Table 2. Overall Findings of Association Between Electronic Health Record Nudges and Health Care Quality Measures.
| Measure type and concept | Citation(s) | Measures | Overall findingsa |
|---|---|---|---|
| Patient safety | |||
| Appropriate prescribing | Campbell et al,21 2021 | Anticholinergic discontinuation | 7.8% vs 8.2%; P = .65 |
| Appropriate prescribing | Kraemer et al,22 2022 | Opioid prescriptions at index visit | OR = 0.74 (95% CI, 0.46-1.18) |
| Appropriate prescribing | Kraemer et al,22 2022 | Continued use of opioid prescriptions | OR = 1.08 (95% CI, 0.94-1.24) |
| Appropriate prescribing | Kraemer et al,22 2022 | Concurrent opioid and benzodiazepine use | OR = 1.10 (95% CI, 0.94-1.29) |
| Appropriate prescribing | Tamblyn et al,23 2012 | Psychotropic prescription | Immediate-acting benzodiazepines: mean difference = −0.008 (95% CI, −0.05 to 0.03); long-acting benzodiazepines: mean difference = −0.006 (95% CI, −0.001 to −0.000); antidepressants: mean difference = −0.011 (95% CI, −0.03 to 0.01); immediate potency opiates: mean difference = 0.001 (95% CI, −0.00 to 0.01); low potency opiates: mean difference = −0.004 (95% CI, −0.01 to 0.00); anticonvulsants: mean difference = 0.006 (95% CI, −0.00 to 0.01); antipsychotics: mean difference = 0.005 (95% CI, −0.00 to 0.01) No.of psychotropic medications prescribed: mean difference = −0.02 (95% CI, −0.09 to 0.05) |
| Appropriate prescribing | Gill et al,24,2011; Abdel-Kader et al,25 2011 | Discontinued NSAIDs | Gill et al: OR = 1.18 (95% CI, 0.99-1.40); Abdel-Kader et al: OR = 1.43 (95% CI, 0.32-6.33) |
| Appropriate prescribing | Tamblyn et al,23 2012 | Drug-related injuries | Mean difference: −0.17 (95% CI, −0.32 to −0.02) |
| Appropriate prescribing | Flottorp et al,26 2002; Høye et al,27 2013; Meeker et al,28 2016; Gulliford et al,29 2019 | Ordering antibiotics for viral infections | Flottorp et al: −3.0% difference, P = .003 (pharyngitis); −0.4% difference, P = .64 (urinary tract infections); Høye et al: OR = 0.72 (95% CI, 0.60-0.86) (upper respiratory infections); Meeker et al: DiD: −5% (95% CI, −7.8 to 0.1) (suggested alternatives mechanism); DiD: −7% (95% CI, −9.1 to −2.9) (accountable justification mechanism); Gulliford et al: IRR = 0.88 (95% CI, 0.78-0.99 (upper respiratory infections) |
| Appropriate prescribing | Gill et al,24 2011 | Provided guideline-concordant care | OR = 1.19 (95% CI, 1.01-1.42) |
| Appropriate prescribing | Tamblyn et al,30 2003 | Inappropriate prescribing of new medications | RR = 0.82 (95% CI, 0.69-0.98) |
| Appropriate prescribing | Tamblyn et al,30 2003 | Inappropriate discontinuation of medications | RR = 1.06 (95% CI, 0.89-1.26) |
| Appropriate prescribing | Fortuna et al,31 2009 | Prescribing of heavily marketed hypnotics | RR = 0.74 (95% CI, 0.57-0.96) |
| Effectiveness | |||
| Diabetes | Sequist et al,32 2005 | Eye exam screening | HR = 1.38 (95% CI, 0.81-2.32) |
| Diabetes | Sequist et al,32 2005 | Receiving recommended diabetes care | OR = 1.30 (95% CI, 1.01-1.67) |
