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Table 5 Contextual analysis. Domains adapted from Stange and Glasgow [10].

From: A randomized trial of decision support for tobacco dependence treatment in an inpatient electronic medical record: clinical results

Domain Findings Implications for E-STOPS design and implementation
Relevant theory or participant mental models Push-pull capacity model for guideline implementation [11] Provided conceptual model for study and means of framing E-STOPS for various stakeholders
National, state, local public policy HITECH act encourages adoption of EHRs; tobacco screening, treatment as early publicly reported core measure Important “push” factors that facilitated framing of intervention to hospital leadership
Pertinent community norms, resources Primary care access is modest in local community; care often fragmented between hospital, outpatient providers Use of health IT/EHR designed to facilitate communication between providers
Health care system organization, payment systems, IT, other support systems IT reports to finance; new EHR installed near planned launch of E-STOPS need to address potential return on investment for tobacco treatment, re: pay-for-performance and public reporting of core measures; compliance with CMS, Joint Commission mandates Need to address potential return on investment for tobacco treatment, re: pay-for-performance and public reporting of core measures; compliance with CMS, Joint Commission mandates
Practice culture, staffing Physicians, nurses want to treat tobacco dependence; may have limited skills, knowledge, resources to do so E-STOPS designed to minimize provider workload, provide choice, but make treatment the default choice.
Patient populations, subgroups Many adult smokers admitted to hospital; hospitalization as period of enforced abstinence, “teachable moment” for tobacco E-STOPS limited to inpatient units on medical services, to capitalize on “teachable moment”.
Relevant historical factors, recent events Steady decline in prevalence of smoking, but undertreatment still common in healthcare settings; growth of value-based performance models Used to provide rationale for E-STOPS to physicians, nurses, administrators
Culture, motivations surrounding monitoring, evaluation Physicians want to treat smokers; some concerns about added workload, role of hospital-based personnel in treating tobacco dependence; concerns about performance assessment Physicians assured that feedback was confidential, would not be shared with supervisors.