The Tobacco Free use case scenario supports creation of an electronic referral system that enables electronic coordination between case management systems and healthcare providers’ electronic health records.
Tobacco cessation programs such as Quitline are services offered to individuals wishing to stop using tobacco. These programs typically include counseling, community forums and organized peer support for tobacco users trying to quit tobacco. Smokers who take part in cessation programs are more likely to successfully quit smoking – defined as abstinence for six months or more – than those who attempt quitting on their own.
Tobacco cessation programs typically utilize case management systems that must collect comprehensive and timely program referrals from healthcare providers. A referral includes information on the referring provider, diagnosis data, and the patient’s preferences for contact. Currently, this information is collected by healthcare providers and faxed to a tobacco cessation program when a patient indicates they are ready to quit tobacco use in the next 30 days and would like a referral to a cessation program.
An interoperable Electronic Referral (eReferral) System between healthcare providers and case management systems will help identify and provide assistance to consumers wishing to reduce tobacco use.
“Tobacco Free” is a scenario under the Electronic Referrals use case.
The following documents are available:
Use Case Summary:
The “Persona” Story
Ron Oatman is a care coordinator for a mid-sized patient-centered medical home (PCMH) that services a number of surrounding rural communities. Ron loves his job because he plays a critical role in making sure patients have the resources they need to thrive outside of healthcare office walls.
Ron likes to feel appreciated, but he also knows that success for him means his effort is almost imperceptible to patients as they seamlessly transition from a hospital or an appointment back to their homes. It’s Ron’s job to make care effortless for patients but paperwork and inefficient workflows get in the way of Ron performing his job. He wants patients to be happy with their care, but that’s hard to make happen when he is drowning in paperwork.
One example of this paperwork burden that frustrates Ron the most is the time-consuming program referral process. When PCMH provider Dr. Rachel Mondi refers one of her patients to a support program, it is Ron’s job to fill out and send referral forms to the proper recipients (i.e. support programs, other providers, health insurance organizations). Once the paperwork is done and faxed or emailed to a healthcare provider for care coordination, Ron rarely receives any confirmation that the referral was received and almost never receives feedback or updates on a patient’s care to pass along to providers like Dr. Mondi.
As part of grading their performance, the PCMH office uses a quality measures dashboard to identify which practices and processes need improvement. At this time, the office is focused on the areas of “Smoking Cessation” and “Transitions of Care.”
When Ron spoke to the coordinators at a participating Tobacco Cessation program, they recommended that the PCMH office implement Tobacco Free electronic referrals. As they explained it to Ron, the Tobacco Cessation program receives provider referrals in real time that include the comprehensive medical information needed to plan an intervention. This drastically reduces the time, follow-up and paperwork that previously slowed down the start of their patient engagement. The electronic process also allows the Tobacco Cessation coordinators to send progress information to the PCMH and/or its electronic health record system, which would not only increase communication for Ron’s office but also could help their quality measure incentive programs.
Ron spoke to his management and they agreed to try electronic referrals. Ron immediately appreciated that Tobacco Free referrals can now be ordered by providers like Dr. Mondi, automatically generated, packaged directly into a patient’s structured medical documents, and sent out electronically from the medical home’s electronic health record system.
Ron is elated to finally have a method of closing one of the referral coordination loops for his patients. While Ron appreciates that this use case means a lot less faxing on his part, he more importantly believes that the new improvement will make a difference for the people he serves. He is also noticing that his co-workers are smiling more.