Implementation of a Behavioral Economics Electronic Health Record (BE-EHR) Module to Reduce Overtreatment of Diabetes in Older Adults

Abstract

Background: Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence.

Objective: This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults.

Design: A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019.

Participants: Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes.

Interventions: A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification.

Main measures: Patient-level CW compliance.

Key results: CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%).

Conclusions: The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics.

Nih trial registry number: NCT03409523.

Keywords: behavioral economics; clinical decision support; diabetes; electronic health records.

Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

Figure 1

Timeline of BE-EHR module component development and implementation in Vanguard and Pilot practices. Blue text indicates development/refinement tasks and green text indicates implementation steps.

Figure 2

CW compliance rates in 4-week discrete intervals across all five practice locations. Data to the left of the first vertical dashed bar indicate baseline CW compliance rates prior to initial launch in only the Vanguard practices. Data to the right of the second vertical bar indicate CW compliance rates after activation of the nudges at all five practices.