A Computerized Aid to Support Smoking Cessation Treatment
for Hospital Patients
Kate E. Koplan, MD, MPH1,3,4,5, Susan Regan, PhD1,2, Robert C. Goldszer, MD, MBA1,4,
Louise I. Schneider, MD1,3, and Nancy A. Rigotti, MD1,2,3
1Harvard Medical School, Boston, MA, USA;2Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, MA, USA;
3Tobacco Treatment Task Force, Partners HealthCare, Inc., Boston, MA, USA;4Department of Internal Medicine, Brigham and Women's
Hospital, Boston, MA, USA;5Present address: Harvard Vanguard Medical Associates, Boston, MA, USA.
BACKGROUND: Hospital-based interventions promote
smoking cessation after discharge. Strategies to deliver
these interventions are needed, especially now that
providingsmokingcessation advice or treatment, orboth,
to inpatient smokers is a publicly reported quality-of-care
measure for US hospitals.
OBJECTIVE: To assess the effect of adding a tobacco
order set to an existing computerized order-entry system
used to admit Medicine patients to 1 hospital.
DESIGN: Pre-post study.
MEASUREMENTS AND MAIN RESULTS: Proportion of
admitted patients who had smoking status identified, a
smoking counselor consulted, or nicotine replacement
change. In 4 months after implementation, the order set
was used with 76% of Medicine admissions, and a known
intervention increased the proportion of admitted patients
had NRT ordered (1.6 to 2.5%) (p<.0001 for both). Con-
comitantly, the hospital’s performance on the smoking
cessation quality measure improved.
CONCLUSIONS: Adding a brief tobacco order set to an
existing computerized order-entry system increased a
hospital’s provision of evidence-based tobacco treat-
ment and helped to improve its performance on a
publicly reported quality measure. It provides a model
for US hospitals seeking to improve their quality of care
KEY WORDS: hospital medicine; medical informatics; physician
behavior; smoking cessation; quality improvement.
J Gen Intern Med 23(8):1214–7
© Society of General Internal Medicine 2008
Smoking is the leading preventable cause of death in the
United States.1Smoking cessation decreases smoking-
attributable morbidity and mortality, even when cessation
occurs after the onset of a smoking-related disease.2,3A
hospitalization provides a smoker with an opportunity to stop
smoking. Initiating a smoking intervention in the hospital
increases a smoker’s odds of stopping smoking after discharge
by 65%.4,5Since 2004, hospital quality-of-care standards set
by the Joint Commission (JCAHO) and Medicare (CMS) have
included a tobacco measure.6It assesses the proportion of
smokers who received smoking advice, counseling, or medica-
tion during a hospitalization for acute myocardial infarction
(AMI), congestive heart failure (CHF), or pneumonia. This
measure is reported quarterly on a public website7and is
included in pay-for-performance reimbursement programs.
To meet this quality standard, hospitals must document that
smoking cessation advice or assistance was consistently provid-
ed to every smoker admitted with a qualifying diagnosis. The
simple documentation of patients’ smoking status is associated
with higher hospital quality rankings on the JCAHO/CMS
measure.8Smokingstatusis usually recorded inhospital charts,
but rarely in a way that can beextracted systematically toensure
that a patient’s smoking is addressed before discharge. This
Computerized order-entry systems are becoming more widely
adopted by US hospitals to improve hospital quality and safety.
These systems typically include templated order sets and
on an initiative to improve the delivery of evidence-based tobacco
treatment to hospitalized smokers by building into 1 hospital’s
computerized order-entry system a new tobacco-related order
template that prompted clinicians to identify every admitted
patient’s smoking status and facilitated the ordering of smoking
cessation counseling and medications.
Using a pre-post study design, we tested the impact of adding a
tobacco order template to an existing computerized clinician
order-entry template used to admit patients to Brigham and
Women’s Hospital (BWH) in Boston, MA. The study was
approved by the hospital’s Institutional Review Board.
