ask, triage, manage · 2013. 2. 18. · ask, triage, manage page 6 evaluation of atm (ask, triage,...

Ask, Triage, Manage

Evaluation of ATM (Ask, Triage, Manage) December 2009

Evaluation of a project to create and pilot a solution to support effective brief intervention and triaged pathways for smoking cessation in primary care

A collaborative project between Harbour Health and Comprehensive Health Services

with funding from the Ministry of Health

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Acknowledgements and thanks To Professor Paul McDonald, Waterloo University (Canada), for granting his kind permission for Harbour Health to transform his paper based Smoking Cessation Triage Tool into a solution to suit the New Zealand environment To the Harbour Health General Practitioners and Practice Nurses who volunteered to pilot ATM in their practices To the ATM Steering Group for providing the knowledge and support to guide development, analyse the feedback and provide future direction for ATM: Lis Cowling Harbour Health

Brian Millen Waitemata District Health Board Denise Barlow National Heart Foundation Murray Speight Comprehensive Health Services Paul Carver Harbour Health With assistance, support and valuable feedback from:

Dr David Hopcroft Comprehensive Health Services Sue Freeman Harbour Health In addition to the valuable feedback from: Mark Wallace-Bell National Heart Foundation Dr Hayden McRobbie Inspiring Limited And to the Ministry of Health for funding this pilot project Evaluation prepared by: Lis Cowling (Project Lead) Brian Millen Harbour Health Waitemata DHB Telephone: 09 415 1091 Telephone: 09 486 1491 x 7218 [email protected] [email protected] Murray Speight Comprehensive Health Services Telephone: 09 415 1091 [email protected]

42B Tawa Drive, Albany, Auckland 0632 P O Box 302-163, North Harbour Postal Centre, Auckland 0751

Telephone: 09 415 1091 Facsimile: 09 415 1092

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Index

Executive Summary 4 Background 5 ATM Design 6 Evaluation 8

On-line Survey Feedback 15 Final ATM Design 20

ATM National Rollout Enhancements Recommended 21 ATM – Additional Applications 22 ATM – Screen Shots 24 ‘A Brief Set of Assessment Items for Smoking Cessation Treatment Matching and Stepped Care’ Paul McDonald et al, University of Waterloo 27

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Executive Summary ATM is the solution developed to facilitate successful implementation of the ABC approach for primary care by primary care. This simple but comprehensive decision support tool was created to guide and support general practice teams to be more capable, competent and comfortable in supporting those who smoke. ATM was framed on a paper based smoking cessation triage tool, developed by Professor Paul McDonald and his team at Waterloo University (Canada). This project took the Canadian tool, with permission, broke it down, analysed and re-crafted it for the New Zealand environment. Feedback from those who trialled ATM in their general practices was extremely positive with the greatest uptake from those who used ATM with patients at least twice.

• 73.9% said that ATM was helpful or very helpful in bringing up the issue of smoking with their patient

• 83.3% said that ATM was helpful or very helpful in exploring smoking cessation options with their patients

• 70.8% said that ATM was helpful or very helpful in knowing the best service to refer their patient to

Lack of time and reimbursement was raised as a barrier to more using ATM which could be addressed by simply allowing smoking cessation to be incorporated into the CarePlus eligibility criteria. This would complete the package.

Web based and linking with MedTech, ATM provides an integrated, decision support tool designed with both health professional and patient’s needs in mind. With its many functions, ATM provides the means for the Ministry of Health to realise its full investment in the ABC’s of Smoking Cessation within Primary Care. While the principal focus was on developing a tool for primary care, a paper based version was co-developed for use within secondary services where consultations are often carried out at the bedside. Further application of this one page ATM form is almost limitless.

