Sharing a Hybrid Electronic Health Record + Fast Healthcare Interoperability Resources Clinical Decision Support across Health Systems: Automating Smoking Cessation for Pediatric Caregivers

Abstract

Objective

Experiences sharing complex workflow-integrated clinical decision support (CDS) across health systems are sparse and not well reported. This case study presents the sharing of a hybrid electronic health record (EHR)-native and SMART-compatible CDS tool for automating provision of smoking cessation treatment for caregivers during pediatric visits.

Methods

We conducted a comprehensive needs assessment using sociotechnical frameworks to identify workflow gaps and technical requirements. A multidisciplinary team of clinical informaticians, software developers, and EHR analysts guided the technology transfer. Iterative testing and feedback informed modifications. The evaluation tracked questionnaire uptake, tobacco use identification rates, and treatment acceptance metrics.

Results

The needs assessment revealed critical artifacts such as data architecture, source code repositories, and regulatory requirements, which informed adaptations for the recipient health system. In the preimplementation phase, JXPORT was identified for transferring EHR-native components and the EHR's Active Guidelines Framework was needed to extend the Fast Healthcare Interoperability Resources standard with ordering, posting flowsheet values, and launching activities in the embedded web application. The implementation process resulted in key modifications including same-day nicotine replacement therapy delivery through internal pharmacy services and optimized questionnaire design to improve usability. At the source system, 5.8% (n = 3,391) of caregivers reported active tobacco use with 46.9% (n = 1,590) accepting cessation resources. At the recipient system, 24.3% (n = 167) of caregivers listed tobacco use and 28.1% (n = 47) accepted treatment.

Conclusion

The cross-system sharing of eCEASE serves as a nascent model for disseminating complex CDS tools and highlighted opportunities for improvement. Future work should focus on creating validated dissemination frameworks and improving use of standards for EHR integration.

Keywords

EHR-native - FHIR - clinical decision support - smoking cessation - pediatric visits - dissemination - interoperability - technology transfer

Note

Data presented in screenshots are fake and intended only for presentation of the workflow.

Authors' Contributions

S.N.S. conceptualized the study, performed software development, performed formal analysis, performed investigation, performed project management, and wrote the original draft of the manuscript. E.K. and N.R. conceptualized the study, performed software development, performed formal analysis, performed investigation, curated data, performed project management, performed visualization, and critically reviewed the manuscript. E.N.B. and D.J.K. performed validation and critically reviewed the manuscript. J.G.T. performed software development, performed formal analysis, curate data, and critically reviewed the manuscript. J.P.W., A.G.F., and B.P.J. provided oversight and leadership, performed project administration, and critically reviewed the manuscript. R.W.G. conceptualized the study, performed investigation, provided oversight and leadership, performed project management, and critically reviewed the manuscript.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by the CHOP Institutional Review Board.

