OBJECTIVE: To describe user acceptance of and satisfaction with the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG) at the Henry Ford Health System.
STUDY DESIGN: A previous investigation assessed compliance with the 5 As (ask, advise, assess, assist, and arrange) of the TUC ACPG across 3 study arms. This article describes user satisfaction with the TUC ACPG after implementation.
METHODS: In all study arms, providers completed a survey before participating in a focus group.
RESULTS: All providers in the TUC arm indicated that they â€œalmost alwaysâ€ asked their patients about tobacco use. Providers in the TUC arm were generally satisfied with the features of the TUC ACPG, particularly the ease of electronically referring a patient to the Smoking Intervention Program. Barriers to use included time constraints, lack of staff, and the desire to â€œopt outâ€ of the program for patients in specific situations (eg, patients with terminal illnesses).
CONCLUSION: Because ACPGs are incorporated into electronic medical records, it is important to obtain provider input before implementation, to supply technology that is user friendly and fits into the work flow of the clinic, and to afford physicians the autonomy to opt out of the guideline in specific clinical circumstances.
(Am J Manag Care. 2007;13(part 1):313-315)
Tobacco-use cessation is an important national priority as tobacco-related conditions account for significant mortality. The integration of a tobaccouse cessation automated clinical practice guideline will help to remind physicians to address tobacco-related issues within the context of an office visit.
A previous article described the outcomes of implementing a Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG) at Henry Ford Health System. The current study assessed user satisfaction with and acceptance of that guideline.
Overall, provider and staff acceptance of the TUC ACPG was high. The major barrier cited to the use of the ACPG was lack of time and human resources. It is important to obtain provider input at the start, to provide technology that is user friendly and fits into the workflow of the clinic, and to afford the providers with the autonomy to opt out ofthe guideline.In a previous article,1 the outcomes of the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG) regarding adherence to the 5 As (ask, advise, assess, assist, and arrange) at the Henry Ford Health System were presented. The addition of the TUC ACPG into the electronic medical record led to modest increases in the percentages of individuals who were asked about their tobacco use, who were assessed with regard to their willingness to quit, and who had follow-up care arranged. There were no differences in the percentages of those advised or assisted to quit. This article describes the user acceptance of and satisfaction with the TUC ACPG.
Paneled patients from 6 adult primary care clinics participated; 2 control clinics received no intervention at all (arm 1), 2 clinics received a check-in screen only (arm 2), and 2 clinics received the TUC intervention (arm 3). The check-in screen provided a simplified method for entering patient vital signs into the electronic medical record and served as a second control. The study intervention automated the 5 As of the TUC ACPG via the check-in screen.
Satisfaction data were collected through provider surveys and focus groups 6 months after implementation. Providers indicated on a Likerttype scale how often they carried out each of the 5 As for a typical adult patient and how often a set of factors influenced whether they implemented TUC recommendations. Providers in the intervention arm rated the usefulness of TUC screen features. In the focus groups, questions pertained to the use of the guideline, discussion of other lifestyle behaviors, patient reaction to the guideline, and factors involved in choosing not to follow the guideline.
Data analyses were performed using SAS version 8.2 (SAS Institute, Cary, NC), and χ2 tests were used for categorical analyses. The study was approved by the Henry Ford Health System Human Subjects Committee (institutional review board).
Of 37 providers who participated in the study, 35 were physicians and 2 were physician assistants. One hundred percent of providers in the TUC arm indicated that they asked the typical adult patient if he or she uses tobacco, the highest rate of any of the study arms (P = .05, data not shown). With respect to advise, assess, and assist, the rates of providers who answered “almost alwaysâ€ or “frequentlyâ€ were similar in all arms and varied from 75% to 100%. No provider answered “almost alwaysâ€ for arrange, with most indicating that they arranged “some of the time.â€ Except for the “askâ€ point of the guideline, none of the differences between the groups were statistically significant.
Responses to questions about various roadblocks to TUC guideline implementation are given in the Table. For all study arms, time constraints were cited most frequently as the primary barrier to following the TUC guideline, a response often accompanied by the perception of having insufficient staff. Providers also indicated that the guideline might not be appropriate for some patients (eg, patients with terminal illnesses). The only statistically significant difference between the study arms was for the question about time constraints, with 41.7% of TUC providers indicating that time constraints “extremelyâ€ limited their ability to carry out the guideline.