Received November 6, 2007
Revised February 6, 2008
Accepted March 3, 2008
Published online May 9, 2008
Standardized admission order templates are used to admit
patients to the Medical Service. Templates are available but not
required for admissions to other services. We added a tobacco
order set to 4 admission templates: basic admission orders,
AMI, CHF, and pneumonia. (Fig. 1) The smoking order set
required the admitting clinician to identify and record the
patient’s smoking status (as smoker, nonsmoker, or unknown
status) to complete the patient’s admission. The “unknown
Figure 1. The tobacco order template added to the clinician order entry system.
Koplan et al.: A Computerized Aid to Support Smoking Cessation Treatment
status” option was intended for use when illness or other
circumstance precluded smoking status identification at ad-
mission. For smokers, the system automatically generated an
order requesting a referral to the hospital’s smoking counselor
and provided a check-box for ordering nicotine replacement
therapy (NRT) or bupropion, along with simple decision
support to ensure correct dosing. Completing the new template
required approximately 8 seconds. Previously, ordering a
smoking cessation consultation and cessation medication
required about 90 seconds and accessing multiple screens.
The hospital information system did not previously capture
patient smoking status, prompt smoking counselor consulta-
tions or orders for NRT or bupropion, or provide decision
support for medication dosage.
The template was implemented on February 6, 2006. In the
preceding month, Internal Medicine house staff received a brief
educational program consisting of a one-hour lecture, 2
emails, and a pocket card in which the rationale for the change
and details of the new template were explained.
We compared outcomes between 4-month periods before
and after the template was implemented. We focused on the
Medical Service where admission templates were routinely
used but also report results for other hospital services to
detect spill-over effects. The primary outcomes were NRT
orders and smoking counselor consultations. NRT orders were
obtained from hospital pharmacy records. Smoking counselor
consults were obtained from the electronic database kept by
hospital smoking counselors. The rate of smoking status
identification and the smoking prevalence of patients admitted
could be assessed only in the postintervention period because
previously these data were not electronically collected. Hospi-
tal databases provided information on the number and
characteristics of admissions during the study period and on
JCAHO/CMS smoking measures scores.
Data analysis was performed using Stata statistical soft-
ware.10The unit of analysis was hospital admission. We
present rates of template use, smoking status identification,
and NRT and consult orders. To compare rates over time, the
denominator was all admissions rather than all admitted
smokers because patient smoking status preintervention was
not known. We assumed that the smoking prevalence of
hospital admissions was stable over the short study period.
We used binomial tests to compare the rates of template use
and smoking status identification by hospital service and to
assess change in the rates of NRT and consult orders before
and after the intervention.
Brigham and Women’s Hospital had 17,024 admissions (5,414
to Medicine, 11,610 to other services) during 4 months before
template implementation and 17,530 admissions (5,627 to
Medicine, 11,903 to other services) during 4 months after
implementation. Median postimplementation length-of-stay
was 4 days.
The tobacco order template was used for 7,278 (41.5%) of
the 17,530 admissions in the postimplementation period.
Template use was higher on the Medical Service (n=4,290 of
5,627, 76.2%) than on other services (2,988 of 11,903, 25.1%).
Smoking status was recorded as known (i.e., smoker or
nonsmoker) for 5,281 (72.6%) of the 7,278 admissions in
which the template was used and as unknown for 1,997
(27.4%). A higher proportion of Medical Service admissions
had a known smoking status compared with other services
(80.7% vs 64.2%, p<.001). The prevalence of current smoking
among the 5,281 admissions with known smoking status was
12% on both the Medical Service and all other services.
The frequency of NRT orders and smoking counselor
referrals increased after template implementation. (Fig. 2) The
proportion of all admitted patients with NRT ordered rose from
1.6% preimplementation to 2.5% postimplementation
(p<.0001). The proportion with a smoking consult rose from
0.8% to 2.1% (p<.0001). Increases in both modalities were
greater on the Medical Service than on other services. Post-
implementation, a smoking consult was ordered for 95% of the
633 known smokers, and NRT was ordered for 38% of them.
