IMPORTANCE: Nudges have been increasingly studied as a tool for facilitating behavior change and may represent a novel way to modify the electronic health record (EHR) to encourage evidence-based care.
OBJECTIVE: To evaluate the association between EHR nudges and health care outcomes in primary care settings and describe implementation facilitators and barriers.
EVIDENCE REVIEW: On June 9, 2023, an electronic search was performed in PubMed, Embase, PsycINFO, CINAHL, and Web of Science for all articles about clinician-facing EHR nudges. After reviewing titles, abstracts, and full texts, the present review was restricted to articles that used a randomized clinical trial (RCT) design, focused on primary care settings, and evaluated the association between EHR nudges and health care quality and patient outcome measures. Two reviewers abstracted the following elements: country, targeted clinician types, medical conditions studied, length of evaluation period, study design, sample size, intervention conditions, nudge mechanisms, implementation facilitators and barriers encountered, and major findings. The findings were qualitatively reported by type of health care quality and patient outcome and type of primary care condition targeted. The Risk of Bias 2.0 tool was adapted to evaluate the studies based on RCT design (cluster, parallel, crossover). Studies were scored from 0 to 5 points, with higher scores indicating lower risk of bias.
FINDINGS: Fifty-four studies met the inclusion criteria. Overall, most studies (79.6%) were assessed to have a moderate risk of bias. Most or all descriptive (eg, documentation patterns) (30 of 38) or patient-centeredness measures (4 of 4) had positive associations with EHR nudges. As for other measures of health care quality and patient outcomes, few had positive associations between EHR nudges and patient safety (4 of 12), effectiveness (19 of 48), efficiency (0 of 4), patient-reported outcomes (0 of 3), patient adherence (1 of 2), or clinical outcome measures (1 of 7).
CONCLUSIONS AND RELEVANCE: This systematic review found low- and moderate-quality evidence that suggested that EHR nudges were associated with improved descriptive measures (eg, documentation patterns). Meanwhile, it was unclear whether EHR nudges were associated with improvements in other areas of health care quality, such as effectiveness and patient safety outcomes. Future research is needed using longer evaluation periods, a broader range of primary care conditions, and in deimplementation contexts.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
In our EHR world, we call “nudges” best practice alerts. They can help improve immunization rates and some quality metrics like mammograms and colorectal cancer screening. It’s difficult to react to all the nudges and still address specific patient concerns, which can be numerous. Health systems need to grant their primary care physicians grace when the measures don’t move. There are many balls to juggle in primary care.
Physician rater
"Nudges" are suggestions in the EMR that steer clinicians toward behaviors without mandating change. These nudges were studied in a large number of records and found to be somewhat supported by the evidence. Clearly, more data are needed to determine the real value of nudges.
, McMaster University