title: Enhancing the electronic health record to increase counseling and quit-line referral for parents who smoke.
abstract: OBJECTIVE
  To assess the impact of an electronic health record (EHR) modification and brief clinician training on tobacco smoke exposure (TSE) management in pediatric primary care.
  
  
  METHODS
  Within a teaching hospital-based, urban primary care setting, we modified the EHR to include TSE screening prompts, decision support, educational literature, and simplified referral to the state quit line (QuitWorks). A brief training was conducted for the 48 clinic physicians (34 residents and 14 attendings). We collected cross-sectional, independent, random samples of EHR data from well-child visits for children ≤12 years old seen 3 months before (2024 visits) and 3 months after (1895 visits) the intervention and pooled client data from QuitWorks to evaluate TSE screening, counseling, and quit-line referrals. A needs assessment questionnaire examined preintervention attitudes and practice around TSE management; follow-up questionnaires explored satisfaction and subjective changes in skills.
  
  
  RESULTS
  The baseline needs assessment revealed that although most clinicians agreed that it is appropriate for pediatricians to conduct TSE screening, counseling, and referral during well-child visits, only about half screened, 42% counseled, and 28% routinely offered to refer smoking parents. In pre-post analyses of 117 and 112 EHR-documented positive screens, the intervention was associated with a 16-fold greater likelihood of counseling among positive screens (adjusted odds ratio 16.12; 95% confidence interval 7.28, 35.68). Referrals to QuitWorks increased from 1 before to 31 after the intervention.
  
  
  CONCLUSIONS
  Implementation of EHR modifications and a brief training to support TSE management was associated with higher rates of counseling and quit-line referrals for parents who smoke.
authors.affiliation: Division of General Academic Pediatrics/Center for Child and Adolescent Health Research and Policy, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Mass. Electronic address: msharifi@partners.org.
authors.forename: Mona
authors.initials: M
authors.lastname: Sharifi
authors.affiliation: Division of General Pediatrics, Boston University School of Medicine, Boston, Mass.
authors.forename: William G
authors.initials: WG
authors.lastname: Adams
authors.affiliation: Division of General Academic Pediatrics/Center for Child and Adolescent Health Research and Policy, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Mass.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Winickoff
authors.affiliation: Division of General Pediatrics, Boston University School of Medicine, Boston, Mass.
authors.forename: Jing
authors.initials: J
authors.lastname: Guo
authors.affiliation: Boston Public Health Commission, Boston, Mass.
authors.forename: Margaret
authors.initials: M
authors.lastname: Reid
authors.affiliation: Division of General Pediatrics, Boston University School of Medicine, Boston, Mass.
authors.forename: Renée
authors.initials: R
authors.lastname: Boynton-Jarrett
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002648:Child; D002675:Child, Preschool; D003376:Counseling; D003430:Cross-Sectional Studies; D003661:Decision Support Techniques; D057286:Electronic Health Records; D005260:Female; D015277:Hotlines; D006801:Humans; D007223:Infant; D065186:Interrupted Time Series Analysis; D016015:Logistic Models; D008297:Male; D008403:Mass Screening; D010290:Parents; D012017:Referral and Consultation; D012907:Smoking / Q000628:therapy*; D011795:Surveys and Questionnaires; D014028:Tobacco Smoke Pollution / Q000517:prevention & control*
chemical_list: D014028:Tobacco Smoke Pollution
keywords: clinical decision support systems; electronic health record; guideline adherence; quit line; tobacco smoke pollution; tobacco use cessation