Enhanced physician prompts in prenatal electronic medical records impact documentation on smoking cessation

doi:10.4236/ojog.2013.310132

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Open Journal of Obstetrics and Gynecology, 2013, 3, 717-721 OJOG

http://dx.doi.org/10.4236/ojog.2013.310132 Published Online December 2013 (http://www.scirp.org/journal/ojog/)

Enhanced physician prompts in prenatal electronic

medical records impact documentation on smoking

cessation*

Lisa D. Levine1#, Ji tsen Chang2, Irwin R. Merkatz3, Peter S. Bernstein3

1Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, University of Pennsylvania Perelman

School of Medicine, Philadelphia, USA

2Department of O bstetrics and Gynecology, Cedar Sinai Medical Cen te r, Los Angeles, USA

3Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, Montefiore Medical Center,

Bronx, USA

Email: #[email protected]

Received 20 November 2013; revised 5 December 2013; accepted 12 December 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-

ABSTRACT

Objective: Smoking cessation during pregnancy is a

modifiable intervention that can improve maternal

and neonatal outcomes. Encouraging smoking cessa-

tion is an assessed measure of the Meaningful Use

incentives to ensure best practices with the increased

use of the electronic medical record (EMR). Physician

EMR prompts ha ve been used shown to be successfu l

with preventive care but there is a paucity of data

evaluating prompts within obstetrics. The objective of

this study is to determine the effectiveness of en-

hanced smoking cessation prompts in a prenatal

EMR. Methods: A retrospective cohort study of an

enhanced smoking cessation prompting system within

our prenatal EMR was performed. Pregnant women

who reported tobacco use at first prenatal visit were

included. The number of times a smoking cessation

method was offered and documented, the number of

documented attempts at smoking cessation, and the

final number of cigarettes smoked were compared

pre and post the enhancement of the smoking cessa-

tion prompting system. Results: 95 patients were in-

cluded (48 pre-enhancement; 47 post-enhancement).

Post-enhancement, the documentation of smoking

cessation method offered increased (0 vs. 1, p = 0.03)

and documentation of smoking cessation attempts

increased (1 vs. 2, p = 0.006). There was no change in

the final number of cigarettes smoked (p = 0.9). Con-

clusions: Enhanced prompting systems increase do-

cumentation related to smoking cessation with no

change in number of cigarettes smoked. In the era of

Meaningful Use guidelines which focus on documen-

tation in the EMR, continued research must be done

to assure that software enhancements and improved

documentation truly result in improved patient care.

Keywords: Prenatal EMR; Physician Prompts; Smoking

Cessation

1. INTRODUCTION

The increased risk of poor pregnancy outcomes among

women who smoke is well known and the importance of

smoking cessation during pregnancy is a goal empha-

sized by numerous professional and public health or-

ganizations [1-3 ]. In additio n, efforts to encourag e smok-

ing cessation have become a measure to be reported to

the federal government as part of Meaningful Use incen-

tives designed to ensure best practices with the adoption

of electronic medical records (EMR) by health care or-

ganizations [4].

While directed counseling sessions by trained profes-

sionals have been shown to be an effective approach for

achieving smoking cessation among pregnant women,

the data suggest that physicians must also offer effective

tobacco cessation interventions throughout prenatal care

[5,6]. Rigotti and colleagues demonstrated that although

80% of the pregnant women in their study were encour-

aged to quit smoking by their prenatal care provider, only

*Disclosure: None of the authors hav e a conflict of interest;

Sources of funding: This study was supported in part by a career de-

velopment award in Women’s Reproductive Health Research: K12-

HD001265-14;

#Corresponding autho

OPEN ACCESS

L. D. Levine et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 717-721

718

44% of them were offered a specific smoking cessation

method [7].

In the wake of a changing healthcare system where the

providers have less time with each patient, there may be

an increasing role for reminders and prompts to encour-

age providers to address important issues during office

visits. For example, studies have demonstrated that ap-

propriate physician reminders and prompts result in im-

proved delivery of preventive care in a variety of settings

[8-11]. Most recently, Klatt et al. demonstrated effec-

tiveness of administration of influenza vaccine during

prenatal care with the use of physician prompts [12].

