# Combining International Standards to Develop Clinical Decision Support for Parent Smoking Cessation in Pediatrics

## TL;DR

This paper describes a system to help parents quit smoking in pediatric settings using international health standards, significantly improving access to treatment.

## Contribution

A scalable clinical decision support platform for parent smoking cessation using FHIR, SMART on FHIR, and CDS Hooks standards.

## Key findings

- The system identified 7847 smoking parents and connected 2954 to treatment services in one year.
- Using international standards enabled interoperability but required nonstandard enhancements and lacked community partner integration.
- CDS systems using these standards are feasible but face limitations in workflow support and third-party communication.

## Abstract

Smoking is associated with severe health consequences. Secondhand smoke exposure among children increases the risk of sudden infant death syndrome, chronic respiratory diseases such as asthma, and lung cancer in adulthood. For many parents, pediatricians are the primary source of interaction with the health care system. Nevertheless, in pediatric settings, appropriate tobacco treatments are rarely, if ever, provided to parents who smoke. To best address tobacco use among parents, it is ideal to develop scalable solutions that are coordinated across health systems, community partners, and national services within pediatric settings. We describe our experience in developing and implementing a parent tobacco treatment platform within a pediatric institution that leverages multiple international standards to support interoperability, with the overarching goal of providing a model for how such work can be approached. The clinical decision support (CDS) system includes clinician- and patient-facing components, connects parents to 3 different treatment options (nicotine replacement therapy, text-based counseling, and telephonic counseling), and incorporates 3 international standards (Fast Healthcare Interoperability Resources [FHIR], SMART on FHIR, and CDS Hooks). FHIR is used across all components. SMART on FHIR is limited to the clinician-facing tool, and CDS Hooks is used in the patient-facing portion. While health care interoperability standards supported a significant portion of the overall system, nonstandard technologies and enhancements of existing standards were also required. Furthermore, no connections with community partners could use existing interoperability standards. Over one year, the CDS was used in 194,946 visits, identified 7847 parents who smoked, and connected 2954 parents to 6320 distinct treatment services, a significant improvement compared to prior efforts. Our project demonstrates that building CDS systems using international standards, such as SMART on FHIR, FHIR, and CDS Hooks, is possible, but challenges remain. Limits in the CDS Hooks standard to support common workflows and a lack of communication standards used by third parties outside the health care system represent areas for future work. To support these requirements, additional electronic health record–specific records and communication mechanisms are required.