Clinical Decision Support Tool for Parental Tobacco Treatment in Hospitalized Children

Summary

Objectives

To create and evaluate the feasibility, acceptability, and usability of a clinical decision support (CDS) tool within the electronic health record (EHR) to help pediatricians provide smoking cessation counseling and treatment to parents of hospitalized children exposed to secondhand smoke (SHS).

Methods

Mixed method study of first-year pediatric residents on one inpatient unit. Residents received training in smoking cessation counseling, nicotine replacement therapy (NRT) prescribing, and use of a CDS tool to aid in this process. The tool, which alerted when a patient was identified as exposed to SHS based on the history taken on admission or during a prior encounter, had the following capabilities: adding SHS exposure to the patient’s problem list; referral to Free Quitline through discharge instructions; and linking to a printable NRT prescription form. We measured feasibility by EHR utilization data. We measured acceptability and usability of the tool by administering questionnaires to residents.

Results

From June-August 2015, the alert triggered for 106 patients, and the tool was used for 52 (49%) patients. 41 (39%) patients had SHS exposure added to the problem list, 34 (32%) parents were referred to the Quitline through discharge instructions, and 15 (14%) parents were prescribed NRT. 10 out of 15 (67%) eligible pediatricians used the tool. All clinicians surveyed (9 out of 10) found the tool acceptable and rated its usability good to excellent (average System Usability Scale score was 85 out of 100, 95% CI, 76-93).

Conclusions

A non-interruptive CDS tool to help residents provide smoking cessation counseling in the hospital was feasible, acceptable, and usable. Future work will investigate impacts on patient outcomes.

Keywords

Clinical decision support - secondhand smoke exposure - tobacco - usability

 

Conflict of Interest

The authors declare that they have no conflicts of interest in the research.

