Active Choice Intervention in EHR Is Effective for Clinician Ordering of Screening Tests

A quality improvement study indicated that nudges in the electronic health record were associated with a significant increase in clinician ordering of screening tests for breast and colorectal cancer.

A JAMA Network Open investigation found that an active choice intervention in the electronic health record (EHR) directed to medical assistants was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests.1

However, the intervention was not associated with a significant change in patient completion of either type of cancer screening test during a 1-year follow-up. The results suggested that nudges may need to be combined with other interventions to improve patient completion.

In this quality improvement study of 69,916 patients, an active choice intervention delivered to medical assistants through the EHR was associated with a significant 22-percentage point increase in clinician ordering of breast cancer screening tests and a significant 14-percentage point increase in clinician ordering of colorectal screening tests.

According to a Stanford Medicine National Physician Poll, conducted with The Harris Poll, 62% of time devoted to each patient is being spent in the EHR, and 7 out of 10 physicians (71%) agree that EHRs greatly contribute to physician burnout.2

“Clinicians are increasingly being asked to do more with a fixed amount of time with a patient. By directing the intervention to medical assistants, this reduced the burden on busy clinicians to respond to alerts and instead gave them more time to have a discussion with their patients about screening,” Esther Hsiang, MD, MBA, School of Medicine, University of California, San Francisco, said in a press release.3

Cancer screening tests also involve a burdensome and complex process for patients. Patients must often schedule another appointment either with gastroenterology or radiology. In this study, patients were mostly on their own to complete these steps and were not routinely sent reminders or given assistance to follow through with scheduling the tests and completing them.

“Once cancer screening is ordered, the patient still has to take several steps to complete it. These several steps can add up to high hurdles, especially if patients have lower motivation to begin with. Future interventions should test ways to nudge patients to complete cancer screenings,” Mitesh S. Patel, MD, MBA, MS, Penn Medicine Nudge Unit, University of Pennsylvania, said in the release.

Several other randomized trials have found that direct outreach on colorectal cancer screening, to patients or their clinicians, also led to small increases in patient completion. Future studies could evaluate ways to nudge scheduling and attendance at these appointments, as well as reduce the reduce the effort required to do so.

Patel is currently working on developing a new study to test nudges for both parties while also attempting to eliminate or alleviate some of the hurdles to completing screenings. 

1. Hsiang EY, Mehta SJ, Small SD, et al. Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants with Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests. JAMA Netw Open.
2. Stanford Medicine. What Physicians Want From EHRs. Stanford Medicine website. Published 2018. Accessed November 15, 2019.
3. Nudge Increases Cancer Screening Orders, But Patient Facing Nudge Needed, Too [news release]. Philadelphia, PA: Perelman School of Medicine at the University of Pennsylvania; November 13, 2019. Accessed November 14, 2019.