American Journal of Preventive Medicine
Review articleElectronic Medical Records to Increase the Clinical Treatment of Tobacco Dependence: A Systematic Review
Introduction
In 2008, an estimated 46 million people or 20.6% of all adults in the U.S. were cigarette smokers.1 Although this represents a substantial decline in smoking prevalence over the past 50 years,2 prevalence has remained relatively constant for the last few years, and it is far short of the Healthy People 2010 goal of 12%.3
Approximately 30 million smokers in America visit a primary care physician each year (about 65% of all smokers), but only a small minority of these patients leave their primary care encounter linked to evidence-based counseling, medications, and/or follow-up that could boost their likelihood of successful cessation.4 Evidence-based U.S. Public Health Services clinical practice guidelines for treating tobacco use and dependence recommend systematic identification and intervention for this high-risk behavior.5 Changes in health systems operations that institutionalize the identification and clinical treatment of patients who use tobacco are a particularly promising way to better use the primary care visit to help patients quit tobacco use. System-level changes that might increase the frequency of effective cessation delivery are taking advantage of the electronic health record for clinician reminders, linking patients to services, and monitoring and feedback.
Health information systems such as electronic medical records, computerized decision support systems, and electronic prescribing are increasingly identified as potentially valuable components to improve the quality and efficiency of patient care. Electronic medical records (EMRs) are likely to disseminate rapidly now that there are legal and financial incentives to do so. There is widespread hope that electronic connectedness will lead to improvements in healthcare quality and costs,6 so a substantial national investment is being made in EMR adoption. The Health Information Technology for Economic and Clinical Health Act (HITECH Act) 7 contained within the American Recovery and Reinvestment Act of 2009 will provide $36 billion to promote electronic medical records and to form regional centers to foster community-wide electronic health information exchanges.
These two occurrences—inadequate tobacco-cessation support during clinical encounters and this rapid dissemination of EMRs—create a need to evaluate the evidence for any beneficial connections between the two, and to identify gaps in this evidence. Therefore, a systematic literature review was conducted to identify studies that address the relationship between EMRs and the use or impact of tobacco-cessation clinical guidelines.
Section snippets
Evidence Acquisition
The search included the electronic retrieval systems and databases PubMed (MEDLINE), Ovid CINAHL, ISI Web of Science, Engineering Village, Embase, and Academic Search Premier. The search was limited to studies published in English from January 1990 to December 2009. A search was completed for the combination of the following in each database: (1) medical records or health records; (2) electronic or automated; (3) smoking or tobacco.
In addition, the reference lists of retrieved studies were
Review of Identified Studies
The title and abstract identified using the Keyword searches were read independently by two of the authors. The reviewers were looking for research interventions involving adult smokers and an electronic medical record where the EMR was used to facilitate cessation support, either directly or indirectly (e.g., by providing audit and feedback). The abstracts were categorized as either:
- A
trials of an EMR intervention on quit rates;
- B
trials of an EMR intervention on change in clinician behavior;
- C
use
Evidence Synthesis
Table 1 is a summary of the ten studies that tested the use of an EMR to increase the treatment of adult smokers. All of the studies were conducted in primary care settings, and all measured changes in the U.S. Public Health Service guideline-recommended action steps,5, 8 also known as the 5A's: asking every patient if they use tobacco, advising all tobacco users to quit, assessing willingness to make a quit attempt, assisting patients with quitting, and arranging follow-up for patients.
The
Discussion
This systematic review found only two randomized controlled studies that tested the use of an existing EMR to improve documentation and treatment of tobacco use in primary care settings, by reminders, feedback, and/or facilitation of referrals. These studies found only modest improvements in some clinical guideline–recommended actions for tobacco. None of the reviewed studies included a direct assessment of patient quit rates. Although Linder et al.13 reported documented change in smoking
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