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Background The MoH Tobacco Update (2008)’s cessation focus states “more smokers making more quit attempts using NRT more often”. The ABC approach to smoking cessation was designed to create an environment conducive to achieving this goal. For general practice teams however, the ability to incorporate this into their everyday consult was not easily realised. While the underlying principle behind the ABC approach is not to make everyone specialists, most health professionals will require at least a moderate level of understanding to maintain a professional relationship with their patient. When a health professional prompts a quit attempt, the patient expects that they can advise on the best form of treatment based on their individual need. In saying that, unless health professionals have the confidence, knowledge and understanding required to understand smoking at this level, the issue of smoking cessation is unlikely to be raised in the first place. Introducing a method of triage allows health professionals to provide a ‘custom fit’ service that appreciates how the level of support required for a successful quit attempt can range from self help through to intensive support. The concept of the ATM (Ask, Triage, Manage) Tool is based on the paper based triage tool developed by Professor Paul McDonald and his team at Waterloo University, Canada. Professor McDonald gave written permission for Harbour Health to transform and rebuild this paper based triage tool into a web based IT Support and Decision Tool which can be imbedded into the PMS Systems within Primary Care.

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ATM Design In May 2009, the steering group first met to brainstorm, re-create and translate Waterloo University’s Triage Tool to suit the New Zealand general practice setting. Over many meetings, each constituent component was broken down, analysed and re-crafted to have the best possible chance of eliciting a quick but correct response from patients in our New Zealand general practice environment. The design of ATM mirrors the philosophy underpinning the ABC approach. It was recognised that not every patient who smoked would be willing to accept cessation support. In this respect, ATM generates a random sentence containing brief advice; each highlighting the fact that there are many options available and that quitting smoking does not have to be difficult. This brief advice is verbalised by the health professional, printed and handed to the patient. Each handout is personalised, contains the same brief advice just given and links to on-line resources. For those who are willing to consider the possibility of a quit attempt, the tool uses a number of questions to assess the appropriate level of intervention required. ATM’s seven weighted questions relating to readiness, psycho-social, addiction, environmental and support factors provide a score that ultimately determines the correct level of behavioural and pharmacological support. Referral options are pre-populated from MedTech 32, printed and can then be faxed to the respective service. Additionally, a mouse click takes the recommended pharmacotherapy directly into the prescription pad. Once again, a personal letter is generated outlining what has just occurred during the consult. The letter also contains additional information such as how nicotine affects your system, how to use prescribed medication(s) and which service they have been referred to. In recognition of the fact that people with pre-existing mental health and/or alcohol and other drug conditions often have complicating factors that require specific attention, ATM has the ability to provide best practice advice on how to support these patients. Pharmacotherapy is covered in depth and easily available with ATM. This includes information on the various contraindications, prescribing information and drug interactions which is available easily at hand.

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When the framework of ATM’s structure had been finalised, work commenced on the function, look and flow of this IT solution. Creating web based tools that linked with the practice PMS (Patient Management System – MedTech 32) had already been developed by Comprehensive Health Services in the form of the GASP Asthma decision support tool. The advantage of web-based tools is that there is effectively only one copy of the tool rather than each practice having to ensure they have the latest possible version loaded into their PMS Systems. Web based tools allow changes to be made and immediately available and with a back end data capture system, information can be extracted in real time without visiting individual practices and downloading this locally.

The first version of ATM was available for piloting by the end of September 2009. Volunteers were sourced from those general practitioners (GPs) that had previously attended the ABC Approach training through their respective Peer Review Groups and during which, had expressed interest in piloting ATM in their practice. Twenty-eight General Practitioners and seven Practices Nurses (PNs) from twelve general practices affiliated with Harbour Health were visited in their respective practices and trained in the use of ATM. The seven PNs attended this ATM training upon GP request. This then gave those practices the option for the GP to complete the “B” with the PNs available to spend slightly longer on the “C” or refer to “C with medications” interventions.

These 12 practices were visited over a two week period from the end of September with the pilot period running eight weeks, being October and November 2009. To keep motivation high for those participating in the ATM pilot, newsletters were developed and sent to inform each practice:

• How many times ATM was used on an individual basis (by initials and graphed)

• How many times ATM was used per practice based on percentage of enrolled population

• Age and Gender breakdown • Intervention breakdown • Top ten prescriptions

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For some, the graphed information in these newsletters created friendly rivalry between the practices and the individuals involved. Every two weeks, the information extracted from ATM was analysed and graphed via the Comprehensive Health Services Claims Management System, and fed back via the newsletters.