Given the new Meaningful Use reporting standards, it

is important to understand th e potential utilit y of prompt-

ing providers to address smoking cessation through the

use of an EMR. The objective of this study, therefore,

was to determine the effectiveness of an enhanced

smoking cessation prompting system in our prenatal

EMR. We hypothesized that this enhancement would

lead to improved counseling and assistance with quitting

methods, improved documentation of smoking status and

cessation attempts, and increased success at overall

smoking cessation.

2. METHODS

A retrospective cohort study was performed with appro-

val from the Montefiore Medical Center Institutional

Review Board. In 2003, a prenatal EMR (AS OBGYN,

AS Software, Inc., Fort Lee, NJ) was implemented. At

the first prenatal visit the EMR guides providers throug h

a comprehensive list of questions to assist in obtaining a

complete risk assessment for each patient. These include

specific questions regarding patient tobacco use. A posi-

tive answer to any question creates an entry on the prob-

lem list for the patient in the EMR. This problem list is

presented to the healthcare provider at each prenatal visit

along with any notes that have been written in relation to

that problem entry at any subsequent visit. In the initial

version in 2003, the tobacco us e q u es tions only pro mpted

the providers to ask how many cigarettes the women

smoked prior to pregnancy and how many they were

currently smoking. The documented responses to these

prompts became a structured text note that was con-

nected to the tobacco use entry on the patient’s problem

list.

In 2006, the format of these questions were enhanced

to further prompt the provider to advise the patient to

quit, to assess the patient’s willingness to quit, and to

offer a referral to the New York State Tobacco Quitline

support program (Tab le 1 ). The structured text of these

questions, along with the responses, also appears in the

problem list entry.

Women who reported tobacco use at first prenatal visit

Table 1. Smoking cessation questions in EMR.

1) Number of cigarettes per day prior to pregn ancy:

2) Number of cigarettes per d ay during pregnancy:

3) Did you advise to quit/remain abstinent?*

4) Does the patient report they’re ready to quit?*

5) Since, last visit, have they tr ied to quit?*

6) Has a referral been made to the Quitline or other method of

cessation offered?*

*New questions implem ented in 2006.

and who continued their care at one of the Montefiore

Medical Center sites that utilized the AS OBGYN soft-

ware were included in the study. The providers at these

sites include attending and resident physicians. Each

woman may be seen for prenatal care by a variety of

practitioners. Women must have initiated prenatal care in

the first or second trimester in order to allow for multiple

opportunities for providers to discuss smoking cessation.

Patients who miscarried or terminated their pregnancies

after their first prenatal visit or who transferred their

prenatal care to a site outside of our institution were ex-

cluded.

Patients with an estimated delivery date (EDD) in

2005, the year immediately prior to the EMR changes,

were chosen as the unexposed group, and patients with

an EDD in 2007, one year after the enhanced tobacco

prompts were implemented, were chosen as the exposed

group. In all of the patients, tobacco use involved only

cigarette smoking. No other changes to the prenatal risk

assessment were made during this time period. No inter-

val training was given to providers regarding counseling

on smoking cessation or smoking cessation techniques

during this time period. Patients were randomly selected

during these two time periods.

Data collection included: age, parity, race, number of

prenatal visits, number of cigarettes smoked prior to

pregnancy, number smoked at the first prenatal visit,

number of previous attempts at quitting, number of quit-

ting attempts in pregnancy, number of years smoking,

final number of cigarettes reported to have been smoked

in pregnancy, amount of times provider documented

smoking cessation status, whether or not a specific

method for smoking cessation was offered, and smoking

status at post partum visit.

Our primary outcome was the number of times a

smoking cessation method was offered to a patient. Our

secondary outcomes were the number of times the cur-

rent smoking status was documented, the number of

times a provider documented a patient’s attempt at

smoking cessation, the number of cigarettes the patient

cut down to, and the success of smoking cessation at post

partum visit. Data were abstracted by two of the authors

(LDL, JC) who received training with AS OBGYN soft-

ware and had specific guidelines for detecting the out-

L. D. Levine et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 717-721 719

comes. Given that the date of the prenatal visit is listed

next to the problem list text, the abstractors were not able

to be blinded to the exposure.

