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Nudging 

decision making

Choice architecture, or the way in which information is framed, is part of everyday medical decision making. Simple changes such as defaults and framing can be effective tools to improve patient care without increasing burden on clinicians.

Key learnings from our research and consulting projects

Active choice

Active choice is the act of prompting a decision now, rather than delaying that decision to the future. Active choice can be used to prompt a clinician to engage in a behavior (e.g. prompt a patient to receive a flu vaccine) or a patient (e.g. complete advanced directives).

INCREASE VACCINATION RATES
We used an active choice intervention in the electronic health record to increase influenza vaccination rates by 9.5 percentage points. Across the entire health system, this led to 5000 more patients being vaccinated.
 
COMBINATIONS CAN WORK BETTER
In a randomized trial of primary care physicians, we used a combination of active choice and peer comparison feedback on clinician performance to triple the prescribing of statin medications for patients that were at high-risk of cardiovascular events. This led to health system wide adoption of these types of nudges for statin prescribing.
 
SELECTED PUBLICATIONS 

Variations in Influenza Vaccination by Clinic Appointment Time and an Active Choice Intervention in the Electronic Health Record to Increase Influenza Vaccination.

Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin Prescribing.

Defaults

In a clinical environment with an electronic health record, defaults automatically exist. Sometimes defaults can be alphabetical, other times numeric. However, not much thought is put into the design of choices. Setting defaults will require more access to systems.

 
REDUCE WASTE
Defaults are a strong tool to initiate and sustain behavior change amongst clinicians, especially when attempting to decrease low-value care.In a randomized trial of radiation oncologists, we used nudges in the electronic health record to reduce the rate of unnecessary imaging in palliative cancer patients from 68% to 32%. This saved more than 3000 unnecessary imaging tests per year.
 
CONSIDER EXISTING WORKFLOWS
When designing a behavior change strategy, it’s essential to consider existing workflows in order to determine if a default is best path for change. Any process change must be designed with the intention of reducing work.
 
 
SELECTED PUBLICATIONS

Effect of Introducing a Default Order in the Electronic Medical Record on Unnecessary Daily Imaging During Palliative Radiotherapy for Adults With Cancer.

Information Framing

The way in which information is presented can have a considerable impact on what someone does with that information.

TRANSPARENCY IS POWERFUL 
In a prior project, we found interesting results indicating that by presenting the price of frequently ordered inpatient laboratory tests, two opposing outcomes occurred: physicians decreased their ordering of expensive tests while they simultaneously increased their ordering of inexpensive tests. This indicates that although price transparency is an effective nudging tool, it may need to be combined with other behavioral approaches to maximize its potential.
 
OPT-OUTS WORK
We previously conducted a clinical trial which explored the effect of opt-in vs. opt-out framing on enrollment in a COVID-19 testing program. This project found an opt-out framed recruitment strategy significantly increased enrollment into the program when compared to an opt-in strategy.
 
SELECTED PUBLICATIONS 

Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests.

Effect of Opt-In vs Opt-Out Framing on Enrollment in a COVID-19 Surveillance Testing Program.