Evaluation The evaluation questions were set before the commencement of the project pilot and were designed to inform not only the success of the pilot stage but to mould the final version of ATM for wider dissemination: 1. Ease of use and acceptance of the ATM Tool for Primary Care 2. Number of interventions recorded from brief through to referral 3. Number of appropriate referrals to other smoking cessation providers 4. Number of inappropriate referrals to other smoking cessation providers 5. General feedback from the General Practice Teams

A survey-monkey on line survey was developed to provide feedback around the evaluation questions concerning ease of use and acceptance by primary care along with fields to gain general feedback from the general practice teams. In addition to emailing the survey link, each participant received an update ATM newsletter along with a printed copy of the feedback form that could be faxed to Harbour Health and added to the on-line feedback.

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MB (PN), 45MP (PN), 25

DW, 19PH, 13

JA, 11AK, 10RU (PN), 10

ZE, 10CD, 9

LT, 7VF, 7

SF (PN), 6NS, 6DH, 6

AC, 6LP, 4

GW, 5JS, 5

A (PN), 4CW (PN), 3

KW, 2

AA (PN), 2AP, 1

CA, 1JL, 1

MP, 1MW, 1VN, 1

0 10 20 30 40 50

MB (PN)

MP (PN)DW

PHJAAK

RU (PN)ZE

CDLTVF

SF (PN)NS

DHAC

LPGW

JS

A (PN)CW (PN)

KWAA (PN)

APCAJL

MPMW

VN

Use by Individual to 30 Nov 09 (n=221)

Evaluation Questions 1 and 5: “Ease of use and acceptance of the ATM Tool for Primary Care” and,

”General feedback from the General Practice Teams” (Survey-monkey analysis follows the evaluation section) Statistics at a glance: ATM Training and Use: • 28 General Practitioners (GPs) and 7 Practice

Nurses (PNs) volunteered to pilot the ATM Tool in 12 General Practices affiliated with Harbour Health

• 21 GPs and 7 PNs used the ATM once or more • 15 GPs and 7 PNs used the ATM twice or more • Period of pilot: 8 weeks (October 2009 and

November 2009) Feedback Surveys: • 28 GPs and 7 PNs invited to participate • 25 Surveys completed (71% return rate) • Note: Some returned the survey but had not

used ATM in their consults. These surveys were not discounted but were included and formed part of the overall results.

Feedback Summary: 72% responded that ATM was User-friendly

50% reported that ATM mostly fitted into their normal consult time

73.9% said that ATM was helpful or very helpful in bringing up the issue of smoking with their patient

83.3% said that ATM was helpful or very helpful in exploring smoking cessation options with their patients

70.8% said that ATM was helpful or very helpful in knowing the best service to refer their patient on to

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When it came to the usefulness of the functions of ATM: 70.8% stated that the Brief Advice was useful or very useful 83.4% found the Recommendations useful or very useful 83.3% said the Referrals were useful or very useful 91.7% reported that the ability to prescribe was useful or very useful 87.5% said they found the prescribing information and contraindications section helpful

or very helpful 95.9% stated the patient information printouts were useful or very useful 50% said the graph showing the lung cancer death rates was useful or very useful There was a split vote on how an ATM use would appear in the ‘daily record’ in MedTech but 68% said they would like to see it linking to ‘screening’. Improvements suggested and barriers to ATM use have been noted and are outlined in the recommendations sections. Anecdotal comments from GPs:

“The ATM was good for taking the pressure off me being seen as nagging. By telling the patient that he had to fill in the form (and that hopefully I would get paid for it) it took the blame off me for asking. This way the patient seemed more at ease for answering the questions.” “The ATM tool focused the patient more on where they were at with their smoking. During the consultation, they might change their mind about ‘giving it a go’ or they may even phone up the next day to say they would like to try.” “I think it is a fantastic aid to introducing the idea of smoking cessation. It somehow seems to focus the patient's thinking, as they concentrate on the questions and the recommendations derived from their answers. It takes things from a vague discussion to concrete steps. I think patients are impressed by it. I had one patient, an intelligent, busy woman, who had tried Champix etc, and really wasn't interested in rehashing old ground but was re-motivated by the ATM Tool and agreed to start nortriptyline.”

