Open Journal of Obstetrics and Gynecology, 2013, 3, 717-721 OJOG Published Online December 2013 (
Enhanced physician prompts in prenatal electronic
medical records impact documentation on smoking
Lisa D. Levine1#, Ji tsen Chang2, Irwin R. Merkatz3, Peter S. Bernstein3
1Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, University of Pennsylvania Perelman
School of Medicine, Philadelphia, USA
2Department of O bstetrics and Gynecology, Cedar Sinai Medical Cen te r, Los Angeles, USA
3Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, Montefiore Medical Center,
Bronx, USA
Received 20 November 2013; revised 5 December 2013; accepted 12 December 2013
Copyright © 2013 Lisa D. Levine et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-
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Objective: Smoking cessation during pregnancy is a
modifiable intervention that can improve maternal
and neonatal outcomes. Encouraging smoking cessa-
tion is an assessed measure of the Meaningful Use
incentives to ensure best practices with the increased
use of the electronic medical record (EMR). Physician
EMR prompts ha ve been used shown to be successfu l
with preventive care but there is a paucity of data
evaluating prompts within obstetrics. The objective of
this study is to determine the effectiveness of en-
hanced smoking cessation prompts in a prenatal
EMR. Methods: A retrospective cohort study of an
enhanced smoking cessation prompting system within
our prenatal EMR was performed. Pregnant women
who reported tobacco use at first prenatal visit were
included. The number of times a smoking cessation
method was offered and documented, the number of
documented attempts at smoking cessation, and the
final number of cigarettes smoked were compared
pre and post the enhancement of the smoking cessa-
tion prompting system. Results: 95 patients were in-
cluded (48 pre-enhancement; 47 post-enhancement).
Post-enhancement, the documentation of smoking
cessation method offered increased (0 vs. 1, p = 0.03)
and documentation of smoking cessation attempts
increased (1 vs. 2, p = 0.006). There was no change in
the final number of cigarettes smoked (p = 0.9). Con-
clusions: Enhanced prompting systems increase do-
cumentation related to smoking cessation with no
change in number of cigarettes smoked. In the era of
Meaningful Use guidelines which focus on documen-
tation in the EMR, continued research must be done
to assure that software enhancements and improved
documentation truly result in improved patient care.
Keywords: Prenatal EMR; Physician Prompts; Smoking
The increased risk of poor pregnancy outcomes among
women who smoke is well known and the importance of
smoking cessation during pregnancy is a goal empha-
sized by numerous professional and public health or-
ganizations [1-3 ]. In additio n, efforts to encourag e smok-
ing cessation have become a measure to be reported to
the federal government as part of Meaningful Use incen-
tives designed to ensure best practices with the adoption
of electronic medical records (EMR) by health care or-
ganizations [4].
While directed counseling sessions by trained profes-
sionals have been shown to be an effective approach for
achieving smoking cessation among pregnant women,
the data suggest that physicians must also offer effective
tobacco cessation interventions throughout prenatal care
[5,6]. Rigotti and colleagues demonstrated that although
80% of the pregnant women in their study were encour-
aged to quit smoking by their prenatal care provider, only
*Disclosure: None of the authors hav e a conflict of interest;
Sources of funding: This study was supported in part by a career de-
velopment award in Women’s Reproductive Health Research: K12-
#Corresponding autho
L. D. Levine et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 717-721
44% of them were offered a specific smoking cessation
method [7].
In the wake of a changing healthcare system where the
providers have less time with each patient, there may be
an increasing role for reminders and prompts to encour-
age providers to address important issues during office
visits. For example, studies have demonstrated that ap-
propriate physician reminders and prompts result in im-
proved delivery of preventive care in a variety of settings
[8-11]. Most recently, Klatt et al. demonstrated effec-
tiveness of administration of influenza vaccine during
prenatal care with the use of physician prompts [12].
