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RESEARCH ANALYSIS | Evaluation of EHR Nudge Interventions to Shape ChoiceArchitecture in Surgical Opioid Prescribing

    

 

RESEARCH ANALYSIS

 

Evaluation of EHR Nudge Interventions to Shape Choice

Architecture in Surgical Opioid Prescribing

 

Dylan G. Scholes, BS

Rowan-Virtua School of Osteopathic Medicine

 

SUMMARY POINTS


-       Opioid overprescribing for postoperative surgical pain has contributed to the opioid epidemic, with opioid oversupply posing a risk for misuse and diversion.

 

-       Electronic Health Record (EHR) - based nudges can influence prescribing patterns and optimize decision-making through changes to existing choice architecture.

 

-       Adoption of nudge interventions may be limited by stakeholder disengagement and integration issues; however, their proven impact on improved care delivery warrants further investigation.

 

ANALYSIS

 

Background


Opioid overprescribing has been acknowledged as a contributing factor to the US opioid epidemic. Recent data collected by the US Centers for Disease Control and Prevention suggest that opioid prescription rates have decreased by 46.7% since 2012 (1). Despite this downward trend, opioid oversupply remains a problem, particularly in the setting of surgery, where opioids are used to treat postoperative pain (2). Studies have demonstrated that upwards of 71% of opioid pills prescribed postoperatively go unused, and as many as 92% of patients have leftover pills from their opioid prescriptions (2, 3). This oversupply represents a potential source for misuse and diversion. The apparent mismatch between opioid prescribing and opioid consumption underscores the importance of renewed opioid stewardship initiatives.

  

One potential role for optimizing opioid prescribing is leveraging clinical decision support tools, specifically nudge interventions embedded within electronic health records (EHR). Nudges are low-cost interventions that can steer behavior and optimize decision-making through deliberate design changes to existing choice architecture (4). The nudge ladder model taxonomizes nudges according to their intended impact on behavior and includes passive approaches that emphasize information delivery, to more assertive designs that employ default options (4, 5). EHR embedded nudges have been shown to successfully enhance care delivery, including increasing vaccination rates, reducing inappropriate antibiotic prescriptions, and promoting uptake of statins (4,6). Furthermore, with >90% of hospitals in the United States utilizing EHR systems, nudges may represent a scalable tool that can be updated to reflect emerging clinical guidelines (5,6). This research analysis aims to explore the potential role of EHR-based nudge interventions in influencing opioid prescribing patterns, with a particular emphasis on surgical specialties where opioid oversupply remains a concern.

 

Findings


There are a limited number of studies investigating the role of EHR-based nudges in influencing surgical opioid stewardship. A review of PubMed and Embase demonstrated a limited diversity of design types, with several studies electing to focus on peer comparison data and email-based notifications. However, in 2018, a pre-post intervention study conducted at Yale New Haven Health System evaluated the effect of an EHR default opioid prescription change in patients undergoing outpatient surgery (7). Within the EpicCare ordering module, researchers lowered the default number of pills from 30 to 12. Physicians retained the right to override the default order. For patients receiving outpatient surgery, prescription orders for 30 pills decreased from 39.7% pre-intervention to 12.9% post-intervention (p <0.001) while orders for 12 pills increased from 2.1% to 24.6% (Figure 1) (7). A subsequent linear regression analysis demonstrated a decrease of 5.22 pills per prescription following implementation of the EHR default opioid prescription change. Within a single health system, the impact of this nudge-based initiative was an estimated reduction of 25,000 fewer 5 mg oxycodone pills dispensed over 3 months (7).

 


 

A second study by Kearney et al. evaluated the impact of a default opioid prescribing tool embedded within two Epic order discharge sets (8). In 2019, the prescribing tool went live within the EHR of a multihospital health system and was targeted at hand, plastic, orthopedic, and spine surgeons to reduce opioid prescription pill quantities and morphine milligram equivalents (MMEs) at the time of postoperative discharge (8). Stakeholders across the four specialties linked CPT codes for 1,382 surgical procedures to tiered default opioid discharge sets. Each tier (1-4) corresponded to increasing tiers of opioid pills – 6, 15, 25, and 40 pills – dispensed at the time of discharge. A system-wide analysis demonstrated negligible improvements in opioid prescribing at or below the suggested default order, with an overall improvement of <5% (8). However, in a subgroup analysis of 6 hand surgeons who championed the prescribing tool, a more pronounced reduction in MMEs was observed. Results from this subgroup demonstrated a 26% decrease in median MMEs prescribed at the time of discharge, decreasing from 100 to 75, which was statistically significant (8). This decrease was sustained over 20 months (Figure 2).


