For cancer screening, nudges need to be directed to both clinicians and patients

Reviewed by Kate Anderton, B.Sc. (Editor)Nov 15 2019

When the electronic health record is programmed to automatically flag and create orders for patients needing cancer screenings, doctors are significantly more likely to order them, a new Penn Medicine study shows. However, the study showed that the other part of the equation -- patients following through on those screenings -- was unaffected by the increase in orders.

"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," said Mitesh Patel, MD, MBA, the director of the Penn Medicine Nudge Unit and the senior author of the study published today in JAMA Network Open.

Currently, primary care physicians have to remember to manually check the electronic health record (EHR) to determine whether a patient is eligible for a cancer screening. Then, they must discuss it with the patient and put in an order, if need be. Because of physicians' busy schedules and limited time with patients, this can get lost in the shuffle, especially as the day goes along, as previous research by Patel and this study's lead author, Esther Hsiang, MD, MBA, showed.

To alleviate some of that strain and guide primary care doctors to get more patients screened, Hsiang, a researcher in the Nudge Unit at the time of this study, and Patel evaluated a nudge implemented by the University of Pennsylvania Health System that involved programming the EHR to check whether patients were due for colorectal or breast cancer screenings. This check occurred while patients met with a medical assistant, who kicks off visits with some of the routine steps, such as checking vital signs. Once the medical assistant finished their tasks, the EHR prompted them to accept or decline a screening order. If accepted, the order would be set up so that the doctor would be reminded to discuss it with the patient and sign off on it, involving no further technical effort.

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.

Lead author Esther Hsiang

With the nudge in place at three different practices in the health system from September 2016 until the end August 2017, screening order rates for breast cancer jumped by 22 percent compared to practices without the nudges. Overall, of all patients due for a screening in those practices, nearly 88 percent had one ordered. For colorectal cancer, the order rate jumped by nearly 14 percent compared to the other practices, with 82 percent of overdue patients, total, having a screening ordered.

In spite of these gains, there was almost no change in the rates of patients who actually followed through and completed their screenings.

Once cancer screening is ordered, the patient still has to take several steps to complete it. That includes scheduling an appointment, sometimes conducting prep -- such as bowel prep for a colonoscopy -- and then going to the appointment. 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 Patel, the director of the Penn Medicine Nudge Unit

That's exactly what Patel is working on now, developing a new study to test nudges for both parties while also attempting to eliminate or alleviate some of the hurdles to completing screenings.

And while the study only focused on two specific types of cancer, these nudges have a wider potential.

"Since EHRs are used by more than 90 percent of physicians, this is a really scalable approach," Patel said. "It is likely that it could be successful for other types of screening."