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Table 1 Rapid cycle approaches to validate nudges and optimize clinical work flow

From: Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

Domain Initial approach Iterative work Output
Clinician nudge Best practice alert (BPA) identifying patient tobacco use and potential referral to tobacco use treatment.
Key questions:
-Specific message content
-Format and timing of alert
-Pre-selected referral
-Best method to understand why a referral order may not be appropriate
Method:
Usability testing with clinician end-users, with specific questions focused on understanding of what the system was trying to convey, key action(s) to be taken, likes/dislikes of the prototype, and any missing elements
Key feedback:
-Overall satisfaction with simple and concise design
-Alert should be available when first opening the clinical encounter
-Pre-select desired outcome
Clinician best practice alert created as an opt-in default, options for accountable justification, and guidance for when in the clinical encounter the BPA should appear.
Patient nudge Informational message describing importance of tobacco use treatment during cancer care and available evidence-based treatment options
Key questions:
- Best method to deliver message (for example, via text message, patient portal, or traditional mail)
Method:
Focus group comprised of cancer patients and caregivers viewed the message and provided responses to open-ended questions about its potential impact. Options for how the messages should be delivered were also reviewed and feedback on mode and timing was ascertained.
Key feedback:
-Send message through patient portal
-Suggested wording improvements to clarify treatment options
Deliver patient nudge via patient portal with key wording changes
Identifying cancer patients who use tobacco BPA prompting key staff to inquire about tobacco use
Key questions:
Which staff were best positioned to inquire about tobacco use?
Method:
The BPA to assess patient tobacco use was initiated to evaluate compliance, trial randomization, and potential contamination, but with the nudges enacted in silent mode.
Key feedback:
We failed to include key staff conducting these assessments across several clinical sites who were not included in our original study.
Extend BPA to the full spectrum of staff responsible for initial patient contact