It is acknowledged that the ATM pilot was carried with a relatively small cohort and within a short timeframe. However, the pilot included a mix of practice sizes, practice team configurations, and levels of existing smoking cessation knowledge. ATM did not work best in any one situation but it was observed to work best for those who used it with patients at least twice.

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4

52

80

1

58

3

12

11

0 20 40 60 80 100

Asian Smokefree

Brief Advice only

In-House GP/PN

Pregnancy Smokefree

Quit Book only

Quit Line

Smoke Stop

Smokefree Communities

ATM Intervention as at 30 Nov 09 (n=221)

Evaluation Questions 2, 3 and 4 “Number of interventions recorded from brief through to referral” “Number of appropriate referrals to other smoking cessation providers” “Number of inappropriate referrals to other smoking cessation providers”

Graphs created from the raw data captured during the pilot period, courtesy of the Comprehensive Health Claims Management System:

The above graph displays ATM’s use during the pilot phase. ATM was opened, used and saved into the practice PMS MedTech 32, 221 times. This graph depicts similar results to those experienced during the Waterloo University study. By creating a triaged referral pathway dependent upon the needs of the patient, intensive services which may have been the previous intervention of choice by memory recall, were not inundated. To the contrary, with the information and decision support a few click buttons away, it shows that the vast majority of interventions were kept within the practice setting. Those trialling ATM, mixed and matched interventions such as shown by breaking down the “Quit Book Only” (below) where 52% of the time medication was also scripted. Even in “Brief Advice”, medication was again scripted 23% of the time.

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1111111111

22

33

1028

0 5 10 15 20 25 30

7mg Patch4mg Gum2mg Gum

1mg Lozenge21mg Patch + 2mg Lozenge21mg Patch + 1mg Lozenge

14mg Patch + 2mg Gum7mg Patch + 2mg Lozenge

VareniclineNortiptyline14mg Patch

21mg Patch + 2mg Gum21 mg Patch

Bupropion21mg Patch + 4mg Gum

Just the Quit Book

ATM - Breakdown of Quit Book only Section (n=58)

40

5

3

2

1

1

0 10 20 30 40 50

Just Brief Advice

21mg Patch + 4mg Gum

21mg Patch

Varenicline

21mg Patch + 1mg Lozenge

2mg Gum

ATM - Breakdown of Brief Advice Section (n=52)

Appropriateness or inappropriateness of referrals could only be ascertained by looking at those referrals received by Harbour Health’s Smokefree Communities smoking cessation programmes. All of these referrals were appropriate and in addition, our Coordinator reported that on at least two occasions, those referred arrived for appointments proudly displaying the patient information letter generated from ATM. Adding to the acceptability of ATM was the ‘pick and mix’ variety of interventions and referral options which not only work with ethnic, cultural and priority populations but also suit lifestyle options, such as Smokestop, for those who preferred additional support via interactive internet.

Ask, Triage, Manage


5819

128

654432

0 10 20 30 40 50 60

NRT Patch 21 mg NRT Gum 4 mgNRT Patch 21 mg

NRT Patch 21 mg NRT Lozenge 2 mgVarenicline Tab 1 mg

Nortriptyline Tab 25 mgNRT Patch 21 mg NRT Gum 4 mg Bupropion …

NRT Patch 14 mgNRT Patch 21 mg NRT Lozenge 1 mg

Bupropion Tab 150 mgNRT Gum 2 mg

ATM - Top Ten Prescription Variations to 30 Nov 09 (n=121)

Prescribing ATM links with MedTech 32 scripting allowing NRT, Bupropion, Varenicline and Nortriptyline to be prescribed in the correct quantities, with a simple mouse click. Prescribing information and contraindications are also available to be accessed this way. During the pilot, the top ten prescription variation show that NRT co-therapy was the medication of choice, scripted 62% of the time. This is in line with the NRT recommendations outlined in ATM.

