Capturing tobacco status using an automated billing system: steps toward a tobacco registry

In 1999, Group Health Cooperative (GHC), a health system with 575,000 enrollees, launched a quality improvement initiative to systematically record patient tobacco-use status and provider intervention using an automated billing system. Performance feedback and senior-level incentives were added to foster compliance with the automated recording. Prior to this period, tobacco-use status was recorded primarily via a paper-based chart system, with billing-system recording averaging only 7.5% of primary care visits. In 2000, tobacco-use status was recorded using the billing system in an average of 82% of visits (p<0.001). Significant increases (p<0.0001) were also observed for the absolute number of visits in which automated entry of tobacco-use status was documented using the billing system, as well as for visits where intervention was documented. In 1998, tobacco use was documented in 22,086 visits, with intervention documentation in 13,235 of these visits. By 2000, tobacco-use documentation increased to 76,180, with intervention documentation in 45,527. This work demonstrates the feasibility of using automated performance feedback and senior-level incentives to increase provider compliance with a new system of tobacco status identification and intervention. Other potential uses of this system, and potential limitations, are discussed.