EHR nudges: Development and testing of a behavioral economics electronic health record module

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Project Summary This study aims to leverage the power of behavioral economics with electronic health record technology to promote appropriate diabetes care for older adults. Despite a variety of efforts, inappropriate care persists. The ABIM Foundation’s Choosing Wisely Campaign identifies focus areas for improvement; one of ten Choosing Wisely initiatives chosen by the American Geriatrics Society promotes less aggressive glycemic targets and limited pharmacologic therapy for older adults with diabetes. Changing provider behavior, however, is challenging, and existing information-based approaches fall short. Novel concepts from behavioral economics, a field that blends insights from economics and psychology to recognize that humans make predictable decision errors, have shown promise in a variety of healthcare settings. Incorporating such approaches within the electronic health record (EHR) will allow seamless integration into clinical workflow with minimal additional cognitive burden, and provide a mechanism for widespread scaling of effective interventions. We propose to develop a behavioral economics-based EHR module to promote appropriate clinical care of older adults with diabetes. Specific aims include: 1) To develop a scalable, EHR customization toolkit that leverages behavioral economic insights (the BE-EHR module) to promote appropriate diabetes care in older adults based on the American Geriatric Society’s Choosing Wisely guideline. We will implement a user-centered design process to incorporate behavioral economic approaches into existing clinical decision support tools and clinical workflows to design, iteratively refine, and usability test the new module. 2) To pilot test the new BE-EHR module’s feasibility and acceptability and generate preliminary estimates of clinician compliance with the Choosing Wisely guideline. We will conduct a 6-month, single-arm pilot study of the BE- EHR module in 4 outpatient primary care and/or geriatrics clinics to measure utilization and feasibility, and to estimate its impact on appropriate care delivery. 3) To test the ability of the BE-EHR module to reduce inappropriate diabetes treatment among older adults. We will conduct an 18-month, rigorous, pragmatic, cluster-randomized, controlled trial in 70 sites within the NYU Langone Medical Center ambulatory network to determine the BE-EHR module’s impact on appropriate diabetes care among older adults. This proposal combines a unique, experienced multi-disciplinary team with a ground-breaking approach to improve the care of older Americans with diabetes.