 

 

The potential utility of nudges in influencing opioid prescribing patterns has also been explored in non-surgical settings. A 2023 retrospective study examined the impact of a best practice alert (BPA) that notified prescribers of initial opioid prescriptions exceeding CDC-recommended guidelines for acute pain (9). As an active choice alert, prescribers were required to reduce the initial opioid prescription or provide an acknowledgement if they wished to proceed with an order exceeding the 7-day recommendation. Following the implementation of the BPA, 83.3% of prescribers chose to decrease the opioid quantity of the initial prescription. The BPA was associated with an opioid prescription decrease from 12.09 days pre-intervention to 6.58 days post-intervention (9).

 

Discussion

EHR-based nudge interventions may represent a cost-effective approach to influence physician decision-making. Despite several studies reporting an overall decrease in opioid prescriptions following the implementation of a nudge-based intervention, these studies are not without their limitations. Evidence suggests that nudges may contribute to alert fatigue and that poor integration into existing workflows may hinder their adoption (10). Kearney et al. report limited adoption of their opioid prescribing tool due to unfamiliarity with the workflow and additional clicks required within the EHR to acknowledge the alert (8). These studies suggest that the successful implementation of EHR-based nudges requires comprehensive education along with stakeholder engagement (4).

 

As more hospital systems move to digital platforms, the role of clinical decision support tools should be leveraged to optimize clinical care delivery. Given their proven impact on improved care delivery with other healthcare initiatives, EHR-based nudge interventions in this setting warrant further investigation.

 

REFERENCES

 

1.         Moncrieff T, Moncrieff J. A comparison of opioid prescription trends in England and the United States from 2008 to 2020. Int J Risk Saf Med. 2023;34(3):287-291. doi:10.3233/jrs-220040

2.         Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review. JAMA Surg. Nov 1, 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831

3.         Upp LA, Waljee JF. The Opioid Epidemic. Clin Plast Surg. Apr 2020;47(2):181-190. doi:10.1016/j.cps.2019.12.005

4.         Harrison JD, Patel MS. Designing Nudges for Success in Health Care. AMA J Ethics. Sep 1 2020;22(9):E796-801. doi:10.1001/amajethics.2020.796

5.         Last BS, Buttenheim AM, Timon CE, Mitra N, Beidas RS. Systematic review of clinician-directed nudges in healthcare contexts. BMJ Open. Jul 12 2021;11(7):e048801. doi:10.1136/bmjopen-2021-048801

6.         Belli HM, Troxel AB, Blecker SB, et al. A Behavioral Economics-Electronic Health Record Module to Promote Appropriate Diabetes Management in Older Adults: Protocol for a Pragmatic Cluster Randomized Controlled Trial. JMIR Res Protoc. Oct 27 2021;10(10):e28723. doi:10.2196/28723

7.         Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY. Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA Surg. Nov 1 2018;153(11):1012-1019. doi:10.1001/jamasurg.2018.2083

8.         Kearney AM, Kalainov DM, Zumpf KB, Mehta M, Bai J, Petito LC. Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System. J Hand Surg Am. Nov 2022;47(11):1035-1044. doi:10.1016/j.jhsa.2022.08.009

9.         Nguyen M, Ledan S, Cheng C, et al. Impact of Clinical Decision Support Within the Electronic Medical Record on Opioid Prescribing and Dispensing. Perm J. Dec 15 2023;27(4):64-71. doi:10.7812/tpp/23.063

10.       Blecker S, Pandya R, Stork S, et al. Interruptive Versus Noninterruptive Clinical Decision Support: Usability Study. JMIR Hum Factors. Apr 17 2019;6(2):e12469. doi:10.2196/12469

 

 

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© 2021. Rothman Orthopaedic Institute Foundation for Opioid Research and Education.

The Rothman Orthopaedic Institute Foundation for Opioid Research & Education is a non-profit 501c3 organization dedicated to raising awareness of the risks and benefits of opioid, educate physician / physicians / policymakers on safe opioid use, and support research and education aimed to advance innovate pain management strategies that can decrease opioid use.

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