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