Review Finds EHR Nudge Interventions Drive Care Quality Improvements

Non-interruptive EHR nudge interventions, such as changing choice default options, can help drive care quality improvement, according to a study published in JAMIA.

Interruptive clinical decision support (CDS) interventions can be helpful to EHR users, but they are also primarily linked to clinician burden and alert fatigue.

On the other hand, EHR nudge interventions are non-interruptive changes to the choice architecture that aim to encourage behavior change.

Researchers searched Medline, Embase, and PsychInfo in January 2022 for studies on the effects of non-interruptive EHR nudge interventions in hospital EHRs to improve care.

The review evaluated five categories of nudge interventions: changing choice defaults; making information more visible; changing the range or composition of options; making information more or less salient; and changing option-related effort.

Overall, 79.2 percent of EHR nudge interventions were successful in achieving improvements in care quality. 

Changing choice default options was the most frequently applied nudge in EHRs and improved care delivery in all reviewed studies. These interventions influenced medication or fluid use, laboratory testing, and appropriate care.

The review authors noted that other EHR nudge interventions, while less frequently adopted, should also be considered in CDS design.

All nudges that changed defaults reported a positive effect over the study period, while other interventions reported mixed outcomes over time.

For example, the effects of changing choice effort returned to baseline over one study's period while they were maintained in another. This finding underscores the need for long-term research on the effectiveness of EHR nudges.

Not all interventions were successful in improving care outcomes, the authors noted. Some studies reported that they modified their intervention over the study period to facilitate better CDS integration into clinician workflows.

Additionally, one study reversed an intervention once the researchers deemed that the nudge had shifted test ordering to a likely inappropriate magnitude.

"These issues highlight the need for system designers to consider the complexity of the sociotechnical system within which they are implementing CDS and the need for robust evaluation of the effects of any changes," the review authors wrote.

They noted that while further evidence is needed on EHR nudges, EHR managers and designers can use nudge interventions to inform CDS design while considering the local context.

"EHR vendors could examine ways to support the application of nudges in their systems, for example by including guidance about the design of order sentences and order sets, and use of defaults as potential elements in CDS design," the authors added. "Ideally, modifications to CDS should be monitored and evaluated to determine whether they are having the desired effect."