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Atrius Health System

Atrius Health, formerly called Harvard Vanguard Medical Associates, has integrated tobacco into EHRs and clinical workflow and have tracked and measured performance with remarkable results.

This system and workflow has evolved over many years. After several attempts, Dr. Thad Schilling, a Clinical Tobacco Champion, was appointed. He engaged in a methodical process of detailing this workflow and then rolling it out in four, and then eight more, of 17 sites and measured throughout.

Below is a diagram of the Atrius clinical and EPIC workflow to address tobacco and their teaming arrangements:

HVMA Workflow_for_Research_Section


The process diagrammed includes a number of steps and a team of three staff members – a Medical Assistant (MA), an Advance Practice Clinician (APC), typically a nurse manager, and a physician who rely on one another in order to properly record an intervention. The heart of their workflow is a team comprised of the Medical Assistant, the Visit Clinician (the MD the patient is seeing that day) and an Advanced Practice Clinician, typically a nurse manager. There are clear roles and scripts for each member of the team and also for the quitline, which is called QuitWorks, in Massachusetts.

Atrius has been using EPIC for many years and recently upgraded their system. At that time, Atrius implemented fully electronic quitline referrals from their EPIC system (referrals are transmitted to the quitlines with patient ID attached from the EMR to the quitline electronically each night). The question we addressed is what impacts does a system - such as the one Atrius implemented - have on smoking rates and patient health?

The tobacco intervention system shown above was implemented in 12 clinic sites between January 1, 2007 and April 2009. For all 12 sites, there was a significant increase in the identification rate of tobacco users after the date established for “systems change.”

Atrius experienced 11% fewer smokers in 2.5 year period, accelerating prevalence beyond tax increases. Further reductions in tobacco use (quits) led to improved health, defined as a decrease in office visits for smoking related diagnoses by 4% and 2.5% for all office visits. This amounted to thousands of visits saved per year, pointing to capacity savings and cost savings, just in primary care.

In this example, the system had a protocol in place to refer patients to the state’s quitline (QuitWorks). About 27% of tobacco users who received an intervention were referred to quitline. When an e-referral system was launched, referrals from the entire organization Atrius Health, serving over half a million patients, doubled in 3 months post implementation of e-referrals from the EPIC system.


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