| Diabetes, hypertension | Sequist et al,32 2005; Abdel-Kader et al,25 2011; Sequist et al,33 2018; Tamblyn et al,34 2018 | Antihypertensive prescriptions | Sequist et al (2005): HR = 1.42 (95% CI, 0.94-2.14) (ACE inhibitors for patients with diabetes); HR = (95% CI, 0.72 - 1.63); (β-blockers for CAD); Abdel-Kader et al: OR = 0.84 (95% CI, 0.50-1.41) (ACE or ARB for CKD); Sequist et al (2018): 76% vs 79%, P = .17 (ACE or ARB for high-risk CKD); 64% vs 65%, P = .57 (ACE or ARB for low-risk CKD); Tamblyn et al: RR = 1.65 (95% CI, 1.17-2.33) (diuretics for newly diagnosed hypertension); RR = 0.61 (95% CI, 0.43-0.86) (other antihypertensives for newly diagnosed hypertension); RR = 1.10 (95% CI, 0.73-1.66) (prescribing 1 antihypertensive for newly diagnosed hypertension); RR = 0.91 (95% CI, 0.60-1.37) (prescribing 2 or more antihypertensives for newly diagnosed hypertension); RR = 1.09 (95% CI, 0.79-1.52) (diuretic for established hypertension); RR = 0.91 (95% CI, 0.66-1.27) (other antihypertensives for established hypertension); RR = 1.13 (95% CI, 0.90-1.42) (1 antihypertensive prescribed for established hypertension); RR = 0.88 (95% CI, 0.70-1.11) (2 or more antihypertensives prescribed for established hypertension) |
| Diabetes, other (CAD, hyperlipidemia) | Sequist et al,32 2005; Gill et al,35 2009; Adusumalli et al,36 2023 | Statin prescriptions | Sequist et al: HR = 1.10 (95% CI, 0.65-0.85 (only patients with diabetes); Sequist et al: HR = 1.51 (95% CI, 1.05-2.17) (only patients with CAD); Gill et al: OR = 0.05, P > .05 Adusumalli et al: 5.5% difference (95% CI, 3.2%-8.1%) |
| Immunizations | Frank et al,37 2004 | Tetanus immunizations | RR = 1.89 (95% CI, 1.59-2.25) |
| Immunizations | Frank et al,37 2004; Loo et al,38 2011 | Pneumococcal immunizations | Frank et al: RR = 1.70 (95% CI, 1.10-2.62); Loo et al: OR = 2.01 (95% CI, 1.30-3.11) |
| Immunizations | Frank et al,37 2004 | Measles, mumps, and rubella immunizations | RR = 1.25 (95% CI, 0.82-1.93) |
| Immunizations | Frank et al,37 2004; Fiks et al,39 2009; Loo et al,38 2011; Szilagyi et al,40 2015 | Influenza immunizations | Frank et al: RR = 0.96 (95% CI, 0.78-1.18); Fiks et al: OR = 1.22 (95% CI, 0.94-1.61); Loo et al: OR = 1.53 (95% CI, 1.23-1.91); Szilagyi et al: OR = 0.93 (95% CI, 0.69-1.25); OR = 0.89 (95% CI, 0.69-1.16) (reported data across 2 sites separately) |
| Immunizations | Fiks et al,41 2013; Szilagyi et al,40 2015 | HPV immunizations | Fiks et al: HR = 1.5 (95% CI, 1.2 - 2.0 (dose 1); HR = 1.0 (95% CI, 0.8-1.1) (dose 2); HR = 1.1 (95% CI, 0.9-1.3) (dose 3); Szilagyi et al: OR = 0.92 (95% CI, 0.60-1.40; OR = 0.96 (95% CI, 0.59-1.56) (dose 1 at 2 clinics); OR = 1.01 (95% CI, 0.57-1.77); OR = 1.06 (95% CI, 0.68-1.66) (dose 2 at 2 clinics); OR = 0.93 (95% CI, 0.69-1.25); OR = 1.13 (95% CI, 0.68-1.88) (dose 3 at 2 clinics) |
| Immunizations | Stockwell et al,42 2015; Szilagyi et al,40 2015; Stephens et al,43 2021 | Pediatric immunizations | Stockwell et al: RR = 0.90 (95% CI, 0.83-0.98) (up-to-date immunizations); Szilagyi et al: OR = 1.44 (95% CI, 0.82-2.56); OR = 1.16 (95% CI, 0.68-1.99) (Tdap from 2 clinics); OR = 1.15 (95% CI, 0.64-2.05); OR = 1.08 (95% CI, 0.82-1.41) (MCV4 at 3 clinics); Stephens et al: 3.7% difference (95% CI, 1.8%-5.6%) (among young children); 3.2% difference (95% CI, 0.6%-6.9%) (among adolescents); 0.8% difference, 95% CI, −0.3% to 1.8%) (under-immunizations) |
| Immunizations | Fiks et al,39 2009 | Having up-to-date influenza immunization | 3.4% difference (95% CI, −1.4 to 9.1) |