Consultation was not ordered for all smokers because clin-
icians could opt out of a referral. Because smoking status on
the template cannot be updated after admission, NRT was also
ordered for 3.1% of the 6,645 patients not classified as
smokers by template. This rate of NRT ordering is higher than
existed for all admissions before template implementation (p
<.0001). If these patients are considered smokers, the smoking
prevalence of hospital admissions increases to 15.3%.
The hospital’s quarterly score on the JCAHO/CMS compos-
ite smoking measure that summarized all 3 measured diagno-
ses (AMI, CHF, and pneumonia) increased from 86%
preimplementation (fourth quarter 2005) to 95% postimple-
mentation (second quarter 2006) and remained at the higher
level subsequently. This performance moved BWH’s tobacco
score on the smoking measure from below the 50th percentile
to approaching the 90th percentile. Similar improvements
were seen for each of the 3 specific diagnoses measured.
Adding a short tobacco order set to a hospital’s existing
computerized clinician order-entry system dramatically in-
creased the provision of evidence-based tobacco treatment to
Figure 2. Orders for nicotine replacement therapy and smoking
counseling consultations, 4 months before and after implementa-
tion of the tobacco template.
Koplan et al.: A Computerized Aid to Support Smoking Cessation Treatment
inpatients and was followed by improvement in the hospital’s Download full-text
scores on publicly reported quality-of-care standards. We show
that physicians could easily record patient smoking status
when a routine electronic system was implemented. With
automated ordering of smoking consultations and decision-
supported NRT ordering, the proportion of patients receiving
these treatments increased substantially. The positive effect
was strongest on the Medical Service, the target of the
intervention, but spill-over to other services occurred. The rate
of NRT orders increased even for those not classified as
smokers at admission, indicating that the template may have
raised awareness of the importance of this therapy.
Although adult smoking prevalence in Massachusetts is
18%,11only 12% of patients were identified as smokers at
admission. An additional 3% received NRT during their stay,
indicating that smoking status is sometimes ascertained only
after admission. Allowing the template to be accessible after
admission would likely further improve smoker identification.
This study has limitations. First, because of limited fund-
ing, we measured processes of care rather than smoking
cessation outcomes. Fortunately, the evidence base linking
the processes measured to smoking cessation outcomes is
strong.5Second, assessment of cessation medications exclud-
ed bupropion because we could not determine whether
bupropion was ordered for depression or smoking. However,
bupropion is not widely used to treat inpatient smokers. Third,
our intervention occurred simultaneously with an education
campaign encouraging nurses to document smoking and
consult the smoking counselor. This could have confounded
the increase in smoking counselor referrals and the improve-
ment in JCAHO tobacco scores. However, confounding of NRT
ordering would have been limited because nurses do not order
medications. Our finding that improvement in NRT and
smoking consult ordering was greater on the Medical Service
where the template was targeted than on other services that
also received the nursing education program argues that the
observed increase is primarily attributable to the template.
Finally, identifying and treating inpatient smokers need not be
done by physicians. Hospital systems could off-load some tasks
to other health care team members including admissions and
In summary, adding a tobacco order set to a hospital’s
computerized order-entry system improved the care of inpa-
tient smokers and provides a model for US hospitals seeking to
meet the JCAHO/CMS quality standard.
Acknowledgment: There were no additional contributors to this
manuscript. Sources of funding consist of the following: Brigham
and Women’s Hospital, Department of Medicine, Medical Residency
Office; NIH/NHLBI (Mid-Career Award in Patient-oriented Research
to Dr. Rigotti - #K24 HL04440); and Partners HealthCare, Inc.
Conflict of Interest Statement: Kate Koplan, Susan Regan, and
Louise Schneider have no conflicts of interest. Robert Goldszer
has served as a consultant with Leader Health. Nancy Rigotti
has served as a consultant with Pfizer and Sanofi-Aventis
and has received grants from Pfizer, Sanofi-Aventis, and Nabi
Corresponding Author: Kate E. Koplan, MD, MPH; 275 Grove St.,
Suite 3-300, Auburndale, MA 02466, USA (e-mail:kkoplan@
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