit and in answering questions about the Quitline. Physicians felt that additional training for MAs and nurses could increase referrals as well.
Clinical information systems (see Table )
The lack of internal information systems that tracked smokers in the practice longitudinally and external information systems that provided useful feedback from the Quitline to clinicians on the progress of referred smokers was a barrier to consistent guideline implementation. The sites did not have an internal tracking system for generating aggregated data on tobacco use treatments provided to smoking patients or for quickly retrieving and charting progress reports that were faxed back from the Quitline; as a result, clinicians were not able to easily track and conduct timely follow-up with smokers who received a fax referral. Participants also pointed out that staff constraints made it difficult to assign staff to follow up with smokers between clinic visits.
Respondents also felt that the Quitline progress reports were of minimal use. Participants expressed limited understanding about the specifics of the Fax-to-Quit program and frustration at the seemingly low rates of Quitline contact of patients. Physicians and staff suggested several ways to improve the usefulness of Quitline progress reports to better assist them with patient management. For example, physicians wanted summary reports that described how the Quitline counselors intervened with their patients, including suggestions for follow-up care.
Themes related to clinical information systems and patient self-management
Patient self-management (Table )
Physicians indicated that the Fax-to-Quit program was an important patient resource to encourage self-management. They believed it served as an important educational resource, a behavior change program to help with quitting, and a message to patients that smoking cessation was a priority.
Although there were some positive responses from patients who had received the calls and medication from the Quitline, providers reported significant patient resistance to receiving a call at home from a stranger and skepticism about providing the information required on the referral form. Overcoming this resistance added significant time to completing the referral process.
Respondents believed that greater patient knowledge about the Fax-to-Quit and the benefits of the program would lead to higher receptivity when asked to participate. They suggested taking advantage of patient flow and the long waiting times for patients to see their doctor to educate patients on the Fax-to-Quit program, which could reduce time spent explaining the program during the visit. Staff also described a previous program that enrolled patients in Medicaid managed care programs in the waiting room and indicated that a similar approach might work for the Fax-to-Quit program.