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'Nudge Unit' Studies How Physician Decisions are Influenced

By HealthLeaders Media News  
   July 22, 2016

The best nudges optimize medical decisions and improve the value of care. They "influence decisions, but they don't restrict choice," says study author.

It's not always easy to tell physicians how to practice medicine, which is why a subtle nudge often can be more effective than a shove.

With generic prescribing, for instance, researchers at the Perelman School of Medicine at the University of Pennsylvania discovered that making a simple change to prescription default options in electronic health records systems immediately boosted generic prescribing rates from 75% to 98%, according to a study in JAMA Internal Medicine.

The research is one of the first from the Penn Medicine Nudge Unit, which is testing ways that "nudges" can be used to optimize medical decisions and improve the value of care.

"The general concept of the nudge unit is something first popularized in the UK by former prime minister David Cameron to improve policies and programs," says study lead author and Penn's Nudge Unit Director Mitesh S. Patel, MD, MBA, MS.

"We wanted to try to structure this more formally within our healthcare system. Nudges are really moving past education and reminders" to think about how people are influenced and make decisions, he says.

The Unit also determines whether providers are using their "fast-thinking" or "slow-thinking" brains."

"Many of the things we do, especially in healthcare, we use our fast-thinking or automatic brain," Patel says, such as getting into the habit of automatically ordering a chemistry panel every day for a patient.

The Nudge Unit is studying whether nudges influence certain choices, such as whether including cost information in the EHR will limit physicians from ordering unnecessary tests, or the effect of including a "yes" or "no" choice within the EHR for orders such as mammograms.

Importantly, these nudges "influence decisions, but they don't restrict choice," Patel says.

Effect on Prescribing Practices

In the generic prescribing study, researchers tracked prescribing rates for oral medications given for 10 common medical conditions and used an opt-out checkbox in the EHR.

When a physician prescribed a drug for a patient, the EHR would default to an equivalent generic. The physician, however, could still prescribe the brand name when warranted, by selecting the "dispense as written" checkbox.

For most drugs, physicians specified that the brand name should be prescribed only 2% of the time.

There was an exception when physicians prescribed Synthroid for patients with thyroid conditions because it has different hormone levels than its generic version, Levothyroxine.

In this case, physicians opted out and selected the brand name 22% of the time, illustrating that the system preserved the physician's ability to choose.

Patel notes that part of what the Nudge Unit is studying is how to improve the manner in which physicians are already being influenced.

"Defaults exist throughout the environment no matter what," he says. Physicians are "already being nudged. We're just making sure we're doing a better job of that."

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