Sometimes, relatively small changes to the design of the clinical environment or how information is framed are all that’s needed to make big improvements to patient outcomes and transform care delivery. There’s an emerging field of study on these changes—which are known as nudges—that already has produced a host of best practice recommendations.

Ethics in Health Care

Explore the AMA Journal of Ethics for articles, podcasts and polls that focus on ethical issues that affect physicans, physicians-in-training and their patients.

An article published in the AMA Journal of Ethics® (@JournalofEthics) describes how to design and implement nudges using a systematic approach. The article—written by Joseph D. Harrison, a clinical psychology doctoral student at Philadelphia College of Osteopathic Medicine, and Mitesh Patel, MD, director of the Penn Medicine Nudge Unit, one of the world’s first behavioral design teams embedded within a health system—also lays out how to do it safely and effectively.

Some nudges focus merely on delivering infrequent messaging that can influence everyday decisions. An example is sending reminders to physicians about how their performance compares with others in their health system on statin prescribing.

Other nudges depend on framing existing information or specifying when, where or how goal-directed behavior will be enacted.

“For example, in a randomized clinical trial of five primary care practices, posting a commitment letter in patient examination rooms for 12 weeks resulted in an absolute decrease in inappropriate antibiotic prescribing of 19.7% relative to the control group, for which no commitment letters were posted,” the authors wrote.

More involved nudges take place at the time of decision-making by enabling active choice or by setting the evidence-based option as the default. These are often more effective than less aggressive nudges, and they may better address suboptimal EHR design.

“Changing defaults is a good approach when clinicians and patients have weakly held preferences for the options and guidelines clearly indicate that the default option is evidence based,” the authors wrote.

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“Nudges are more likely to be successful when they fit well into the workflow of key decision-makers,” says the article. “Moreover, there is often an opportunity to shift work away from busy clinicians and onto other members of the team.”

One study, for example, sought to relieve cardiologists of the burden of identifying patients with low rates of cardiac rehabilitation. The EHR was used to automatically identify eligible patients and to template referral forms, increasing referral rates from 15% to 85%.

“Designing nudges for successful implementation requires careful attention to—and engagement with—relevant stakeholders, including personnel responsible for information systems, frontline clinicians and health system leadership,” the authors wrote.

Dr. Patel noted several strategies that worked in her own research:

  • Identify the project as a quality improvement initiative.
  • Meet with relevant faculty to summarize guidelines and give feedback on their performance.
  • Make the intervention transparent and communicate it to the relevant department.
  • Get feedback from physicians post-intervention to identify ways to improve it.

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EHR changes are all too often “deployed without first experimentally comparing the intervention with a control and evaluating it for longer-term periods or for unintended consequences,” the authors wrote.

Randomized trials are all-important, they added.

“This more rigorous approach could provide faster feedback for transferring changes that work in one setting to other settings throughout the health system, while curtailing changes that may reduce cognitive burden but do not improve patient care,” they wrote.

As a case in point, in one of Dr. Patel’s studies that looked at how to increase primary care doctors’ statin prescribing rates with automated patient dashboards, a single message comparing physicians’ performance to their peers’ significantly increased engagement.

“This rapid experiment allowed us to incorporate these elements in the design of larger interventions throughout the entire primary care network,” the authors wrote.

The September 2020 issue of AMA Journal of Ethics further explores behavioral architecture in health care and features an “Ethics Talk” podcast interview with Dr. Patel about how to identify and avoid the potential ethical pitfalls of guiding behavior.

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