Providers in the intervention group typically found the key features of the TUC ACPG to be useful in their daily work; they especially liked the 1-click documentation. Few respondents indicated that the features were “not at all usefulâ€ or “somewhat useful.”
In the focus groups, most providers in each study arm stated that they followed the guideline, with only time constraints and a patient's serious or terminal physical condition precluding the use of the ACPG. Additional reasons to forgo guideline adherence included the following: (1) the current visit was unrelated to tobacco use, (2) the provider already advised the patient to quit, (3) the provider forgot, and (4) the provider did not fully understand the guidelines.
Most providers in the TUC arm indicated that they complied with all 5 As of the TUC ACPG. By contrast, providers in the other study arms indicated that they almost always asked, advised, and assessed. Some indicated that they assisted, but few arranged. Providers in the intervention arm found the automated referral to be easy and quick. In contrast to other study arms, providers in the TUC arm indicated that they placed increased emphasis on following the guidelines during patient visits.
Many providers said that they talked with their patients regarding weight gain as a possible outcome to any quit attempt. Providers in the TUC arm indicated that, with the increased discussion of tobacco use through the ACPG, there was less time availableto discuss other lifestyle behaviors.
Lomas et al2 suggest that guidelines for practice may predispose physicians to consider changing their behavior, but unless there are other incentives or there is the removal of disincentives, guidelines are unlikely to effect rapid change in actual practice. Aliberti and Holt3 indicate that providers' willingness to accept or use a new technology is based, in part, on physician “buy inâ€ and physician incentives. They advise physician involvement in the development and implementation phases to gain acceptance and compliance with guidelines. At the Henry Ford Health System, providers and support staff were involved in ACPG development. Therefore, the primary barrier to the use of the guideline at the Henry Ford Health System may lie more in factors such as the time available to spend with each patient and the personal history of the patient.
Automated Clinical Practice Guidelines help to integrate evidence-based recommendations into the smooth work flow of a provider's practice. To attain acceptance and use of these guidelines, providers and staff must believe that they have sufficient time to carry out the guidelines and that they retain decision-making autonomy over when and how to address specific issues. Our study showed a high level of satisfaction with the TUC ACPG. The major barriers to the use of the TUC ACPG were time constraints and the desire of providers to override the guideline in specific patient circumstances.
Overall, provider and staff acceptance of the TUC ACPG was high. The major barriers cited to the use of the ACPG were lack of time and human resources. As ACPGs are incorporated into electronic medical records, it is important to obtain provider input at the start, to provide technology that is user friendlyand fits into the work flow of the clinic, and to afford providers the autonomy to opt out of the guideline in specific clinical circumstances as warranted.
Author Affiliations: From the Henry Ford Health System, Detroit, Mich. Funding Source: This study was supported by grant B70035 from the United States Department of Defense.
Correspondence Author: Susan M. Szpunar, MPH, DrPH, St John Hospital and Medical Center, Department of Education, 19251 Mack Ave, Grosse Pointe Woods, MI 48236. E-mail: firstname.lastname@example.org.
Author Disclosure: The authors (SMS, PDW, DD, RNE, JDC) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter discussed in this manuscript.
Authorship Information: Concept and design (SMS, PDW, DD, RNE, JDC); acquisition of data (SMS, PDW, JDC); analysis and interpretation of data (SMS, JDC); drafting of the manuscript (SMS, PDW, DD, JDC); critical revision of the manuscript for important intellectual content (SMS, PDW, DD, RNE, JDC); statistical analysis (SMS, PDW, JDC); provision of study materials or patients (JDC); and obtaining funding (PDW, JDC); administrative, technical, or logistic support (DD, JDC); supervision (RNE, JDC).1. Szpunar SM, Williams PD, Dagroso D, Enberg RN, Chesney JD. The effect of the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline. Am J Manag Care. 2006;12:665-673.
3. Aliberti E, Holt TJ. Physician attitudes toward computerized practice guidelines. Manag Care Q. 1996;4:70-75.