Ask, Triage, Manage


191

12

1

12

5

0 50 100 150 200 250

European

Maori

Pacific-I

Asian

Other

ATM Assessments by Ethnicity to 30 Nov 09 (n=221)

215

77

102

25

0

20

40

60

80

100

120

06..17 18..24 25..44 45..64 65+

ATM Age Breakdown to 30 Nov 09 (n=221)

Female, 129

Male, 92

ATM Gender to 30 Nov 09 (n=221)

3

1634

80

63

25

ATM Utilisation by Quintile to 30 Nov 09 (n=221)

5

4

3

2

1

Not stated

26

97 98

0

20

40

60

80

100

120

2009-9 2009-10 2009-11

ATM Use by Month to 30 Nov 09 (n=221)

Graphed Demographics

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How user-friendly was the ATM Tool?

Answer Options Response Percent

Response Count

Very 72.0% 18 Reasonably 16.0% 4 A little 8.0% 2 Not at all 4.0% 1 Comments 7

answered question 25skipped question 0

Comments 1. too much required - too many fields 2. it will take you few times to get used to it 3. I would like to change first question from 'absolutely not' to 'not at this time' - as most people

want to stop but just not ready. 4. I often found I printed the question sheet instead of the patient handout by mistake 5. easy to use, initial quiz quick if in contemplative stage, but a consultation in itself if they were

ready to quit 6. Did not like the fact that I HAD to print something prior to being able to file it 7. Cannot fill in questionnaire since I have not used the tool. There is no time to "fit" this into a hectic

schedule. It needs to be a funded and dedicated consultation. - otherwise no use no matter how user friendly

In general, did using the ATM Tool fit within your normal consultation time? Answer Options Response

Percent Response

Count Always 4.2% 1 Mostly 50.0% 12 Sometimes 29.2% 7 No 16.7% 4 Comments 9

answered question 24skipped question 1

Comments 1. will need to be a lot slicker and more enmeshed to MedTech to be regularly useful 2. Referred by GPs to myself do use Tool as did not usually fit into their consult time 3. not possible to tackle every smoker but good as add on to routine consult 4. Needed extra time5-10mins 5. if I was really busy I would do it faster!! 6. I could imagine that if pushed for time, and those doctors who only allocate 10 mins to a consultation,

would find it rushed. 7. had to use it quickly 8. Didn’t use but had a good look 9. as above

72.0%

16.0%

8.0%

4.0%

Very

Reasonably

A little

Not at all

0.0% 20.0% 40.0% 60.0% 80.0%

How user-friendly was the ATM Tool?

0.042

0.5

0.292

0.167

Always

Mostly

Sometimes

No

0 0.2 0.4 0.6

In general, did using the ATM Tool fit within your normal consultation time?

Survey-monkey On-line Survey Results

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Did the ATM Tool: (please tick one answer per sub question) Answer Options Not at all Not really Helpful Very

helpful Response

Count - help to prompt you to bring up the issue of smoking with your patient? 17.4% (4) 8.7% (2) 39.1% (9) 34.8% (8) 23

- help to explore options with your patient around smoking interventions? 16.7% (4) 0 45.8% (11) 37.5% (9) 24

- help you to know the best service to refer your patient to? 8.3% (2) 20.8% (5) 33.3% (8) 37.5% (9) 24

Comments 4 answered question 24

skipped question 1

Comments 1. We are very fortunate to have a nurse who specialises in smoking, she is the best anyway. 2. never had time to risk using it other than a couple of practice runs 3. I only see patients for smoking cessation 4. Good to have the list of referral services for easy access - otherwise is difficult to remember who

is eligible for what

How useful were the following functions of the ATM Tool? (please tick one answer per sub question) Answer Options Not at all Not really Useful Very

useful Response

Count

- Brief Advice 4.2% (1) 25% (6) 37.5% (9) 33.3% (8) 24 - Recommendations 4.2% (1) 12.5% (3) 41.7% (10) 41.7% (10) 24 - Referrals 8.3% (2) 8.3% (2) 58.3% (14) 25% (6) 24 - Prescribing 4.2% (1) 4.2% (1) 37.5% (9) 54.2% (13) 24 - Prescribing information and contraindications 4.2% (1) 8.3% (2) 29.2% (7) 58.3% (14) 24