Given the new Meaningful Use reporting standards, it
is important to understand th e potential utilit y of prompt-
ing providers to address smoking cessation through the
use of an EMR. The objective of this study, therefore,
was to determine the effectiveness of an enhanced
smoking cessation prompting system in our prenatal
EMR. We hypothesized that this enhancement would
lead to improved counseling and assistance with quitting
methods, improved documentation of smoking status and
cessation attempts, and increased success at overall
smoking cessation.
A retrospective cohort study was performed with appro-
val from the Montefiore Medical Center Institutional
Review Board. In 2003, a prenatal EMR (AS OBGYN,
AS Software, Inc., Fort Lee, NJ) was implemented. At
the first prenatal visit the EMR guides providers throug h
a comprehensive list of questions to assist in obtaining a
complete risk assessment for each patient. These include
specific questions regarding patient tobacco use. A posi-
tive answer to any question creates an entry on the prob-
lem list for the patient in the EMR. This problem list is
presented to the healthcare provider at each prenatal visit
along with any notes that have been written in relation to
that problem entry at any subsequent visit. In the initial
version in 2003, the tobacco us e q u es tions only pro mpted
the providers to ask how many cigarettes the women
smoked prior to pregnancy and how many they were
currently smoking. The documented responses to these
prompts became a structured text note that was con-
nected to the tobacco use entry on the patient’s problem
In 2006, the format of these questions were enhanced
to further prompt the provider to advise the patient to
quit, to assess the patient’s willingness to quit, and to
offer a referral to the New York State Tobacco Quitline
support program (Tab le 1 ). The structured text of these
questions, along with the responses, also appears in the
problem list entry.
Women who reported tobacco use at first prenatal visit
Table 1. Smoking cessation questions in EMR.
1) Number of cigarettes per day prior to pregn ancy:
2) Number of cigarettes per d ay during pregnancy:
3) Did you advise to quit/remain abstinent?*
4) Does the patient report they’re ready to quit?*
5) Since, last visit, have they tr ied to quit?*
6) Has a referral been made to the Quitline or other method of
cessation offered?*
*New questions implem ented in 2006.
and who continued their care at one of the Montefiore
Medical Center sites that utilized the AS OBGYN soft-
ware were included in the study. The providers at these
sites include attending and resident physicians. Each
woman may be seen for prenatal care by a variety of
practitioners. Women must have initiated prenatal care in
the first or second trimester in order to allow for multiple
opportunities for providers to discuss smoking cessation.
Patients who miscarried or terminated their pregnancies
after their first prenatal visit or who transferred their
prenatal care to a site outside of our institution were ex-
Patients with an estimated delivery date (EDD) in
2005, the year immediately prior to the EMR changes,
were chosen as the unexposed group, and patients with
an EDD in 2007, one year after the enhanced tobacco
prompts were implemented, were chosen as the exposed
group. In all of the patients, tobacco use involved only
cigarette smoking. No other changes to the prenatal risk
assessment were made during this time period. No inter-
val training was given to providers regarding counseling
on smoking cessation or smoking cessation techniques
during this time period. Patients were randomly selected
during these two time periods.
Data collection included: age, parity, race, number of
prenatal visits, number of cigarettes smoked prior to
pregnancy, number smoked at the first prenatal visit,
number of previous attempts at quitting, number of quit-
ting attempts in pregnancy, number of years smoking,
final number of cigarettes reported to have been smoked
in pregnancy, amount of times provider documented
smoking cessation status, whether or not a specific
method for smoking cessation was offered, and smoking
status at post partum visit.
Our primary outcome was the number of times a
smoking cessation method was offered to a patient. Our
secondary outcomes were the number of times the cur-
rent smoking status was documented, the number of
times a provider documented a patient’s attempt at
smoking cessation, the number of cigarettes the patient
cut down to, and the success of smoking cessation at post
partum visit. Data were abstracted by two of the authors
(LDL, JC) who received training with AS OBGYN soft-
ware and had specific guidelines for detecting the out-
Copyright © 2013 SciRes. OPEN ACCESS
L. D. Levine et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 717-721 719
comes. Given that the date of the prenatal visit is listed
next to the problem list text, the abstractors were not able
to be blinded to the exposure.
