Background and challenges to implementation:
We know that providers are more willing to refer patients if an automatic referral is imbedded into the Electronic Medical Record (EHR). Extensive education to improve knowledge for healthcare providers to refer tobacco using patients to cessation services will help the patient better understand the services in which they are being referred and could improve overall acceptance rates.

Intervention or response:
The intervention included monthly referral numbers from Quitline data for a 29 month period from January 2015 to May 2017. Our research questions included an increasing trend of number of referral by EHR, and whether EHR is a significant factor for the rate of acceptance by comparing this to paper-based fax referrals to the same service. Two analysis were conducted to answer the research questions: 1) a time series analysis looking at the trend of number of referral by EHR; 2) A MANOVA testing whether EHR is a significant factor for number of referrals and rate of acceptance.

Results and lessons learnt:
The average acceptance rates were 7.0% for EHR referrals and 4.2% for fax referrals. Based on time-series models, there was a seasonally increasing trend of referral by EHR (B=.13, R2=.62). Both the average numbers of Quitline referrals and the rate of acceptance were statistically significantly different between EHR and fax referral (p < .001). Although compared to paper-based referrals, number of Quitline referrals by EHR was lower, the acceptance rates was higher if referred by EHR.

Conclusions and key recommendations:
Integrating an electronic referral for cessation services provides favorable results in provider adherence to referring patients to services and the patients' willingness to accepting services to quit tobacco. The key finding and recommendation is to continue to work in the field of integrating a systematic approach to referring patients to cessation services through the EHR. Patient acceptance of services significantly improved with a systematic approach in place.