- Patient Information Printouts 4.2% (1) 0 54.2% (13) 41.7% (10) 24 - Graph - Lung cancer death rates 25% (6) 25% (6) 41.7% (10) 8.3% (2) 24 Comments 7

answered question 24 skipped question 1

Comments 1. The graph doesn’t open fully, need to scroll to show patient. Could be a bit more animated eg

like latest Heart Foundation graphs showing CVD risk. 2. The brief advice may not reflect what the practitioner wants to say and a bit time consuming

scrolling down (could this be made easier?) Referral forms are great but would be fantastic if medical classifications and long term drugs could populate too. Patient information printouts could have more info on using NRT - eg. to advised about use of NRT at night. The graph is good - but dont think there is time in a consultation to talk about this too.

3. Need more than 1 box for referrals as often referred Quit book/Smokestop & In House Counselling combined.

4. I found it a little clumsy re referrals 5. i didn't know there was the lung cancer death rate 6. Have not used the graph 7. did not use lung cancer graph but small numbers to date

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After using the ATM Tool, how would you like it to appear in the Daily Record in MedTech:

Answer Options Response Percent

Response Count

As a Summary e.g. time to first cigarette in morning; number smoked; how likely to stop; past addictions/mental illness; etc

50.0% 12

As a Heading e.g. ATM - Brief Advice only; ATM - Referral GP/PN Inhouse

50.0% 12

Comments 2


Comments

1. plus referral option GP/In house etc and prescription 2. keep it minimal

Would it be useful for the ATM Tool to link to 'Screening' in Medtech?

Answer Options Response Percent Response Count

Yes 68.0% 17 No 8.0% 2 Not sure 24.0% 6 Comments 4


Comments

1. Screening gets overpopulated. This is not a screening item. 2. needs self & re-population - eg smoking status to get into

Classifications 3. diff if get info / suggestion overload 4. Always useful to be in screening for Audit purposes

0.50.5

After using the ATM Tool, how would you like it to appear in the Daily Record in MedTech:

0.68

0.08

0.24

Yes

No

Not sure

0 0.2 0.4 0.6 0.8

Would it be useful for the ATM Tool to link to 'Screening' in Medtech?

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How would you improve the ATM Tool?

Answer Options Response Count

15 answered question 15

skipped question 10 Comments

1. When prescribing NRT it would be good to have automatic prescription for lozenges or gum as well as patches to remind doctors that oral product adds to success rate.

2. unsure as it is pretty good 3. Shorter. Different tool at end to see options available to offer 4. Seems to jump to prescription without meaning to. 5. Seems to be bigger than my screen, so I have to scroll down to answer the last question.

Probably my fault for not setting things up right. 6. Not sure 7. no suggestions 8. Need to have box for patients who tick want to quit BUT are NOT ready to have Rx or referrals

today 9. Maybe could be briefer 10. Link to screening 11. it is an excellent , brief tool to use we just need more training and more people using it 12. I would like to be able to personalise the patient handout , I like it having the patient name on it

but I would like to add more to it, e.g. name of care plus nurse 13. Get funding for a dedicated smoke-quitting consult. 14. fewer clicks to access the form ?not sure that the doc. is saved if pt. not yet ready to give up. 15. A comments field that saves into daily records for gerneral comments action and goals

What barriers did you find when using the ATM Tool? What would help you to use the ATM Tool more often?



skipped question 7

Comments

1. Would be good to link in with the other forms on the PMS - like CVD risk assessment / GASP etc. Would also be great to have an icon on Medtech to find the form faster. Also if there would be a prompt to use tool when client with smoker classification attends appointment. More training for those GPs who are not natural computer users

