Nudging Towards Safer Decision Making
In recent years, the impact of evidence-based decision-making on patient safety has been under close examination. Despite technological advances, the gap between theory and practice remains a challenge to both clinicians and allied health professionals. Due to the complexity and dynamics of health systems, ‘doing the right thing’ is not always as straightforward as it may seem.
According to the World Health Organization’s (WHO) Patient Safety Action Plan 2021-2030, it is estimated that one in 10 people in high-income countries are harmed while receiving hospital care, and up to 15% of hospital spending is due to safety failures in care.[1],[2] This differs to low-and middle-income countries, where it is estimated that one in four patients are subject to harm.[3]
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An important part of this issue is medication safety. Unsafe medication practices and errors are a leading cause of avoidable harm in healthcare systems across the world.[4] During the COVID-19 pandemic, healthcare professionals (HCPs) were increasingly under-resourced and overburdened, which significantly exacerbated the risk of medication errors and associated medication-related harm. It is in this context that medication safety was selected as the theme for the recent World Patient Safety Day 2022.
There is no doubt that health information technology is an important tool to facilitate the delivery of high-quality care. By digitalizing manual tasks such as prescriptions and introducing technological innovations such as medication alerts and clinical reminders, there is an opportunity to improve patient safety by enhancing evidence-based decision-making.
How Clinical Guidelines and Technology Support Patient Safety
The use of clinical guidelines and evidence-based guidance is considered essential practice for improving quality and patient safety.[5] Clinical guidelines are evidence-based recommendations intended to optimise patient care. Guidelines have the potential to influence care outcomes, but for that to be possible they must be implemented effectively.
Technology provides the opportunity to enhance patient safety by digitalizing evidence-based guidance to improve clinical decision-making. More specifically, the use of ’nudges,’ a behavioral economics concept, presents a great opportunity to guide clinicians towards safer decisions. Considering decision making as an important element of safer systems in health care, there is an increased need to foster effective and improved dynamics between people, processes, knowledge and technology to generate an output of safety.
Merging Clinical Knowledge and Nudges in the Workflow
With the time pressures and competing priorities that clinicians routinely face, most end up using intuitive, non-analytic, implicit and biased processes to a greater degree than analytical reasoning. While this rapid decision-making strategy can save time, it is more error-prone when patient cases are complex, and HCPs are stressed or rushed. Therefore, there is an opportunity to support clinicians to make more informed decisions through nudges.
Nudges, as described by Nobel Prize award winner Richard Thaler and Cass Sunstein, are a tool designed to optimize choices by encouraging safer and healthier behaviors. A fundamental aspect of a nudge is the maintenance of individual freedom of choice. This means that even though choice architecture encourages you to make a certain decision, the option to follow through with the prompt is still yours to make.
A clinician’s immediate environment and choice architecture should be purposefully designed in a way that directs them towards the provision of safe care. Changes to the way choices are presented and information is framed within the Electronic Health Record (EHR) can lead to significant differences in the way clinicians order tests and treatments. For example, results from a survey of 166 primary care providers in Chicago have shown that rearranging the visual display of treatment options in the EHR, to nudge appropriate prescriptions, has led to a 11.5% reduction in choosing aggressive treatment options.[6]
Encouraging Informed Decisions
Nudges for HCPs can range from reminders of standard operating procedures to active support for clinical decision-making. Consider the scenario of a nurse starting a shift at an intensive care unit (ICU) and being given a postsurgical case. The nurse logs into the EHR and checks the care plan for that patient, which suggests the parameters to be measured and actions to be performed based on patient assessment and best available guidance. For this patient, blood loss management is included, and subsequent actions are based on a clinical practice guideline. The nurse’s clinical decision is nudged by both a checklist and guidance, avoiding errors of omission, and nudging them towards evidence-based practice.
Nudges for clinicians aim to improve the workflow and steer decision-making towards evidence-based care by reducing the know-do gap (the gap between what we know in theory and what we do in practice). In a study of primary care practices within the University of Pennsylvania Health System, nudges in the EHR were used to increase influenza vaccination rates by 9.5%. Across the 11 primary care practices that were investigated, this led to 5000 more patients being vaccinated.[7] Additionally, within the University of Pennsylvania Health System as part of a randomized trial of radiation oncologists, nudges were implemented in the EHR to reduce the rate of unnecessary imaging in palliative cancer patients from 68% to 32%. This saved more than 3,000 unnecessary imaging tests per year.[8]
Away from the EHR context, organ donation is another area where choice architecture has been applied.[9] Since 2008, Illinois has required that all driving license applicants actively decide whether to register as a donor or not.9 The percentage of donors signed up to the register has increased from 38% to 60% as a result, showing that nudges can have an important and beneficial role in shaping the behaviour of those who interact with healthcare services.9
Looking Ahead
In the wake of the pandemic, NHS workforce shortages are at an all-time high as clinicians are navigating record-breaking backlogs and patient waitlists. Clinicians are being asked to do more with less time. This disruption has emphasized the role evidence-based clinical knowledge and digital technology can play to improve patient safety.
Knowledge-driven digital technology can be combined with choice architectures that nudge healthcare providers towards safer decisions. As systems progress and evolve, healthcare leaders have the opportunity to act as decision-environment architects.
References:
[1] Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris: Organisation for Economic Cooperation and Development; 2017
[2] Slawomirski L, Auraaen A, Klazinga N. The Economics of Patient Safety in Primary and Ambulatory Care: Flying blind. Paris: Organisation for Economic Cooperation and Development; 2018
[3] Health Systems Strengthening Glossary. Geneva: World Health Organization; 2011
[4] https://www.who.int/initiatives/medication-without-harm#:~:text=Unsafe%20medication%20practices%20and%20medication,of%20the%20medication%20use%20process.
[5] Clinical Practice Guidelines: Closing the Gap Between Theory and Practice – Joint Commission International. JCI-Whitepaper_CPGs-Closing-the-gap-between-theory-practice.pdf (clinicalkey.com)
[6] Tannenbaum D, Doctor JN, Persell SD, et al . Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. J Gen Intern Med 2015;30:298–304.doi:10.1007/s11606-014-3051-2
[7] Kim RH, Day SC, Small DS, Snider CK, Rareshide CAL, Patel MS. Variations in Influenza Vaccination by Clinic Appointment Time and an Active Choice Intervention in the Electronic Health Record to Increase Influenza Vaccination. JAMA Netw Open. 2018;1(5):e181770. doi:10.1001/jamanetworkopen.2018.1770
[8] Sharma S, Guttmann D, Small DS, et al. Effect of Introducing a Default Order in the Electronic Medical Record on Unnecessary Daily Imaging During Palliative Radiotherapy for Adults with Cancer: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Oncol. 2019;5(8):1220–1222. doi:10.1001/jamaoncol.2019.1432
[9] GOV.UK., Applying behavioural insight to health, Cabinet Office Behavioural Insights Team. Available at: https://www.gov.uk/government/publications/applying-behavioural-insight-to-health-behavioural-insights-team-paper (Accessed: October 22, 2022).
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