In his book “Nudge,” University of Chicago behavioral economics expert Richard Thaler describes how “small interventions in the environment or incentives can encourage people to make better decisions.”
Decision-making of any kind is heavily influenced by how choices are presented and information is framed. While the basic principles of nudge theory aren’t exactly new, the evidence-based applications are, and the successes of the first nudge units – such as British Prime Minister David Cameron’s Behavioural Insights Team (BIT), which was created in 2010 in an attempt to improve public services and save money – are currently spurring a worldwide boom in the development of teams across nearly every industry focused on finding the most effective ways to influence how decisions are made.
Since its inception, the BIT has worked to apply insights from behavioral economics and decision-making theory to government projects ranging from foster care and adult education to reducing mobile phone theft and improving army recruitment. By applying seemingly small and insignificant changes aimed at influencing behaviors – or “nudges” – to standard operating procedures, the team has produced incredible results, including an increase of 100,000 registered organ donors per year and doubling the number of army applicants.
What kind of small changes are we talking about? It could be something as simple as requiring people to opt-out of something instead of asking them to opt-in. Or, it could be requiring that people select “yes” or “no” to adding a dessert to their online pizza delivery order before allowing them to proceed to check out.
In the health care arena, researchers at Penn Medicine – who recently formed the world’s first nudge unit in a health system – applied nudges to default prescription settings in electronic medical records to encourage physicians to prescribe more generic drugs instead of brand name medications. In the study, researchers tracked prescribing habits for oral medications given for 10 common medical conditions to see if they could influence generic versus brand name prescribing rates. When a physician prescribed a drug for a patient, the electronic medical record would default to an equivalent generic. However, the physician could still prescribe the brand name when warranted by selecting the “dispense as written” checkbox. Prescribing rates were compared before and after the addition of the opt-out checkbox. The results, which were published earlier this month, showed that by simply adding an opt-out checkbox to prescription default options, generic prescribing rates increased from 75 percent to 98 percent. In the long run, this seemingly small change could produce a significant cost savings for both patients and the health system.
“Systematic errors in decision-making – from what providers do (or fail to do) to choices patients make – often hinder our ability to deliver high value care,” said Mitesh Patel, MD, MBA, MS, an assistant of Medicine and Health Care Management, and director of the Penn Medicine Nudge Unit. “Applying principles from behavioral sciences to the way we design applications or systems in which decisions are made, can steer us towards better decisions, higher value and improved outcomes.”
Penn Medicine has a multidisciplinary group of experts in behavioral economics, and through the Center for Health Incentives and Behavioral Economics has been a national leader in applying and testing these concepts within real-world applications. However, the way choices are presented within digital environments, such as the electronic health record – a concept referred to a “choice architecture” – impacts the delivery of care, but has not been closely examined.
The team at Penn is working to design, implement and test various ways in which nudges can be used.
In a manner akin to following its own advice, the Nudge Unit earlier this month launched its Your Big Idea Challenge, a competition that aims to crowdsource ideas for areas in which nudges could be applied to improve care delivery or patient outcomes. The nudge for submissions? Prizes will be awarded to finalists, and everyone who submits an idea will be entered to win an Apple Watch.
To get the creative juices flowing and encourage submissions, the team points to several ways in which nudges have been applied to health care. For example, they note that employees tend to save more for retirement when they have to opt out of saving a portion of their paycheck for their 401k than when they have to opt in, and automatic prescription renewals have been shown to lead to higher medication adherence rates than having the individual actively renew the medication.
“If a simple, low-cost change like adding an opt-out check box to prescription settings can make a significant impact, there are likely other refinements that can be made just as easily that will also result in cost savings for patients and health systems,” C. William Hanson, MD, chief medical information officer at Penn Medicine and a member of the Penn Medicine Nudge Unit’s Advisory Board. “It’s a valuable area of research to continue exploring.”
Elsewhere in the health system, researchers in Penn’s Abramson Cancer Center have also examined how default settings can improve health care delivery for cancer patients. Earlier this year, researchers proposed a default scheme in which the EMR would be programmed in accordance with evidence-based clinical guidelines. When a physician chooses a particular chemotherapy regimen for a patient, the program would offer a particular antiemetic regimen, based on published guidelines, to accompany that chemotherapy choice.
“The beauty is that it would nudge clinicians to make the choice that is based on evidence," lead author Eric Ojerholm, MD, a resident in Radiation Oncology, said in an article from Medscape.