Nudge Units to Improve the Delivery of Health Care

Mitesh S. Patel et al in The New England Journal of Medicine: “The final common pathway for the application of nearly every advance in medicine is human behavior. No matter how effective a drug, how protective a vaccine, or how targeted a therapy may be, a clinician usually has to prescribe it, and a patient accept and use it as directed, for it to improve health. Clinicians’ and patients’ environments influence their decisions about taking these actions, and the seemingly subtle design of information and choices can have outsize effects on our behavior. When the “choice architecture” is designed to influence behavior in a predictable way but without restricting choice, it is often called a “nudge.”…

In 2016, we launched the Penn Medicine Nudge Unit to systematically develop and test approaches using nudges to improve health care delivery. The goals are to improve health care value and outcomes, advance knowledge about how to best implement nudges for impact, evaluate our efforts, and disseminate our findings. Ideas are generated by health system leadership, frontline clinicians and staff, and members of the unit itself. Our early successes and failures reveal some lessons about the role that nudge units can play in improving health care (see table).

First, these units can help health systems understand when it makes sense to use a nudge and when it doesn’t. Nudges can be designed to remind, guide, or motivate behavior. Promising opportunities are those in which suboptimal care can be addressed by targeting a specific decision that drives a less-than-optimal behavior. For example, when prescribing medications, physicians must decide between brand-name and generic formulations. Systems can set generics as the default choice, so that ordering them becomes the path of least resistance even as the ability to opt out and order a brand-name drug is preserved. When we implemented this change in our EHR, prescribing rates for generics increased from 75% to 98%. Clinical settings also play an important role. We found that reducing the default duration of opioid prescriptions may make sense for acute conditions often seen by clinicians in the emergency department but may be inappropriate for clinicians caring for patients with chronic pain.

Second, although nudges have typically been deployed for simple one-off decisions, we’ve found that they can also support more complex decision paths. For example, only 15% of our eligible patients were being referred for cardiac rehabilitation after myocardial infarction. When we asked the cardiologists why, we discovered that the process remained manual, so they had to take action to initiate the referrals — in other words, it was an opt-in system. The process was redesigned as an opt-out system in which referral for rehab was the default; patient identification was automated using the EHR; staff were notified using secure text messaging; and processes were restructured so that cardiologists signed orders in a template for referral on rounds and staff met with patients to set up rehab placement before discharge. The referral rate increased to more than 80%.

Third, stakeholder alignment is critical to nudges’ success. ….

Fourth, nudges can lead to unintended behavior that’s invisible without proper evaluation….(More)”.