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. 2023 Feb 16;30(3):545-550.
doi: 10.1093/jamia/ocac238.

Behavioral "nudges" in the electronic health record to reduce waste and misuse: 3 interventions

Carrie K Grouse  1 , Maggie W Waung  1 , A Jay Holmgren  2 , John Mongan  3   4 , Aaron Neinstein  5   6 , S Andrew Josephson  1 , Raman R Khanna  7
Affiliations

Behavioral "nudges" in the electronic health record to reduce waste and misuse: 3 interventions

Carrie K Grouse et al. J Am Med Inform Assoc. .

Abstract

Electronic health records (EHRs) offer decision support in the form of alerts, which are often though not always interruptive. These alerts, though sometimes effective, can come at the cost of high cognitive burden and workflow disruption. Less well studied is the design of the EHR itself-the ordering provider's "choice architecture"-which "nudges" users toward alternatives, sometimes unintentionally toward waste and misuse, but ideally intentionally toward better practice. We studied 3 different workflows at our institution where the existing choice architecture was potentially nudging providers toward erroneous decisions, waste, and misuse in the form of inappropriate laboratory work, incorrectly specified computerized tomographic imaging, and excessive benzodiazepine dosing for imaging-related sedation. We changed the architecture to nudge providers toward better practice and found that the 3 nudges were successful to varying degrees in reducing erroneous decision-making and mitigating waste and misuse.

Keywords: choice architecture; computerized tomography; decision support; nudge; overuse; waste.

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Figures

Figure 1.
Figure 1.
Ordering of total phenytoin as a percentage of total orders for phenytoin (total phenytoin and free phenytoin) over time in months. The dashed vertical line is the month at which the modified phenytoin order panel was implemented.
Figure 2.
Figure 2.
Ordering of computerized tomographic (CT) abdomen and pelvis as a percentage of total orders for CT scans of the abdomen (CT scans abdomen and pelvis and CT scans of abdomen only) over time in months, in the non-emergency department areas (A) and the emergency department (B). The dashed vertical line in A and B are at 0 and 4 months because the renamed order was introduced in each area at those respective times.
Figure 3.
Figure 3.
Ordering of 2 or fewer lorazepam tablets for imaging sedation as a percentage of total Benzodiazepine orders for sedation over time in months. The dashed vertical line represents the time at which the new order with a reduced number of lorazepam tablets was implemented.
See this image and copyright information in PMC

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