Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review

Objectives To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts. Materials and methods We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively. Results We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects. Discussion Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects. Conclusion Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.