2. time, time and recognition/payment 3. time -within the consultations as they were coming about other things all except once when I

got a patient back 4. Time usually doing during consultation for another problem

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5. Time in a consultations when busy and running late 6. Time and no compensation for that time 7. Time 8. sometimes the time, don't have enough time to go through all the questions especially with

patients coming with long list of complaints 9. some patients quite defensive, did add time to consults 10. none very easy 11. None - patients mostly very willing& pleased to know that extra attention/support was being

paid to them. 12. never enough time in consultation 13. Needs to be brief - takes too long for normal 15 min consult when they have come in for other

reasons 14. I find it is a consultation in itself and very difficult to put in around patients often multiple needs in

one consultation 15. Having a 'dedicated' consult time, funded by the DHB, would seriously increase utilisation of this

tool. As it stands at present, I have used it as an add-on to whatever reason the patient has come in for. "While we're here/Just before you go, let me show you this new thing we've got that looks at how to stop smoking...."

16. Have an icon on top screen 17. Give me more time! 18. as above

Any final comments?



skipped question 8

Comments 1. Very good. Will start using 2. useful in raising topic - i suggested i was doing it for someone else and patients less threatened -

would complete even though no interest at first then would as for suggested Rx. 2 patients went away then rang day or two later for Rx so good at instituting change in thinking or behaviour

3. Thank you for the opportunity to do drug interventions with pub increased results 4. sorry! 5. Overall very useful. 6. no 7. is overall very useful 8. I think its great having this available 9. I think it is a fantastic aid to introducing the idea of smoking cessation. It somehow seems to

focus the patient's thinking, as they concentrate on the questions and the recommendations derived from their answers. It takes things from a vague discussion to concrete steps. I think patients are impressed by it. I had one patient, an intelligent, busy woman, who had tried Champix etc, and really wasn't interested in rehashing old ground but was re-motivated by the ATM Tool and agreed to start nortriptyline.

10. I enjoy using the atm tool 11. great useful tool thanks

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12. Great tool - keep it up/ Would be great to have funding for this as not all patients can be under Care Plus scheme.

13. great good work, loved the feedback 14. generally a helpful addition 15. Fantastic tool which covers all the assessment and reports needed. 16. Disappointed couldn’t use the tool as much as wanted but was on holiday most of the time. 17. Definitely a good tool if refined

Final ATM Design

Following the feedback from those who used ATM , the following changes will be implemented to create the final design for use with MedTech 32:

1. The type of use - “SBA” (Smoking Brief Advice) or “SCS” (Smoking Cessation Support) – will be saved to Screening (can be extracted for PPP payments)

2. On closing, a one line summary of use will be noted in the Clinical Records.

3. Recommendations will be more accurate to reflect the intervention around “Quit Book” with the addition of “Quit Book/No NRT” and “Quit Book/NRT”.

4. After answering “yes” to the mental health and addiction question, the following appears in a box rather than below the question. This box is then able to be closed.

Nicotine withdrawal often leads to increased anxiety, stress, tension and depressed mood. Anyone with a history of mental unwellness or drug/alcohol dependence will therefore benefit from additional support/monitoring during the quit process. Smoking and drug interactions Tobacco smoke includes Hydrocarbons (tars) that cause induction of some liver enzymes (CYP1A2) and can alter the metabolism of a number of medications. Medications metabolized by these enzymes are broken down faster and can result in reduced concentration in the blood. Any reduction in smoking can cause the enzyme activity to slow leading to increased levels of these medications in the blood. Monitoring and dosage reduction may therefore be required

CLOSE BOX

5. Brief Advice - button will “show all” advices so that the person using can select which advice they wish to verbalise, print and give to patient.

6. Under the Moderate - GP In House Recommendation Option, to add: Additional support via Smokestop www or The Quit Group www

This will allow secondary support via web, text or telephone.

7. Change the wording – take off “before” in: Have you previously used (NRT and Service) before?

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Additionally, it is intended that ATM may be opened and used many times for Brief Advice.

However, if a full intervention is completed and a referral and medications are noted, ATM will open the next time with the questions blanked out on the left hand side. The right hand side, containing the recommendations and referral options, will be available for further medications to be scripted and referral options to be revisited if necessary.