| Other (ADHD) | Co et al,44 2010 | Assessing ADHD care | OR = 2.2 (95% CI, 1.2-4.0) |
| Other (asthma) | Bell et al,45 2010 | Prescribing asthma controller | Urban practices: 6% difference, P = .006; suburban practices: 14% difference, P = .03 |
| Other (atrial fibrillation) | Karlsson et al,46 2018 | Anticoagulant prescription | 70.3% vs 70.0%, P = .01 |
| Other (atrial fibrillation) | McKie et al,47 2020 | Guideline-concordant care for atrial fibrillation | OR = 0.94 (95% CI, 0.15 - 5.94) |
| Other (CAD) | Sequist et al,32 2005; Sequist et al,48 2012 | Aspirin prescriptions | Sequist et al (2005): HR = 2.36 (95% CI, 1.37-4.07) (CAD); Sequist et al (2012): 20% vs 18%, P = .43 |
| Other (CAD) | Sequist et al,32 2005 | Receiving recommended coronary artery disease care | OR = 1.25 (95% CI, 1.01-1.55) |
| Other (chest pain) | Sequist et al,48 2012 | Echocardiograms | 51% vs 48%, P = .33 |
| Other (domestic violence screening) | Feder et al,49 2011 | Referral to domestic violence agency | IRR = 22.1 (95% CI, 11.5-42.4) |
| Other (GERD, drug side effects) | Player et al,50 2010; Gill et al,24 2011 | Prescribing gastroprotective medications | Player et al: OR = 1.11 (95% CI, 0.86-1.43) (newly diagnosed GERD); OR = 1.37 (95% CI, 1.12-1.68) (established patients with GERD); Gill et al: OR = 1.33 (95% CI, 1.01-1.74 (among patients receiving NSAIDs) |
| Other (heart failure) | McKie et al,47 2020 | Guideline-concordant care for heart failure | OR = 7.6 (95% CI, 1.2-47.5) |
| Other (hyperlipidemia) | McKie et al,47 2020 | Guideline-concordant care for hyperlipidemia | OR = 1.1 (95% CI, 0.6-1.8) |
| Other (kidney disease) | Abdel-Kader et al,25 2011; Sequist et al,33 2018 | Proteinuria assessment | Abdel-Kader et al: OR = 1.73 (95% CI, 0.77-3.87); Sequist et al: 71% vs 70%, P = .35 (patients with high risk of CKD); 45% vs 21%, P < .001 (patients with low risk of CKD) |
| Other (kidney disease) | Sequist et al,33 2018 | eGFR test | Patients with high risk of CKD: 89% vs 89%, P = .90; patients with low-risk of CKD: 82% vs 80%, P = .20 |
| Other (kidney disease) | Sequist et al,33 2018 | Hemoglobin test | Patients with high risk of CKD: 73% vs 73%, P = .63; patients with low risk of CKD: 61% vs 61%, P = .87 |
| Other (kidney disease) | Sequist et al,33 2018 | Phosphorous lab test | Patients with high risk of CKD: 49% vs 38%, P < .001; patients with low risk of CKD: 23% vs 13%, P < .001 |
| Other (kidney disease) | Sequist et al,33 2018 | 25-OH vitamin D lab | Patients with high risk of CKD: 53% vs 45%, P = .002; patients with low risk of CKD: 31% vs 24%, P = .004 |
| Other (kidney disease) | Sequist et al,33 2018 | Calcium lab | Patients with high risk of CKD: 75% vs 69%, P = .01; patients with low risk of CKD: 59% vs 54%, P = .11 |
| Other (kidney disease) | Sequist et al,33 2018 | Parathyroid hormone lab | Patients with high risk of CKD: 49% vs 39%, P < .001; patients with low risk of CKD: 24% vs 14%, P < .001 |
| Other (kidney disease) | Sequist et al,33 2018 | Annual nephrology visit | Patients with high risk of CKD: 45% vs 34%, P < .001 Patients with low risk of CKD: 17% vs 11%, P = .001 |
| Other (lab monitoring) | Palen et al,51 2006; Feldstein et al,52 2006 | Monitoring laboratory values | Palen et al: 56.6% vs 57.1%, P = .31; Feldstein et al: HR = 2.5 (95% CI, 1.8-3.5), P < .001 |
