Systems Change Interventions to Support Clinicians
Rural communities are conducting systems change interventions to support tobacco cessation.
changes in a hospital, clinic, or healthcare practice refer to the organization's goals, administrative
processes, workflow, technology, staff development, and training. Systems change interventions can support
clinicians in screening patients about tobacco use and providing options for evidence-based treatments.
This model may involve implementing tobacco
use screening, promoting the capacity of clinicians to treat tobacco dependence, and designating staff
in hospitals or clinics to coordinate and assess the delivery of tobacco dependence treatment. Systems
interventions to support clinicians are recommended by the Public Health Service in the Clinical Practice Guidelines for Treating
Tobacco Use and Dependence.
The Centers for Disease Control and Prevention (CDC) Best
Practices for Comprehensive Tobacco Control Programs recommends that states implement health systems
changes to reduce tobacco use. The guidelines describe major components
that health systems may choose to address:
Delivery System Design. Health systems can change the healthcare delivery system
to ensure that care is structured in a way that integrates tobacco use screening and cessation
treatment. This can involve identifying members of the care team who will conduct screening and
counseling, redesigning and implementing a clinical workflow that supports tobacco interventions, and
providing feedback to clinicians about their performance and other metrics associated with tobacco
screening and cessation. The
SAMHSA-HRSA Center for Integrated Health Solutions offers resources for better integration of
behavioral health services within a primary care provider setting.
Clinical Information Systems and Electronic Health Records. Health systems can
develop functionalities in their clinical information systems and electronic health records (EHR)
that facilitate tobacco screening and cessation interventions. This can involve adding a reminder to
the EHR that prompts the provider to screen for tobacco at each visit. Health systems may also choose
to use EHRs to compile data and track metrics associated with tobacco use among their patients. There
are several measures related to tobacco that have been endorsed by the
National Quality Forum (NQF), the organization that
advises the government and other payers on measures that should be used in payment and accountability
programs. NQF-endorsed measures include adult current smoking prevalence; children who are exposed to
secondhand smoke inside the home; and medical assistance with smoking and tobacco use cessation, among
Decision Support Systems. These systems are designed to increase the use of
evidence-based guidelines. Implementing decision support systems may involve training staff on
evidence-based tobacco screening and treatment guidelines and tailoring EHR systems to facilitate the
delivery of evidence-based interventions.
Examples of Systems Change Interventions to Support Clinicians
The Upper Peninsula Health Care Network
(UPHCN) is providing quality improvement activities for primary care provider offices and
rural health clinics through the Lean for Clinical
Redesign Clinical Process Initiative. This involves working with office staff to help map their
workflows and incorporate tobacco cessation metrics into their EHR. Through increased screening of
tobacco use for improved follow-up of quit attempts, UPHCN is aiming to increase access to tobacco
cessation counseling and reduce tobacco use among patients.
Altura Centers for Health implemented a
quality improvement intervention to better identify tobacco users and promote cessation attempts. Altura
providers are prompted to ask each patient about tobacco use by the EHR and linked electronic disease
registry system. Providers then direct tobacco users to cessation services, such as the California Smoker's
Helpline (1-800-No-Butts) and clinic-provided counseling services and
Considerations for Implementation
Widespread systems change is a challenging endeavor. It require significant investments of funding, effort, and
time. In particular, rural communities may need to secure additional resources to implement or adapt EHR
systems. The Rural Health Information Hub's Health
Information Technology in Rural Healthcare topic guide provides additional information about funding
opportunities for rural providers. Additionally, Rural
Health Information Technology Workforce Curriculum Resources are available on RHIhub's website.
Systems changes are often instituted and supported at the health-system level. Rural clinics and
providers will need to coordinate with health system leadership on systems change initiatives.
Additionally, gaining the support and buy-in of clinic leadership and staff is critical to
successfully implementing systems changes. Clinics implementing systems change will likely need to
identify a lead or champion. This can be especially difficult in rural clinics with limited
resources, or in clinics where providers practice intermittently. Clinic managers may need to
redesign workflow to ensure that key members can lead tobacco screening and treatment activities.
Program Clearinghouse Examples
Resources to Learn More
Chapter 6: Department Of Veterans Affairs
This extensive report discusses changes the Veterans Affairs health system has implemented to attempt
to reduce tobacco use among veterans.
Organization(s): Institute of Medicine (US) Committee on Smoking Cessation in Military and
Veteran Populations, Department Of Veterans Affairs Tobacco-Control Activities
Facilitators of Health Systems Change for Tobacco Dependence Treatment: A Qualitative Study of
This research article describes interviews with representatives of health systems, funders, and
technical assistance providers that discuss facilitators to success for tobacco dependence programs.
Author(s): Jansen, A., Capesius, T., Lachter, R., Greenseid, L., & Keller, P.
Journal: BMC Health Services Research
Guide to Working with Health-Care Systems on Tobacco-Use Treatment
This guide describes ways in which healthcare facilities have successfully implemented tobacco
control programs, and gives examples of ways in which business owners, public health agencies, and
healthcare facilities have collaborated to initiate programs.
Organization(s): Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and
Treating Tobacco Use and Dependence: 2008
This report is an update to the 2000 Clinical Practice Guideline was published that describes new and
effective clinical treatments for tobacco.
Organization(s): Tobacco Use and Dependence Guideline Panel, U.S. Department of Health and
Health Systems Change to Increase Tobacco Cessation: What Can State Tobacco Control Programs Do?
Frequently Asked Questions (FAQ)
This document describes how states can address health systems changes to promote tobacco cessation.
Organization(s): Centers for Disease Control and Prevention