Publikationsverlauf

Eingereicht: 02. September 2024

Angenommen: 07. Februar 2025

Accepted Manuscript online:
11. Februar 2025

Artikel online veröffentlicht:
11. Juni 2025

• References

• 1 CDC. Smoking and Tobacco Use. 2024. Trends and Disparities in Secondhand Smoke. Accessed July 12, 2024 at: https://www.cdc.gov/tobacco/secondhand-smoke/disparities.html
• 2 Tsai J, Homa DM, Neff LJ. et al. Trends in secondhand smoke exposure, 2011-2018: impact and implications of expanding serum cotinine range. Am J Prev Med 2021; 61 (03) e109-e117
• 3 National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2014. (Reports of the Surgeon General). Accessed at: http://www.ncbi.nlm.nih.gov/books/NBK179276/
• 4 Hall N, Hipple B, Friebely J, Ossip DJ, Winickoff JP. Addressing family smoking in child health care settings. J Clin Outcomes Manag 2009; 16 (08) 367-373
• 5 Office on Smoking and Health (US). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2006. (Publications and Reports of the Surgeon General). Accessed July 12, 2024 at : http://www.ncbi.nlm.nih.gov/books/NBK44324/
• 6 Mackay D, Haw S, Ayres JG, Fischbacher C, Pell JP. Smoke-free legislation and hospitalizations for childhood asthma. N Engl J Med 2010; 363 (12) 1139-1145
• 7 den Exter Blokland EAW, Engels RCME, Hale III WW, Meeus W, Willemsen MC. Lifetime parental smoking history and cessation and early adolescent smoking behavior. Prev Med 2004; 38 (03) 359-368
• 8 Farkas AJ, Distefan JM, Choi WS, Gilpin EA, Pierce JP. Does parental smoking cessation discourage adolescent smoking?. Prev Med 1999; 28 (03) 213-218
• 9 Bricker JB, Leroux BG, Peterson Jr AV. et al. Nine-year prospective relationship between parental smoking cessation and children's daily smoking. Addiction 2003; 98 (05) 585-593
• 10 Bricker JB, Leroux BG, Robyn Andersen M, Rajan KB, Peterson Jr AV. Parental smoking cessation and children's smoking: mediation by antismoking actions. Nicotine Tob Res 2005; 7 (04) 501-509
• 11 Bricker JB, Peterson Jr AV, Sarason IG, Andersen MR, Rajan KB. Changes in the influence of parents' and close friends' smoking on adolescent smoking transitions. Addict Behav 2007; 32 (04) 740-757
• 12 Winickoff JP, Healey EA, Regan S. et al. Using the postpartum hospital stay to address mothers' and fathers' smoking: the NEWS study. Pediatrics 2010; 125 (03) 518-525
• 13 Nabi-Burza E, Drehmer JE, Hipple Walters B. et al. Treating parents for tobacco use in the pediatric setting: the clinical effort against secondhand smoke exposure cluster randomized clinical trial. JAMA Pediatr 2019; 173 (10) 931-939
• 14 Jenssen BP, Walley SC, Boykan R, Little Caldwell A, Camenga D. Section on Nicotine and Tobacco Prevention and Treatment, Committee on Substance Use and Prevention. Protecting children and adolescents from tobacco and nicotine. Pediatrics 2023; 151 (05) e2023061804
• 15 Drake LA, Suresh K, Chrastil H, Lewis CL, Altman RL. Improving tobacco cessation rates using inline clinical decision support. Appl Clin Inform 2022; 13 (05) 1116-1122
• 16 Hood-Medland EA, Stewart SL, Nguyen H. et al. Health system implementation of a tobacco quitline eReferral. Appl Clin Inform 2019; 10 (04) 735-742
• 17 Jenssen BP, Kelleher S, Karavite DJ. et al. A clinical decision support system for motivational messaging and tobacco cessation treatment for parents: pilot evaluation of use and acceptance. Appl Clin Inform 2023; 14 (03) 439-447
• 18 Jenssen BP, Karavite DJ, Kelleher S. et al. Electronic health record-embedded, behavioral science-informed system for smoking cessation for the parents of pediatric patients. Appl Clin Inform 2022; 13 (02) 504-515
• 19 Holden RJ, Carayon P, Gurses AP. et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics 2013; 56 (11) 1669-1686
• 20 Carayon P, Wooldridge A, Hoonakker P, Hundt AS, Kelly MM. SEIPS 3.0: human-centered design of the patient journey for patient safety. Appl Ergon 2020; 84: 103033
• 21 Thayer JG, Miller JM, Fiks AG, Tague L, Grundmeier RW. Assessing the safety of custom web-based clinical decision support systems in electronic health records: a case study. Appl Clin Inform 2019; 10 (02) 237-246
• 22 Rule 4729:1-3-07 - Ohio Administrative Code. Ohio Laws [Internet]. Accessed July 12, 2024 at: https://codes.ohio.gov/ohio-administrative-code/rule-4729:1-3-07
• 23 Shiffman S, Dresler CM, Hajek P, Gilburt SJA, Targett DA, Strahs KR. Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med 2002; 162 (11) 1267-1276
• 24 Tham E, Swietlik M, Deakyne S. et al; Pediatric Emergency Care Applied Research Network (PECARN). Clinical decision support for a multicenter trial of pediatric head trauma: development, implementation, and lessons learned. Appl Clin Inform 2016; 7 (02) 534-542
• 25 Orenstein EW, Yun K, Warden C. et al. Development and dissemination of clinical decision support across institutions: standardization and sharing of refugee health screening modules. J Am Med Inform Assoc 2019; 26 (12) 1515-1524
• 26 Michel JJ, Flores EJ, Dutcher L, Mull NK, Tsou AY. Translating an evidence-based clinical pathway into shareable CDS: developing a systematic process using publicly available tools. J Am Med Inform Assoc 2021; 28 (01) 52-61
• 27 Talbot JA, Williamson ME, Pearson K, Lenardson J. Advancing Tobacco Prevention and Control in Rural America. National Network of Public Health Institutes; 2019.
• 28 United States Public Health Service Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services; 2020. (Publications and Reports of the Surgeon General). Accessed December 8, 2024 at: http://www.ncbi.nlm.nih.gov/books/NBK555591/