Table 1 Rapid cycle approaches (RCA) to develop, de-risk, and optimize nudges
Domain | Initial approach | Iterative work | Output |
|---|---|---|---|
Clinician nudge | Best practice alert (BPA) encouraging clinicians to order breast MRI screening Key questions: • When is the best time to send nudges to clinicians? • What are the best strategies for sending a nudge to clinicians? | Approach: Sessions with experts in behavioral economics, implementation science, breast cancer screening, and health equity; technical feasibility tests with informatics and radiology leads Key feedback: • BPAs can interfere with clinical workflows, may be perceived as annoying, and can contribute to alert fatigue for clinicians • Integrating a prompt-to-order screening into the mammogram report would be ideal for clinical workflows • When reviewing mammogram reports, the “impression” section is often the first place clinicians look • Embedding text into reports and subsequent randomization of this language is not feasible at certain sites • Clinicians could benefit from additional educational materials | • Rather than a BPA, clinician nudges were included within the “impression” section of mammogram reports to integrate this content into the clinical workflow • The standard clinician nudge was implemented at all sites but one; an EHR-based in-basket message was used at one site • A one-pager and educational website with more information about supplemental breast MRI screening was created, and study leads presented to clinical teams |
Patient nudge | Nudges delivered via text message Key questions: • What are the behavioral barriers affecting the uptake of supplemental breast MRI? • What specific message content would be most salient to patients? | Approach: Meetings with experts in behavioral economics, implementation science, breast cancer screening, and health equity; review by patient advisory committee; rapid mini-pilots with patients Key feedback: • Barriers for patients include cost concerns and an overall lack of awareness about breast MRI, so nudges should highlight these issues • Additional educational material should be provided to help patients learn more about breast density and supplemental MRI • Despite the passage of state laws covering breast MRI for certain patients, insurance coverage is highly variable. There still can be costs associated with breast MRI that can make it infeasible for some patients | • Mini-pilots were conducted via text message to assess engagement rates for three potential patient-directed nudges • Key wording changes were made to increase readability and reduce confusion about costs • A new questions and answers webpage was created to provide patients with additional information • The final patient-directed nudge focused on making the relevant information salient and timely and invoked a sense of urgency and potential scarcity in a clear cue to action |