Table 2

Themes related to decision support and delivery system design

CCM component

Sample Quotes

    Decision support

Chart stamp as an efficient prompt to ask, advise and refer

"Asking on a regular follow up wouldn't really happen if the prompt wasn't there." (Physician)

"It has made me more thorough. I feel like I have much more of a process to remind me." (Physician)

Fax-to-Quit referral form was lengthy and complicated

"That piece of paper [the fax referral form] is still more complicated than my patients can truly understand. You know, third grade level, at the most." (Physician)

"The form should be made simpler because we do have a lot of patients to take care of, and some steps should be eliminated." (Medical Assistant)

Limitations with faxing

"You have to fax it, that's another step. Sometimes the fax machines here don't work. So you have to remember to go back and fax it." (Medical Assistant)

    Delivery system design

Chart stamp integrated into paper flow, MA/physician workflow and responsibilities

"I think the stamp is sustainable because we integrated it very well into the paper flow of the clinic and we also integrated it into the workflow." (Physician)

Chart stamp not integrated into nurse and social worker workflow or responsibilities

"I think for nursing, we don't ask this of the patients. That's why we don't use this. But if we see our patients that smoke, we try to advise the patient even though we are not using the chart stamp." (Nurse)

Fax-to-Quit form not integrated into paper flow or team responsibilities

"It [the chart stamp] was a system change that was integrated. Fax-to-Quit has not become a system change that's integrated. It's become another activity that the physician really still had to take on." (Physician)

"That will probably be the next step if we can actually propel our Medical Assistants and say 'Okay, you can now have a conversation around that too."' (Physician)

Concerns about overburdening staff and staff resistance

"My Medical Assistants should have some time to do the Fax-to-Quit. I know they're busy. I don't ever think they're not doing something. But the front desk is even busier sometimes." (Physician)

Need for further Fax-to-Quit training

"They may have questions and we can't, you know, go through all the questions and really tell them what's going on, because, first of all, most of us are not thoroughly trained ourselves." (Medical Assistant)

Cantrell and Shelley BMC Family Practice 2009 10:81   doi:10.1186/1471-2296-10-81

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