It's all in how you ask; a little 'nudge' increases flu shots by 37%

PHILADELPHIA — A study released Monday suggests that a simple behavioral economics technique known as "active choice" may be able to improve flu vaccination rates. In the study, researchers from the Perelman School of Medicine at the University of Pennsylvania programmed electronic health records  to alert care providers when a patient was eligible, and prompt them to choose to "accept" or "decline" a flu vaccination order. Results showed a 6% increase over clinics that did not use the alert system, representing a 37% relative increase in vaccinations from the prior year.



"Our results indicate that this simple intervention could be an effective and scalable approach to use the design of electronic health records to increase the rate of flu vaccinations," stated study lead author Mitesh Patel, MD, director of the Penn Medicine Nudge Unit, whose work is supported by the Penn Center for Health Incentives and Behavioral Economics. "Nudges are changes to the way choices are framed or presented and can be very effective for changing physician and patient behavior. These findings build on our previous research demonstrating that active choice increased orders for high value screening tests including colonoscopies and mammographies."



Behavioral economic techniques are being studied widely for their potential to improve public health. In the new study, the intervention was programmed as a "best practices alert" in the software - known as EPIC - that many clinics and hospitals use to access and alter patient EHRs.



The research team examined vaccination rates across three clinics - one that used the intervention, and two controls. In the clinic using the intervention, a doctor or medical assistant who signed in to a patient's EHR during the patient's visit would, if the patient was eligible for a flu vaccine, receive an alert requesting that the provider "accept" or "cancel" an order for the flu vaccine. If the order was accepted, the vaccine would be administered then and there. Prior to the intervention, providers had to check manually if a patient was due for the vaccine and then place an order for it.



Starting in mid-February 2012 the researchers began using the intervention. Results of the study showed that from that time until the end of the 2012-2013 flu season, orders for flu vaccines in the clinic rose by about 37% compared to the prior flu season. Based on these findings, the approach was further improved and in September 2016, it was expanded it to all internal medicine outpatient clinics across Penn Medicine.



"Much of the decisions that physicians and patients make has shifted from pen and paper to digital environments such as the electronic health record and patient portals," Patel said. "This presents a significant opportunity to test ways to design choice architecture within these environments to improve health care value and outcomes."



The study is published online this month in the Journal of General Internal Medicine.