We assumed 50% of patients had a smoking cessation

method offered and documented prior to the prompt en-

hancement. Using a 2-sided Type 1 error of 5%, and a

power of 80%, we calculated that we needed 45 patients

in each group to detect an increase in documentation to

80% after the prompt enhancement. All data were ana-

lyzed using Stata version 12.0 (College Station, TX). Ca-

tegorical data including demographic information were

compared using chi-square tests. Continuous data were

analyzed utilizing two sample t-test and Mann-Whitney

U test where appropriate. Statistical significance of p <

0.05 was used.

3. RESULTS

We identified a total of 55 patients that had “tobacco

use” documented at their first prenatal visit and had an

EDD in 2005 and 55 patients with an EDD in 2007. Of

those, 48 patients with an EDD in 2005 and 47 patients

with an EDD in 2007met inclusion criteria (Figure 1).

The average age at first prenatal visit was 27.9 years.

Of the 95 patients that were included in the analyses,

52% had a documented race with 34% Afric an American,

53% Hispanic, and 12% Caucasian. Baseline maternal

demographics between the pre and post enhancement

groups were not significantly different (Table 2).

After the enhanced smoking cessation prompting sys-

tem was introduced, the median number of times a cessa-

tion technique was offered and documented significantly

increased, p = 0.03 (Tab le 3). Additionally, the number

of times a provider documented a patient’s attempt at

smoking cessation during pregnancy significantly in-

creased after the prompt enhancement, p = 0.006. The

median number of times the current smoking status was

documented was not significantly different between the

groups (p = 0.06). The median final number of cigarettes

the patient reported to have cut down to was zero for

both groups with no significant difference between the

groups (p = 0.9), Table 3.

Of the 95 patients that were included in the study, 20

(21%) returned for a postpartum follow-up visit. There

was no difference in the number of women who came for

a postpartum visit between the pre and post enhancement

groups (19% vs. 22%, p = 0.7). Among the 20 women

who returned for a visit, 3 reported smoking at the post-

partum visit, 4 reported continued cessation of smoking,

and 13 had no mention of the smoking status. This was

not significantly different between the two groups (p =

0.09).

4. DISCUSSION

Our study demonstrates a significant increase in the num-

7 patients were excluded:

 3: non-viable pregnancies

 1: transferred care to us

after 1

prenatal visit

 1: transferred care to

another facilit y

 2: only one prenatal vi sit

7 patients were excluded:

 4: non-viable pregnancies

 2: transferred care to us

after 1

prenatal visit

 2: transferred care to

another facility

1: only one prenatal visit

48 patients included 47 patients included

55 patients with

tobacco use at 1

visit

and EDD in 2005

55 patients with

tobacco use at 1

visit

and EDD in 2007

Figure 1. Flowchart of patients included in the study. EDD:

Estimated Delivery Date.

Table 2. Maternal demographic information pre and post prom-

pt enhancement.

Pre-prompt

enhancement

(n = 48)

Post-prompt

enhancement

(n = 47) p-value

Age, years* 26.9 (±6.7) 29.1 (±6.2) 0.1

Race – n (%)

Hispanic

White

11 (39)

12 (44)

4 (14)

6 (27)

14 (64)

2 (9)

0.2

Parity* 1.1 (± 1.6) 1.3 (± 1.4) 0.4

Gestational age at 1st

PNV (weeks)* 13.4 (± 5.4) 15.6 (± 6.6) 0.2

Total No. of PNV* 8.0 (± 3.8) 9.4 (± 4.4) 0.1

No. of prior

attempts to quit** 1 (1 - 4) 1 (1 - 4) 0.2

No. of cigarettes

prior to pregnancy** 10 (4.5 - 20) 7.5 (3 - 17.5) 0.4

No. of cigarettes at

first PNV** 2 (0 - 3) 2 (0 - 5) 0.7

*Mean (±Standard deviation); **Median (Interquartile range); AA: African

American; PNV: prenatal visit; No: number.

Table 3. Results of smoking cessation pre and post prompt en-

hancement.