When ATM opens under these circumstances, a “re-assess” pop up button will be displayed and can be clicked should ATM be opened for a new quit attempt. If this button is clicked, ATM will revert back to its original format with the questions unanswered. This function would also be prompted if no action has been noted for one year.

ATM – National Rollout Below are a set of actions required for a national rollout of the ATM Tool. ATM Enhancements The following enhancements are required to the ATM Tool for national rollout (the existing hosting infrastructure would be sufficient for a national rollout):

• Services directory: build a services directory of the Smoking Cessation services available in each Region/PHO. This directory will be very simple comprising type of service (e.g. Face-Face, Telephone Support), Name, Telephone and Fax, DHB/PHO or national service.

• Enhance the ATM Tool to be aware of the providers Region/PHO and only prompt for services available in the area.

• Develop a single on-line smoking referral form. This form like the existing referral forms

will self populate patient details, but in addition it will use the services directory to populate Name/Phone/Fax of the service. This can then be printed and faxed to the appropriate service.

• Lodge the details of the intervention with a central message store. Patient

identification will only be at the NHI/Date-of-birth level only.

• Minor enhancements are required to ensure the ATM tool is compatible with MyPractice.NET (Compatibility currently exists with MedTech32 only)

• It is desirable to have full end to end electronic referrals. This functionality could be enabled when the service has the capability to lodge referrals on-line. (Currently only Smokestop has this capability). The national rollout can occur prior to this being added.

Ask, Triage, Manage


Central Message Store The outcomes of each intervention will be lodged securely in a central message store. Each PHO and/or DHB will be given a login. From there the intervention details can be downloaded for analysis. Deployment (PMS Linkage) A license to integrate with the MedTech32 system will be required; the Ministry may wish to purchase this at the national level, alternatively this could be done at the PHO level. Most PHO’s already have a license. (NOTE: The MyPractice.NET PMS system does not require any special licensing) For ease of deployment a one click install will be made available. This install will ask the user for their PHO (or DHB if they do not belong to a PHO) and then embed the appropriate links in the PMS to the ATM web-based tool.

ATM – Additional Applications Unlike primary care settings, where the majority of consultations are conducted in close proximity to a computer, secondary care interactions are primarily conducted at the bedside. This limits the practical ability to implement an electronic triage system. In recognition of this, it was decided to develop a paper based system capable of eliciting the same information. It was important to keep this to a single page that collects patient information, follows the ATM triage and recommendation pathways and then becomes the referral form to the identified best option for the patient. Currently many DHB Smokefree Teams act as a central triage system for secondary patients. Under this system, all referrals are faxed to the Smokefree Team who then contact the patients and refer on accordingly.

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However, this is unlikely to represent a long term solution and the paper-based ATM represents a method for introducing a sustainable triage and referral mechanism into secondary care. The rationale behind the ABC approach is to empower all health professionals to be able to provide advice and support to patients who smoke. The paper based ATM form is a significant step forward in this direction for those who work within secondary services. While this was developed for Waitemata DHB, it is anticipated that it could be used in all settings either where electronic access is not readily available or to compliment the web based ATM version. In that respect, the paper based ATM was designed in a way that it could be completed either by the health professional or by the patient. In doing so, the paper based ATM can be used even by health professionals who normally may not have sufficient time to discuss smoking at this level. It is normally difficult to introduce a new form into secondary care practice however given that the form replaces six different referral procedures for community cessation support providers, the paper based ATM has been well received in its initial trial at North Shore and Waitakere Hospitals in Waitemata at the time of writing. The paper based ATM trial is expected to conclude at the end of January 2010 with a view to implementing it into the hospital system by March 2010 if feedback remains positive. The Quit Group After a presentation to The Quit Group, they are now looking at how they could adapt ATM’s framework for their service to reduce the time their advisor’s spend asking questions on their initial calls.

Ask, Triage, Manage


ATM Screen Shots

Ask, Triage, Manage


Ask, Triage, Manage


42B Tawa Drive, Albany, Auckland 0632 P O Box 302-163, North Harbour Postal Centre, Auckland 0751

New Zealand

Telephone: 09 415 1091 Facsimile: 09 415 1092

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