Nudging Provider Adoption of Clinical Decision Support: User-Centered Development of a Behavioral Economic-Inspired Electronic Health Record Tool (Preprint)

BACKGROUND The improvements in care seen with clinical decision support (CDS) have been significantly limited by consistently low provider adoption. Provider attitudes towards CDS, specifically psychological and behavioral barriers, are not typically addressed during any stage of CDS development although they represent an important barrier to adoption. Emerging evidence has shown the surprising power of using insights from the field of behavioral economics to address psychological and behavioral barriers. “Nudges” are a formal application of behavioral economics, defined as positive reinforcement and indirect suggestions which have a non-forced effect on decision making. OBJECTIVE Our goal was to employ a user-centered design process to develop a CDS tool, pulmonary embolism risk calculator (PERK), for pulmonary embolism (PE) risk stratification in the Emergency Department (ED) that would incorporate a behavioral theory-informed “nudge” to address identified behavioral barriers to use. METHODS All study activities took place at a large academic health system in the New York City metropolitan area. This study uses a user-centered and behavioral theory-based approach to achieve two aims: 1. Use mixed methodology to identify provider barriers to use of an active CDS tool for PE risk stratification, 2. Develop a new CDS tool, PERK, which addresses behavioral barriers to provider adoption of CDS by incorporating nudges into the user interface. These aims were guided by the revised ORBIT model. Clinicians using the original version of the tool were surveyed with a quantitative instrument based on a behavior theory framework, Capability Opportunity Motivation Behavior (n=50). A semi-structured interview guide was developed based on survey responses. Inductive methods were used to analyze interview session notes and audio recordings (n=12). Revised versions of the tool were developed that incorporated nudges. RESULTS Functional prototypes were developed using Axure PRO software and usability tested with end users in an iterative agile process (n=10). The tool was redesigned to address four major barriers identified to tool use, including two nudges and a default. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers, along with traditional usability testing, facilitated the development of a tool with greater potential to transform clinical care. The tool will be tested in a prospective pilot trial.