We assumed 50% of patients had a smoking cessation
method offered and documented prior to the prompt en-
hancement. Using a 2-sided Type 1 error of 5%, and a
power of 80%, we calculated that we needed 45 patients
in each group to detect an increase in documentation to
80% after the prompt enhancement. All data were ana-
lyzed using Stata version 12.0 (College Station, TX). Ca-
tegorical data including demographic information were
compared using chi-square tests. Continuous data were
analyzed utilizing two sample t-test and Mann-Whitney
U test where appropriate. Statistical significance of p <
0.05 was used.
We identified a total of 55 patients that had “tobacco
use” documented at their first prenatal visit and had an
EDD in 2005 and 55 patients with an EDD in 2007. Of
those, 48 patients with an EDD in 2005 and 47 patients
with an EDD in 2007met inclusion criteria (Figure 1).
The average age at first prenatal visit was 27.9 years.
Of the 95 patients that were included in the analyses,
52% had a documented race with 34% Afric an American,
53% Hispanic, and 12% Caucasian. Baseline maternal
demographics between the pre and post enhancement
groups were not significantly different (Table 2).
After the enhanced smoking cessation prompting sys-
tem was introduced, the median number of times a cessa-
tion technique was offered and documented significantly
increased, p = 0.03 (Tab le 3). Additionally, the number
of times a provider documented a patient’s attempt at
smoking cessation during pregnancy significantly in-
creased after the prompt enhancement, p = 0.006. The
median number of times the current smoking status was
documented was not significantly different between the
groups (p = 0.06). The median final number of cigarettes
the patient reported to have cut down to was zero for
both groups with no significant difference between the
groups (p = 0.9), Table 3.
Of the 95 patients that were included in the study, 20
(21%) returned for a postpartum follow-up visit. There
was no difference in the number of women who came for
a postpartum visit between the pre and post enhancement
groups (19% vs. 22%, p = 0.7). Among the 20 women
who returned for a visit, 3 reported smoking at the post-
partum visit, 4 reported continued cessation of smoking,
and 13 had no mention of the smoking status. This was
not significantly different between the two groups (p =
Our study demonstrates a significant increase in the num-
7 patients were excluded:
3: non-viable pregnancies
1: transferred care to us
after 1
prenatal visit
1: transferred care to
another facilit y
2: only one prenatal vi sit
7 patients were excluded:
4: non-viable pregnancies
2: transferred care to us
after 1
prenatal visit
2: transferred care to
another facility
1: only one prenatal visit
48 patients included 47 patients included
55 patients with
tobacco use at 1
and EDD in 2005
55 patients with
tobacco use at 1
and EDD in 2007
Figure 1. Flowchart of patients included in the study. EDD:
Estimated Delivery Date.
Table 2. Maternal demographic information pre and post prom-
pt enhancement.
(n = 48)
(n = 47) p-value
Age, years* 26.9 (±6.7) 29.1 (±6.2) 0.1
Race – n (%)
11 (39)
12 (44)
4 (14)
6 (27)
14 (64)
2 (9)
Parity* 1.1 (± 1.6) 1.3 (± 1.4) 0.4
Gestational age at 1st
PNV (weeks)* 13.4 (± 5.4) 15.6 (± 6.6) 0.2
Total No. of PNV* 8.0 (± 3.8) 9.4 (± 4.4) 0.1
No. of prior
attempts to quit** 1 (1 - 4) 1 (1 - 4) 0.2
No. of cigarettes
prior to pregnancy** 10 (4.5 - 20) 7.5 (3 - 17.5) 0.4
No. of cigarettes at
first PNV** 2 (0 - 3) 2 (0 - 5) 0.7
*Mean (±Standard deviation); **Median (Interquartile range); AA: African
American; PNV: prenatal visit; No: number.
