May 08, 2017
When Penn Medicine wanted to improve rates of influenza vaccination among its patient population, Mitesh Patel, MD, MBA, MS, director of the Penn Medicine Nudge Unit, led a team of researchers who programmed a “best practices alert” into the health system’s electronic health record (EHR).
Physicians who signed into the EHR received alerts if patients were eligible to receive the flu vaccine and would either accept or cancel the order. When orders were accepted, physicians immediately administered the vaccine.
Before the researchers implemented the alert, physicians had to manually check if patients were eligible for vaccination. Orders for flu vaccines rose by 37% in the internal medicine clinic where the intervention was initially launched, according to Dr. Mitesh. As it turned out, a little nudge was all that was needed to boost vaccine coverage.
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What is the Nudge Department and what are you in charge of accomplishing in your role?
The name comes from “nudge” programs that have been implemented in country and city governments around the world. Penn Medicine launched the department in 2016, and it was the first of its kind in a health care system. Our goal is to improve health care value and outcomes for the health system, patients, and providers. We typically apply approaches from behavioral economics that can set the default, preferred option, and prompt in EHRs to provide physicians and patients with active choice decisions at the point of care.
Why did you decide to focus on improving rates of influenza vaccination?
Less than half of people in the US get the flu vaccine every year, and EHRs have become mainstream over the past decade. As more providers use EHRs, the decisions they make with their patients are shifting to patient portals. EHRs have therefore become a valuable tool in optimizing how care decisions are made. One of the clinics within Penn Medicine wanted to look at ways to improve vaccine rates and decided to implement the active choice decision. Our results indicated that this simple intervention could be an effective and scalable approach to use EHRs to increase the rate of flu vaccinations, which are estimated to prevent millions of flu cases and tens of thousands of related hospitalizations every year.
Why does such a seemingly simple intervention make such a significant difference in vaccination rates?
A simple reminder is helpful but may not be enough to cause change. There were a couple important elements to the way we designed our prompt. Physicians had to respond to the alert before moving forward in the EHR and could order the vaccine with a single mouse click. The combination of targeted reminders and easy implementation fit within the patient care workflow. Alert fatigue can be an issue with popup reminders, so alerts have to be selective. This intervention was used during a specific time — the flu season, from September 1 to March 31 — and for a specific group of patients.
Did you have to overcome any significant barriers for the program to be successful?
We needed buy-in from the clinical stakeholders who would be impacted with the change, but a lot of the groups worked in silos. Clinicians at the frontlines of care were asking for these types of reminders, but IT professionals were adding one alert after another without knowing which ones they should remove and which they should move forward with. Our goal was to streamline that process. We developed a multidisciplinary steering committee comprised of IT representatives, health system leaders, and members of the behavioral science department. The committee implemented the alerts in a systematic manner and evaluated if the intervention works.
Did you receive any feedback from the physicians?
They were surprised to see that such a simple intervention worked so well. Alerts that physicians don’t have to spend a lot of time managing are often the most powerful. On the flip side, they didn’t want the program’s success lead to the implementation of too many alerts. This intervention was targeted to medical physicians, but there’s no reason the alert couldn’t also be used at health system clinics where pharmacists work. We know patients might not see their doctors during the flu season, but they do go to the pharmacy to get their medications. Pharmacists can therefore play a valuable role in applying the insights of this study to other patient care models.