Nudge Frameworks within CDS

Summary

Rooted in behavioral psychology and behavioral economics, nudge strategies implement subtle psychological cues to influence individual behavior towards a desired outcome. Nudge framework is a system of choice architecture implemented within clinical decision support to influence clinical decision making in a similar fashion. Outside of clinical contexts, nudge strategies have included displaying calorie counts next to commercial food products, or facilitating discounts in exchange for contact information, among countless other examples. Systematic review has shown favorable implementation of nudge frameworks and strategies within CDS.

Science

Nudge strategies were initially codified within the realms of psychology and behavioral economics. Nudge mechanisms are extensive, and have been implemented in many different domains. Nudges mostly rely on heuristics, a concept of automatic thinking humans rely on for quick decision making. Many nudges rely on the concept of social proof heuristics; generally, the need for humans to comply with perceived social norms. In fact, nudge theory has been so popular that the British Cabinet established the British Behavioral Insights Team, or 'Nudge Unit', in 2010 to help study behavioral insights for public policy. In modern UI/UX design, nudges are used extensively to influence consumer decisions, sometimes for good or bad [6].

According to Caraban & Karapanos, within healthcare informatics, nudge mechanisms generally fall within six general categories [5]:

- Facilitate: nudges that reduce the (physical or mental) effort required for an activity, in order to motivate people to pursue it. Mechanisms: default options, opt-out policies, positioning, hiding, suggesting alternatives.

- Confront: nudges that attempt to pause an unwanted action by instilling doubt. They attempt to break mindless behavior and prompt a reflective choice. Mechanisms: throttling mindless activity, reminding of the consequences, creating friction, providing multiple viewpoints.

- Deceive: nudges that use deception mechanisms in order to affect how alternatives are perceived, or how activities are experienced, with the goal of promoting particular outcomes. Mechanisms: adding inferior alternatives (decoy), biasing the memory of past experiences, placebos, deceptive visualizations.

- Social influence: nudges that take advantage of people's desire to conform and comply with what is believed to be expected from them. Mechanisms: invoking feelings of reciprocity, leveraging public commitment, raising the visibility of users' actions, enabling social comparisons.

- Fear: nudges that evoke feelings of fear, loss, and uncertainty to make the user pursue an activity. Mechanisms: making resources scarce, reducing the distance.

- Reinforce: nudges that attempt to reinforce behaviors through increasing their presence in individuals' thinking. Mechanisms: just-in-time prompts, instigating empathy, subliminal priming, ambient feedback.

Implementation and Results

Care must be taken when initially designing and implementing nudge mechanisms within CDS [7]. Multiple review studies have been done describing the types of nudges within CDS [2, 4] as well as their effects on desired provider behavior [1, 3].

The most common form type of nudges implemented was framing information for a clinician through peer comparison, followed by influencing decisions through default choices enabled.

73% of 43 nudge interventions studied by Last et. al. moved providers towards the desired behavior. Default and social comparison nudges were found to be the most effective. Yoong et. al. found an odds ratio of 1.62 that studied nudges would affect behavior in the hypothesized direction. Of the studies that used nudge intervention alone, 55% were effective in a statistically significant manner.

References:

Systematic review of clinician-directed nudges in healthcare contexts [1]

Nudge strategies to improve healthcare providers’ implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews [2]

Using Nudges to Enhance Clinicians’ Implementation of Shared Decision Making With Patient Decision Aids [3]

Behavioral Economics Interventions in Clinical Decision Support Systems [4]

The ‘23 ways to nudge’ framework: Designing technologies that influence behavior subtly [5]

The Power of Nudges, for Good and Bad [6]

Designing Nudges for Success in Health Care [7]

Submitted by Roheet Kakaday