• References

• 1 USDHHS: Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Washington: DC; US Government Printing Office. 2006
• 2 Millett C, Lee JT, Laverty AA, Glantz SA, Majeed A. Hospital admissions for childhood asthma after smoke-free legislation in England. Pediatrics 2013; 131 (02) e495-e501.
• 3 Howrylak JA, Spanier AJ, Huang B, Peake RWA, Kellogg MD, Sauers H, Kahn RS. Cotinine in children admitted for asthma and readmission. Pediatrics 2014; 133 (02) e355-e362.
• 4 Jamal A, Homa DM, O’Connor E, Babb SD, Caraballo RS, Singh T, Hu SS, King BA. Current Cigarette Smoking Among Adults - United States, 2005-2014. MMWR Morb Mortal Wkly Rep 2015; 64 (44) 1233-1240.
• 5 Homa DM, Neff LJ, King BA, Caraballo RS, Bunnell RE, Babb SD, Garrett BE, Sosnoff CS, Wang L. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke--United States, 1999-2012. MMWR Morb Mortal Wkly Rep 2015; 64 (04) 103-108.
• 6 Rigotti NA, Clair C, Munafò MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2012; 05: CD001837.
• 7 Winickoff JP, Hibberd PL, Case B, Sinha P, Rigotti NA. Child hospitalization: an opportunity for parental smoking intervention. Am J Prev Med 2001; 21 (03) 218-220.
• 8 Rosen LJ, Noach MB, Winickoff JP, Hovell MF. Parental Smoking Cessation to Protect Young Children:A Systematic Review and Meta-analysis. Pediatrics 2012; 129 (01) 141-152.
• 9 Winickoff JP, Nabi-Burza E, Chang Y, Finch S, Regan S, Wasserman R, Ossip D, Woo H, Klein J, Dempsey J, Hipple B, Weiley V, Murphy S, Rigotti N. Implementation of a parental tobacco control intervention in pediatric practice. Pediatrics 2013; 132 (01) 109-117.
• 10 Winickoff JP, Nabi-Burza E, Chang Y, Regan S, Drehmer J, Finch S, Wasserman R, Ossip D, Hipple B, Woo H, Klein J, Rigotti N. Sustainability of a parental tobacco control intervention in pediatric practice. Pediatrics 2014; 134 (05) 933-941.
• 11 Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, Committee on Native American Child. From the American Academy of Pediatrics: Policy statement--Tobacco use: a pediatric disease. Pediatrics 2009; 124 (05) 1474-1487.
• 12 American Medical Association. H-490.917: Physician Responsibilities for Tobacco Cessation. Adopted by House of Delegates. Chicago: IL; American Medical Association. 2005. Available from: https://www. google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CCUQFjAB&url=http%3A%2F%2Fwww.amaassn.org%2Fmeetings%2Fpublic%2Fannual05%2F444a05.doc&ei=lgNtVPOxDoXbsASX5oC4Dg&usg=AFQjCNGY8nXkXXtzOILZNpA7TGH2H0aLHw&sig2=kP8fXhDYnp2XzpE3a3akvA.
• 13 Siu AL. Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation StatementUSPSTF Recommendation Statement for Interventions for Tobacco Smoking Cessation. Ann Intern Med 2015; Sep 22.
• 14 Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane Database Syst Rev 2014; 12: CD008743.
• 15 Bernstein SL, Rosner J, DeWitt M, Hsiao A, Dziura J, Toll B. Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record. Implement Sci 2015; 10 (Suppl. 01) A1.
• 16 Sharifi M, Adams WG, Winickoff JP, Guo J, Reid M, Boynton-Jarrett R. Enhancing the electronic health record to increase counseling and quit-line referral for parents who smoke. Acad Pediatr 2014; 14 (05) 478-484.
• 17 Centers for Disease Control and Prevention (CDC).. Behavioral Risk Factor Surveillance System Survey Data. Atlanta: Georgia; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2014
• 18 Kushniruk AW, Patel VL. Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform 2004; 37 (01) 56-76.
• 19 Dumas JS. User-based Evaluations. Edited by Jacko JA, Sears A. In: The Human-Computer Interaction Handbook. Mahwah: New Jersey; Lawrence Earlbaum Associates 2003: 1093-1117.
• 20 Kastner M, Lottridge D, Marquez C, Newton D, Straus SE. Usability evaluation of a clinical decision support tool for osteoporosis disease management. Implement Sci 2010; 05 (01) 96.
• 21 Daniels J, Fels S, Kushniruk A, Lim J, Ansermino JM. A framework for evaluating usability of clinical monitoring technology. J Clin Monit Comput 2007; 21 (05) 323-330.
• 22 Trafton JA, Martins SB, Michel MC, Wang D, Tu SW, Clark DJ, Elliott J, Vucic B, Balt S, Clark ME, Sintek CD, Rosenberg J, Daniels D, Goldstein MK. Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain. Implement Sci 2010; 05 (01) 26.
• 23 Osheroff J, Teich J, Levick D, Saldana L, Velasco F, Sittig D, Rogers K, Jenders R. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, Second Edition. 2 edition.. Chicago: IL; HIMSS Publishing. 2012
• 24 Fiks AG. Designing computerized decision support that works for clinicians and families. Curr Probl Pediatr Adolesc Health Care 2011; 41 (03) 60-88.
• 25 Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, Dorfman SF, Froelicher ES, Goldstein MG, Healton CG, Henderson PN, Heyman RB, Koh HK, Kottke TE, Lando HA, Mecklenburg RE, Mermelstein RJ, Mullen PD, Orleans CT, Robinson L, Stitzer ML, Tommasello AC, Villejo L, Wewers ME, Murray EW, Bennett G, Heishman S, Husten C, Morgan G, Williams C, Christiansen BA, Piper ME, Hasselblad V, Fraser D, Theobald W, Connell M, Leitzke C. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville: MD; U.S. Department of Health and Human Services. Public Health Service. 2008
• 26 Brooke J. A quick and dirty usability scale. In: Jordan PW, Thomas B, Weerdmeester BA, McClelland AL. editors. Usability evaluation in industry. London: Taylor and Francis; 1986.;
• 27 Lewis JR. IBM Computer Usability Satisfaction Questionnaires: Psychometric Evaluation and Instructions for Use. Int J Hum-Comput Interact 1995; 07 (01) 57-78.
• 28 Tsopra R, Jais J-P, Venot A, Duclos C. Comparison of two kinds of interface, based on guided navigation or usability principles, for improving the adoption of computerized decision support systems: application to the prescription of antibiotics. J Am Med Inform Assoc JAMIA 2014; 21 (e1): e107-e116.
• 29 Bangor A, Kortum P, Miller J. Determining What Individual SUS Scores Mean: Adding an Adjective Rating Scale. J Usability Stud 2009; [phone].
• 30 Middleton B, Bloomrosen M, Dente MA, Hashmat B, Koppel R, Overhage JM, Payne TH, Rosenbloom ST, Weaver C, Zhang J. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc 2013; 20 (e1): e2-e8.
• 31 Fiks AG, Alessandrini EA, Forrest CB, Khan S, Localio AR, Gerber A. Electronic medical record use in pediatric primary care. J Am Med Inform Assoc 2011; 18 (01) 38-44.
• 32 Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, Spurr C, Khorasani R, Tanasijevic M, Middleton B. Ten commandments for effective clinical decision support: making the practice of evidencebased medicine a reality. J Am Med Inform Assoc JAMIA 2003; 10 (06) 523-530.
• 33 Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293 (10) 1223-1238.
• 34 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 (7494): 765.
• 35 Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013; 05: CD000165.