Table 3. Results of smoking cessation pre and post prompt en-
(n = 48)
(n = 4 7) p-value
No. of times cessation
technique was offered 0 (0) 1 (0 - 1) 0.03
No. attempts to quit
during pregnan cy 1 (0 - 3) 2 (0 - 5) 0.006
No. of times the smoking sta-
tus was documented 1 (1 - 2) 1 (1 - 4) 0.06
No. of cigarettes reported
to have cut down to 0 (0 - 3) 0 (0 - 3.5) 0.9
Numbers are presented as medians (Inte rquartile range); No: number.
ber of times a specific smoking cessation method was
offered to patients and an increase in provider documen-
tation of quitting attempts made by pregnant smokers
after the implementation of an enhanced smoking cessa-
Copyright © 2013 SciRes. OPEN ACCESS
L. D. Levine et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 717-721
tion prompting system in our pren atal EMR. While these
results are statistically significant, the clinical impact
remains unclear.
Dexheimer et al. conducted a systematic review of
randomized controlled trials that evaluated the use of
physician prompts in preventive care. They found that
computerized reminder systems were effective in in-
creasing preventive care services most significantly in
the delivery of cardiac care and smoking cessation [11].
This study was not performed in a pregnant population;
however, the findings from their study are consistent
with our results. Klatt et al. described an improvement in
influenza vaccination among pregnant women with the
use of physician prompts [12] which supports its use
during prenatal care.
Our study has several strengths. To our knowledge, it
is the first study to look at the use of physician prompts
in addressing smoking status and smoking cessation
during pregnancy. Pregnancy is a unique opportunity to
capture a patient population that is motivated and may
not otherwise seek medical care. Prompts reminding
physicians to discuss specific methods of quitting allows
for additional discussion of smoking status and in creases
counseling which is an impo rtant prev entiv e care service.
Additionally, our study drew from a large number of pa-
tients who were cared for at a number of diverse prenatal
care sites by a variety of providers within an urban area.
We minimized the effects of various secular trends in
documentation that may have occurred in earlier years by
choosing a time period immediately preceding the
prompt enhancement. We also allowed for acclimatiza-
tion by practitioners to use of the enhanced prompts by
choosing a time period one year after the prompt en-
hancement was completed.
Our study was not without limitations. As a retrosp ec-
tive study, chart abstraction must be relied on to obtain
all data. Therefore, it is difficult to ensure actual changes
in practice and counseling versus changes in documenta-
tion alone that may have occurred after the prompt en-
hancement. For example, in 2005, it is not known
whether or not a quitting method was offered to a patient
but not documented in the chart since there was no EMR
prompt reminding a provider to offer a method and
document accordingly at that time. Additionally, we
cannot exclude the possibility that other factors in the
year between the two samples resulted in changes in
provider documentation habits rather than the new en-
hanced prompts in the prenatal medical record system.
Furthermore, our study was not powered to show a re-
duction in tobacco use by our patients, which could ex-
plain the non-significant difference in this outcome.
Since the median number of cigarettes the patients cut
down to was zero in both groups, this may be a low cig-
arette smoking population, further contributing to the
explanation for not seeing a difference between the two
groups. Therefore, a larger sample size might be needed
to show a more robust difference between the groups.
Lastly, the low postpartum visit rate makes it difficult to
conclude the benefit these prompts have on smoking
cessation after pregnancy.
Despite these limitations, our study is important for me-
dical practice and prenatal care. Achieving smoking ces-
sation during pregnancy is a modifiable interv ention that
can improve the outcome of pregnancy [2,3]. The intent
of the government’s inclusion of smoking cessation do-
cumentation into their Meaningful Use Guidelines is to
encourage providers to focus on this important area of
public health. These Guidelines, which focus on docu-
mentation in the medical record, will be used to assess
the care provided to patients [4]. An assumption exists
that electronic medical records will result in improved
documentation and better quality of care for patients.
What is evident from our study is that these guidelines
may lead to improved docu mentatio n; however, the clini-
cal impact remains unclear. There remains a need for
further investigation into the impact that improved docu-
mentation truly has on clinical care and patient outcomes.
In the era of Meaningful Use Guidelines in which pro-
viders are asked to build certain functionalities into their
EMR, continued research must be done to assure that
improvements we observed in documentation will impact
the rate of smoking cessation in our population.
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