The idea of the behavioral “nudge” is everywhere. This behavioral economics concept that says a small adjustment in a person’s environment can enact a larger change in their behavior, has taken health care and other industries by storm. It’s tempting to think of nudges as a silver bullet, catch-all solutions resulting from a quick eureka moment. Boom—a long-standing problem instantly solved by something as simple as implementing an automated reminder.
Sometimes it’s hard to avoid simplifying it to that because the results are often astounding. Just at Penn Medicine, there has been the change of a default option that resulted in generic medicines being prescribed at a 98.4 percent rate; gamifying steps for obese patients to add an extra 1,000 per day; and tripling statin prescription rates by letting doctors know how many of their peers prescribe them.
On top of that, a September symposium hosted by Penn Medicine’s Nudge Unit showed just how popular nudging has become, with 21 different health systems from across the United States and Canada sending representatives.
But nudging requires effort and know-how. Done properly, nudges are intricate, requiring forethought and close monitoring. Otherwise, they likely can’t reach their full potential—and could potentially result in setbacks.
Mitesh Patel, MD, MBA, MS, an assistant professor of Medicine, is the founding director of Penn Medicine’s Nudge Unit. He’s been implementing nudges for years, starting with the one that increased the rate of generic prescriptions. And while he’s had eye-opening success, he’s just as careful with every new nudge as he was with the first.
“We’re nudging clinicians and patients in a healthier direction by making relatively small changes to their environment,” Patel said. “What we’re doing is subtle and often much more effective than a ‘shove,’ but, because of how effective they are, we need to stay just as mindful as if we were shoving.”
Here, Patel explains the deliberate — and delicate — planning that goes behind nudging in health care, and what he and his team do to keep everything going in the right direction.
Q: How do you decide what problems warrant a nudge versus what might require a more systemic change?
A: I think that’s a key question. And it’s usually hard to know right away, but we make it our first priority to find out.
We try to understand the problem by understanding the decision pathway. To do that, we consider the stakeholders, work flow, and where the inappropriate outcome seems to stem from.
Nudges are a better fit if a specific decision leads to a less than optimal behavior. But nudges are less of a fit if the problem has to do with multiple factors or factors that are completely outside of the decision-making process.
Q: Your goal is to enact positive changes with nudges, but how do stay on top of what could backfire?
A: We always try to look for intended and unintended consequences, which are identified by asking the stakeholders and clinicians involved, as well as looking for similar changes in other settings and what their effect was.
Having a Nudge Unit—with people whose entire jobs are to focus on interventions—allows us to monitor all outcomes. In most settings, nudges are being implemented all the time but no one is monitoring the good or bad outcomes. Keeping a steady eye on what’s actually happening is key.
Q: Do you have an example of a time when there was a setback related to a nudge?
A: We led something called the PRICE trial, which added prices into the electronic health record doctors use to order lab tests. The goal was to reduce unnecessary tests, making doctors consider whether the benefits were worth the cost for each patient.
We found that the nudge led to a small decrease in the ordering of expensive tests, but it was offset by another small decrease in the ordering of cheaper tests. That impact made sense, but was not expected.
Q: In cases like that, is it best to shut down the project to stop the setbacks?
A: The PRICE trial preceded the Nudge Unit here, so we didn’t have new opportunities to test it in another way.
Usually, though, it depends on why the setback is occurring. The design is nudging us in some way, no matter what, so technically it is never really shut down, but redesigned to nudge in another way.
We also test our nudges on a smaller scale before deploying them widely. Because we monitor outcomes, the expectation is that we’ll further improve it after the smaller pilot and before a larger rollout.
Q: Is a successful nudge one that pleases everyone?
A: It’s hard to please all of the stakeholders in any situation. But the best nudges make everyone happy by decreasing clinician workload and improving patient outcomes.
However, sometimes that’s not the case, such as when a clinician’s workload actually goes up. These nudges can work, but they have a lower likelihood of lasting success than ones that would decrease workload.
That’s why it’s important to have a nudge unit and think everything through so carefully. Nudges aren’t really about stopping and starting so much as steering. When you’re thinking everything through and evaluating closely, you can steer a little more in one direction, or correct it the other way to try to make things better for everyone involved.