Nudging Health Care Providers’ Adoption of Clinical Decision Support: Protocol for the User-Centered Development of a Behavioral Economics–Inspired Electronic Health Record Tool

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Abstract

Background

The improvements in care resulting from clinical decision support (CDS) have been significantly limited by consistently low health care provider adoption. Health care provider attitudes toward CDS, specifically psychological and behavioral barriers, are not typically addressed during any stage of CDS development, although they represent an important barrier to adoption. Emerging evidence has shown the surprising power of using insights from the field of behavioral economics to address psychological and behavioral barriers. Nudges are formal applications of behavioral economics, defined as positive reinforcement and indirect suggestions that have a nonforced effect on decision-making.

Objective

Our goal is to employ a user-centered design process to develop a CDS tool—the pulmonary embolism (PE) risk calculator—for PE risk stratification in the emergency department that incorporates a behavior theory–informed nudge to address identified behavioral barriers to use.

Methods

All study activities took place at a large academic health system in the New York City metropolitan area. Our study used a user-centered and behavior theory–based approach to achieve the following two aims: (1) use mixed methods to identify health care provider barriers to the use of an active CDS tool for PE risk stratification and (2) develop a new CDS tool—the PE risk calculator—that addresses behavioral barriers to health care providers’ adoption of CDS by incorporating nudges into the user interface. These aims were guided by the revised Observational Research Behavioral Information Technology model. A total of 50 clinicians who used the original version of the tool were surveyed with a quantitative instrument that we developed based on a behavior theory framework—the Capability-Opportunity-Motivation-Behavior framework. A semistructured interview guide was developed based on the survey responses. Inductive methods were used to analyze interview session notes and audio recordings from 12 interviews. Revised versions of the tool were developed that incorporated nudges.

Results

Functional prototypes were developed by using Axure PRO (Axure Software Solutions) software and usability tested with end users in an iterative agile process (n=10). The tool was redesigned to address 4 identified major barriers to tool use; we included 2 nudges and a default. The 6-month pilot trial for the tool was launched on October 1, 2021.

Conclusions

Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers, along with conducting traditional usability testing, facilitated the development of a tool with greater potential to transform clinical care. The tool will be tested in a prospective pilot trial.

International Registered Report Identifier (IRRID)

DERR1-10.2196/42653

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Most cited references 46

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The behaviour change wheel: A new method for characterising and designing behaviour change interventions

Susan Michie, Maartje M. van Stralen, Robert H. West (2012)

Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.

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Systematic review: impact of health information technology on quality, efficiency, and costs of medical care.

Basit Chaudhry, Jerome K Wang, Shinyi Wu … (2006)

Experts consider health information technology key to improving efficiency and quality of health care. To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care. The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005. Descriptive and comparative studies and systematic reviews of health information technology. Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs. 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited. Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

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Effect of clinical decision-support systems: a systematic review.

Tiffani J Bright, Anthony Wong, Ravi Dhurjati … (2012)

Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking. To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation. MEDLINE, CINAHL, PsycINFO, and Web of Science through January 2011. Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes. Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality. 148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n= 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n= 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n= 46; OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects. Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded. Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers. Agency for Healthcare Research and Quality.

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Author and article information

Contributors

Safiya Richardson:

ORCID: https://orcid.org/0000-0002-8576-1102

New York University Grossman School of Medicine550 1st AveNew York, NY, 10016United States1 2122638313srichard12@northwell.edu

Journal

Journal ID (nlm-ta): JMIR Res Protoc

Journal ID (iso-abbrev): JMIR Res Protoc

Journal ID (publisher-id): ResProt

Title: JMIR Research Protocols

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Electronic): 1929-0748

Publication date Collection: 2023

Publication date (Electronic): 18 January 2023

Volume: 12

Electronic Location Identifier: e42653

Affiliations

[1 ] New York University Grossman School of Medicine New York, NY United States

[2 ] Feinstein Institutes for Medical Research Northwell Health Manhasset, NY United States

[3 ] Baylor College of Medicine Houston, TX United States

[4 ] CommonSpirit Health Chicago, IL United States

Author notes

Corresponding Author: Safiya Richardson srichard12@ 123456northwell.edu

Author information

Safiya Richardson https://orcid.org/0000-0002-8576-1102

Katherine Dauber-Decker https://orcid.org/0000-0002-0498-8779

Jeffrey Solomon https://orcid.org/0000-0002-1498-2717

Sundas Khan https://orcid.org/0000-0003-1153-6313

Douglas Barnaby https://orcid.org/0000-0002-2135-0224

John Chelico https://orcid.org/0000-0002-9539-2953

Michael Qiu https://orcid.org/0000-0002-3841-7923

Yan Liu https://orcid.org/0000-0003-4838-7702

Devin Mann https://orcid.org/0000-0002-2099-0852

Renee Pekmezaris https://orcid.org/0000-0003-2731-6489

Thomas McGinn https://orcid.org/0000-0003-1005-227X

Michael Diefenbach https://orcid.org/0000-0003-2821-1507

Article

Publisher ID: v12i1e42653

DOI: 10.2196/42653

PMC ID: 9892982

PubMed ID: 36652293

SO-VID: 787674d3-712e-4785-935e-7eda4608b4b6

Copyright © ©Safiya Richardson, Katherine Dauber-Decker, Jeffrey Solomon, Sundas Khan, Douglas Barnaby, John Chelico, Michael Qiu, Yan Liu, Devin Mann, Renee Pekmezaris, Thomas McGinn, Michael Diefenbach. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 18.01.2023.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.

History

Date received : 14 September 2022

Date revision requested : 24 September 2022

Date revision received : 21 October 2022

Date accepted : 25 October 2022

Custom metadata

ext-peer-rev This paper was externally peer reviewed by the NHLBI Mentored Patient-Oriented Research (MPOR) Review Committee - Heart, Lung, and Blood Initial Review Group - National Heart, Lung, and Blood Institute(National Institutes of Health, USA). See the Multimedia Appendix for the peer-review report;

Keywords: health informatics,clinical decision support,electronic health record,implementation science,behavioral economics,user-centered design,pulmonary embolism

Data availability:

Keywords: health informatics, clinical decision support, electronic health record, implementation science, behavioral economics, user-centered design, pulmonary embolism

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