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A study found that an EHR “nudge” increased breast cancer screenings by 22 percent and colorectal screenings by 14 percent.

Christopher Jason


With doctors’ busy schedules, a “nudge” is needed to prompt medical assistants to set up and order cancer screenings for doctors to sign once they see the patient, according to a study published in JAMA Network Open.

Researchers at Penn Medicine that specialize in EHR nudges found a 22 percent increase in screening orders for breast cancer and a 14 percent increase for those treating colorectal cancer. Overall, 88 percent of the breast cancer patients and 82 percent of colorectal patients included in the study had a cancer screening ordered due to the nudges.

Although the percentage of cancer screenings increased, there were minimal changes in the rates of patients who followed through within one year and completed their screenings. Researchers concluded that further interventions may need to be targeted to patients to complete their screenings.

“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, director of the Penn Medicine Nudge Unit and the senior author of the study.

The study of nearly 70,000 breast or colorectal cancer patients at 25 primary care practices looked at how doctors can use the EHR to increase the rate at which they screen patients for the disease.

 “Clinicians are increasingly being asked to do more with a fixed amount of time with a patient,” said Esther Hsiang, the study’s lead author. “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.”

In the study, the nudge was directed only to medical assistants who could create orders for clinicians to review. The medical assistants would then inform the patients that they were eligible for cancer screening and should discuss screening with their clinician. Researchers targeted medical assistants specifically to account for physician burnout challenges and EHR complexity that often bogs down physicians.

This study design lessened the burden for physicians and encouraged patients to prioritize a discussing a cancer screening. However, due to the more arduous process for completing a screening order – patients usually have to schedule a second appointment – patients did not necessarily respond to the prompts.

“Once cancer screening is ordered, the patient still has to take several steps to complete it,” explained Patel. “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.”

Patel and his team are in the process of developing a new study to test nudges for both the clinicians and the patients to increase the likelihood of patients to follow through and complete their screenings. The researchers also want to branch out and gain more data from more than the two types of cancer that they initially focused on.

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