Optimizing Electronic Health Record Prompts With Behavioral Economics to Improve Prescribing for Older Adults

Summary

Prescribing of potentially unsafe medications for older adults is extremely common; benzodiazepines and sedative hypnotics are, for example, key drug classes frequently implicated in adverse health consequences for vulnerable older adults, such as confusion or sedation, leading to hospitalizations, falls, and fractures. Fortunately, most of these consequences are preventable. Physicians' lack of awareness of alternatives, ambiguous practice guidelines, and perceived pressure from patients or caregivers are among the reasons why these drugs are used more than might be optimal. Reducing inappropriate use of these drugs may be achieved through decision support tools for providers that are embedded in electronic health record (EHR) systems. While EHR strategies are widely used to support the informational needs of providers, these tools have demonstrated only modest effectiveness at improving prescribing. The effectiveness of these tools could be enhanced by leveraging principles of behavioral economics and related sciences.

Conditions

• Aging
• Benzodiazepine Sedative Adverse Reaction
• Anticholinergic Adverse Reaction
• Adverse Drug Event

Interventions

OTHER

Order Entry

An alert will display in the electronic health record when the provider orders one of the high-risk medications for an eligible patient.

OTHER

Open Encounter

An alert will display in the electronic health record when the provider opens the chart of an eligible patient.

OTHER

Follow-up booster Alert

Once the order entry or open encounter alert displays, the provider will have the option to schedule a follow-up message that will be sent 4 weeks after the alert is triggered

OTHER

Cold State outreach

An in-basket message will be sent to the eligible provider 2 days before the eligible patient is scheduled for an in-person visit.

OTHER

Simplified

The alert language itself will be simplified.

OTHER

Sign-off alert

An alert will display in the electronic health record when the medication is sent to sign-off for providers.

OTHER

Pre-commitment

A two-staged pre-commitment electronic health record alert will be used. In the 1st alert, the providers will be prompted to discuss risks of these high-risk medications and share a handout about the risks with their patients, at their own discretion. The second alert will be either an order entry or open encounter alert, depending on the arm the provider is assigned to.

OTHER

Different Risks

Risks of the high-risk medications will be framed differently.

OTHER

Standard Epic Basic Alert

This alert will be representative of the alerts currently firing in the Atrius system and not incorporate any functionality.

OTHER

Enhanced Alert

An enhanced alert (known as a Best Practice Advisory \[BPA\]) will appear on the provider's electronic health record screen and will contain several standard components such as information about why the medication is dangerous for their patient and an order set that will allow providers to order a gradual dose taper for their patient, order alternative medications, place a referral to a behavioral health specialist, provide instructions on how to make lifestyle modifications to improve patient symptoms, and add patient instructions for how to gradually taper off benzodiazepines and sedative hypnotics, as applicable.

Sponsors & Collaborators

• Atrius Health

  collaborator OTHER

• National Institutes of Health (NIH)

  collaborator NIH

• Brigham and Women's Hospital

  lead OTHER

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2020-10-13

Primary Completion

2022-08-01

Completion

2022-08-31

Countries

• United States

Study Locations