Implementation of an Electronic Health Record (EHR) System-Level Intervention for Tobacco Use Screening and Prevention in the Pediatric Healthcare Setting

Introduction: Tobacco use is a “pediatric disease” and clinical practice guidelines recommend that primary care providers screen and counsel youth to prevent tobacco use. Implementation of screening and prevention unfortunately remains suboptimal due to system-level barriers. The goal of this study was to implement and evaluate a system-level Ask, Advise, Connect (AAC) intervention model for pediatric tobacco prevention in the primary care setting. The intervention leverages clinical bioinformatics technologies and translational research strategies to systematize tobacco use screening, counseling, and referral to an online evidence-based tobacco use prevention resource. Here we describe intervention implementation and outcome data.

Methods: We engaged pediatric primary care providers and staff within a large, regional health care system to inform AAC model implementation for all outpatients ages 12-17 seen for well-visits. We adapted the clinic workflow to accommodate patient-reported tobacco use and other risk behaviors via tablet computers immediately prior to the clinical encounter. All data were then synchronized to the EHR and viewable by providers during the office visit. Providers counseled patients according to their tobacco use status (never smoker, current smoker, former smoker) and connected patients to an evidence-based, interactive online tobacco prevention resource. We assessed population-level tobacco use (n = 754), as well as individual risk and protective outcomes in a validation subsample (n = 190) representing 25% of the population total.

Results: The prevalence of lifetime tobacco use was comparable for the screened population (12% cigarette smoking, 9% cigar products, 3% smokeless tobacco, 4% e-cigarettes, 11% hookah) and validation subsample (7% cigarette smoking, 6% cigar products, 3% smokeless tobacco, 9% e-cigarettes, 9% hookah). In the validation subsample, objective Internet tracking metrics revealed that 64% of patients utilized the online prevention resource within 30-days.

Conclusion: These results suggest the feasibility of implementing an EHR-driven system-level intervention to improve tobacco control practices in pediatric primary care. Findings also demonstrate high utilization of evidence-based tobacco prevention resource. Clinical bioinformatics technologies paired with translational research strategies hold promise to demonstrate the effectiveness of brief, systems-level interventions to help prevent pediatric tobacco use.