Electronic referrals to the tobacco Quitline: implementation strategies in a large health system to optimize delivery of tobacco cessation to patients.

Electronic referrals provide an efficient solution for clinicians to connect patients to free tobacco cessation services, such as the tobacco Quitline. However, strategic planning is necessary for the successful adoption of this method across the health care system. The purpose of this study was to develop an implementation strategy for electronic referrals to the tobacco Quitline in a large health system. A clinical decision support tool created a closed-loop e-referral pathway between the electronic health record system and the Quitline. Multilevel strategies were developed to implement the e-referral process across the entire health system, including leadership buy-in, Epic tip sheets, newsletters, training for practice champions and staff, physician educator, patient-focused advertisements, and video clips distribution by the Maryland Department of Health Center for Tobacco Prevention and Control. The implementation of a system-wide e-referral pathway for tobacco cessation involved continuous clinician education and training, systematic quality control, and engaging "champion" clinicians. Postimplementation data analysis revealed that 1,790 e-referrals were received by the Quitline in 2018-2019, of which 18% accepted follow-up services, 18% declined, and 64% were not reached after multiple attempts. Among 322 patients who accepted Quitline services, 55% requested nicotine replacement therapy. Overall, 282 clinicians referred patients, including 107 primary care physicians and 175 specialists; 62 clinicians e-referred 72% patients, thereby emerging as "tobacco champions." The e-referral process is an efficient method for tobacco users to receive a cessation referral from clinicians. Sustainability can be achieved through leadership buy-in, physician ease of use, patient motivation, information technology supports, and reminders.

The liberty of free riders: the minimum coverage provision, Mill's "harm principle," and American social morality.

A direct requirement for most Americans to purchase any product or service .... certainly is an encroachment on individual liberty, but it is no more so than a command that restaurants or hotels are obliged to serve all customers regardless of race, that gravely ill individuals cannot use a substance their doctors described as the only effective palliative for excruciating pain, or that a farmer cannot grow enough wheat to support his own family. The right to be free from federal regulation is not absolute, and yields to the imperative that Congress be free to forge national solutions to national problems, no matter how local--or seemingly passive--their individual origins.