Pre-prompt

enhancement

(n = 48)

Post-prompt

enhancement

(n = 4 7) p-value

No. of times cessation

technique was offered 0 (0) 1 (0 - 1) 0.03

No. attempts to quit

during pregnan cy 1 (0 - 3) 2 (0 - 5) 0.006

No. of times the smoking sta-

tus was documented 1 (1 - 2) 1 (1 - 4) 0.06

No. of cigarettes reported

to have cut down to 0 (0 - 3) 0 (0 - 3.5) 0.9

Numbers are presented as medians (Inte rquartile range); No: number.

ber of times a specific smoking cessation method was

offered to patients and an increase in provider documen-

tation of quitting attempts made by pregnant smokers

after the implementation of an enhanced smoking cessa-

L. D. Levine et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 717-721

720

tion prompting system in our pren atal EMR. While these

results are statistically significant, the clinical impact

remains unclear.

Dexheimer et al. conducted a systematic review of

randomized controlled trials that evaluated the use of

physician prompts in preventive care. They found that

computerized reminder systems were effective in in-

creasing preventive care services most significantly in

the delivery of cardiac care and smoking cessation [11].

This study was not performed in a pregnant population;

however, the findings from their study are consistent

with our results. Klatt et al. described an improvement in

influenza vaccination among pregnant women with the

use of physician prompts [12] which supports its use

during prenatal care.

Our study has several strengths. To our knowledge, it

is the first study to look at the use of physician prompts

in addressing smoking status and smoking cessation

during pregnancy. Pregnancy is a unique opportunity to

capture a patient population that is motivated and may

not otherwise seek medical care. Prompts reminding

physicians to discuss specific methods of quitting allows

for additional discussion of smoking status and in creases

counseling which is an impo rtant prev entiv e care service.

Additionally, our study drew from a large number of pa-

tients who were cared for at a number of diverse prenatal

care sites by a variety of providers within an urban area.

We minimized the effects of various secular trends in

documentation that may have occurred in earlier years by

choosing a time period immediately preceding the

prompt enhancement. We also allowed for acclimatiza-

tion by practitioners to use of the enhanced prompts by

choosing a time period one year after the prompt en-

hancement was completed.

Our study was not without limitations. As a retrosp ec-

tive study, chart abstraction must be relied on to obtain

all data. Therefore, it is difficult to ensure actual changes

in practice and counseling versus changes in documenta-

tion alone that may have occurred after the prompt en-

hancement. For example, in 2005, it is not known

whether or not a quitting method was offered to a patient

but not documented in the chart since there was no EMR

prompt reminding a provider to offer a method and

document accordingly at that time. Additionally, we

cannot exclude the possibility that other factors in the

year between the two samples resulted in changes in

provider documentation habits rather than the new en-

hanced prompts in the prenatal medical record system.

Furthermore, our study was not powered to show a re-

duction in tobacco use by our patients, which could ex-

plain the non-significant difference in this outcome.

Since the median number of cigarettes the patients cut

down to was zero in both groups, this may be a low cig-

arette smoking population, further contributing to the

explanation for not seeing a difference between the two

groups. Therefore, a larger sample size might be needed

to show a more robust difference between the groups.

Lastly, the low postpartum visit rate makes it difficult to

conclude the benefit these prompts have on smoking

cessation after pregnancy.

5. CONCLUSION

Despite these limitations, our study is important for me-

dical practice and prenatal care. Achieving smoking ces-

sation during pregnancy is a modifiable interv ention that

can improve the outcome of pregnancy [2,3]. The intent

of the government’s inclusion of smoking cessation do-

cumentation into their Meaningful Use Guidelines is to

encourage providers to focus on this important area of

public health. These Guidelines, which focus on docu-

mentation in the medical record, will be used to assess

the care provided to patients [4]. An assumption exists

that electronic medical records will result in improved

documentation and better quality of care for patients.

What is evident from our study is that these guidelines

may lead to improved docu mentatio n; however, the clini-

cal impact remains unclear. There remains a need for

further investigation into the impact that improved docu-

mentation truly has on clinical care and patient outcomes.

In the era of Meaningful Use Guidelines in which pro-

viders are asked to build certain functionalities into their

EMR, continued research must be done to assure that

improvements we observed in documentation will impact

the rate of smoking cessation in our population.

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