Table 1.

Rapid cycle approaches to develop, de-risk, and optimize implementation strategies

Domain	Initial approach	Iterative work	Output
Clinician nudge	Best practice alert (BPA) with pended order for genetics counseling Key questions: • What is the best timing and mechanism for sending clinician nudges, since eligible patients won’t be in the clinic very often? • What are the key cognitive heuristics affecting genetic testing ordering?	Method: Meetings with experts in behavioral science, implementation science, health equity, and informatics; discussions with clinicians Key feedback: • Alert fatigue can cause annoyance for care team members • Clinicians preferred a pre-selected recommendation which can be signed efficiently • Status quo bias was a key barrier	“Pend and send” default order for genetic testing with accountable justification for clinicians who decline the order
Patient nudge	Sequential nudges delivered via the patient portal and text message Key questions: • What strategies can be used to overcome inequities in patient portal access? • What are the key cognitive heuristics affecting genetic testing uptake?	Method: Meetings with experts in behavioral science, implementation science and health equity; patient review; pilot tests which contacted 200 patients via the patient portal and text message with two potential nudges Key feedback: • Messages with a clear call to action up front can spur behavior change • Wording changes to increase readability would be valuable • Pilot tests revealed that the message emphasizing ease led to high engagement	Patient portal messages emphasizing ease and text messages emphasizing the importance of taking action to prevent cancer