EHR ‘nudges’ get docs to boost cancer screening orders, but patient follow through lags

Placing virtual reminders in the electronic health record helped push doctors to order more cancer screenings. However, patients may need their own prompt to ensure that the tests are actually conducted, according to a new JAMA Network Open study.

Typically, primary care doctors must manually check the EHR to figure out whether a patient is eligible for a screening. That step often gets lost during the course of a busy day, prompting Penn Medicine researchers to test the use of nudges to get medical assistants to check whether an individual was due for a colorectal or breast cancer screening.

The workflow switch has shown early promise, researchers reported, boosting breast cancer screening orders by more than 22 percentage points, and colorectal screenings by nearly 14 percentage points. Rates of patients actually receiving those screenings, however, did not increase, underlining the need for similar patient prompts, the authors noted.

“Cancer screening involves both the clinician recommending and ordering it as well as the patient taking action to schedule and complete it. Our study found nudges can be very influential, but for cancer screening they likely need to be directed to both clinicians and patients,” Mitesh Patel, MD, senior study author and director of Penn Medicine’s Nudge Unit, said in a statement.

Patel and colleagues tested the intervention at three University of Penn Health System primary care practices between 2016 and 2017. They programed the EHR to check if patients were due for a cancer screening and then asked medical assistants to accept or decline the order after first checking patients’ vitals. When accepted, the system set up the order and reminded docs to discuss and sign off on the screening with the patient.

Following implementation, doctors ordered breast cancer screenings for about 88% of patients and 82% for those requiring colorectal assessment, besting other Penn practices without the prompts. These changes are crucial, researchers wrote, with the Centers for Disease Control estimating that about 37% of adults have not been screened for colorectal cancer, and 28% of women fail to do so for breast cancer.

Patel and colleagues next plan to explore whether patient nudges might help to boost the number of screenings conducted in the future. They also will explore other means to lessen the burden on individuals who must jump through several hurdles before tests. He believes such reminders could eventually be used across all types of cancer.

“Since EHRs are used by more than 90 percent of physicians, this is a really scalable approach,” Patel said in the statement.