| Other (osteoporosis) | Loo et al,38 2011 | Bone density scan | OR = 1.43 (95% CI, 0.94-2.17) |
| Other (substance use) | Linder et al,66 2009 | Smoking cessation prescriptions | 2.0% vs 2.0%, P = .40 |
| Other (substance use) | Linder et al,66 2009 | Smoking counseling referrals | 4.5% vs 0.4%, P < .001 |
| Other (substance use) | Lee et al,54 2023 | Alcohol treatment initiation | 7.8% vs 6.2%, P = .04 |
| Other (substance use) | Lee et al,54 2023 | Positive alcohol screen | 18.0% vs 5.0%, P < .001 |
| Other (substance use) | Lee et al,54 2023 | Assessment DSM-5 Alcohol Symptom Checklist | 80.9% vs 4.1%, P < .001 |
| Other (weight issues) | Schriefer et al,55 2009 | Weight loss prescriptions | 0.5% vs 0.2%, P = .86 |
| Other (weight issues) | Schriefer et al,55 2009 | Weight loss program referrals | 1.1% vs 1.3%, P = 1.00 |
| Other (weight issues) | Schriefer et al,55 2009 | Bariatric surgery referrals | 0.8% vs 0.6%, P = 1.00 |
| Other (weight issues) | Schriefer et al,55 2009 | Combination therapy for patients with obesity | 11.9% vs 6.6%, P = .01 |
| Routine health maintenance (cancer screening) | Frank et al,37 2004 | Cervical smear test | RR = 1.09, 95% CI 0.91-1.29 |
| Routine health maintenance (cancer screening) | Hsu et al,56 2013 | HPV screening | 40.9% vs 1.1%, P < .001 |
| Routine health maintenance (hepatitis screening) | Hsu et al,56 2013; Chak et al,57 2018; Chak et al,58 2020 | Hepatitis B screening | Hsu et al: 34.1% vs 0.0%, P < .001; Chak et al (2018): OR = 3.13 (95% CI, 2.18-4.48); Chak et al (2020): OR = 3.23 (95% CI, 2.24-4.67) |
| Routine health maintenance (hepatitis screening) | Federman et al,59 2017 | Hepatitis C screening | OR = 8.99 (95% CI, 7.57-10.70) |
| Routine health maintenance (wellness screening) | Frank et al,37 2004; Sequist et al,32 2005; van Wyk et al,60 2008; Gill et al,35 2009; O’Connor et al,61 2011; Sequist et al,33 2018 | Lipids screening | Frank et al: RR = 0.89 (95% CI, 0.73-1.09); Sequist et al (2005): HR = 1.41 (95% CI, 1.15-1.72) (among patients with diabetes); HR = 0.99 (95% CI, 0.75-1.29) (among patients with CAD); van Wyk et al: RR = 1.76 (95% CI, 1.41-2.20) (dyslipidemia screening); RR = 1.40 (95% CI, 1.15-1.70) (dyslipidemia treatment); Gill et al: OR = 15.00, P < .05 (for patients of high risk); OR = 1.47, P > .05 (for patients of moderate risk); OR = 0.97, P > .05 (for patients of low risk); O’Connor et al: 3.3% difference, P = .14 (among patients with diabetes); Sequist et al (2018): 82% vs 83%, P = .24 (for patients of high risk of CKD); 72% vs 70%, P = .19 (for patients of low risk of CKD) |
| Routine health maintenance (wellness screening) | Frank et al,37 2004; Sequist et al,32 2005; O’Connor et al,61 2011; Zera et al,62 2015; Weiner et al,63 2020 | Diabetes screening | Frank et al: RR = 0.98 (95% CI, 0.65-1.48); Sequist et al: HR = 1.14 (95% CI, 0.89-1.46) (among patients with diabetes); O’Connor et al: 4.1% difference, P = .045 (among patients with diabetes); Zera et al: OR = 1.04 (95% CI, 0.79-1.38); Weiner et al: 0.72 vs 0.74, P = .07 (A1C tests); 1.55 vs 1.63, P = .49 (No.of glucose tests); 1.20 vs 1.22, P = .63 (No. of creatinine tests) |
| Routine health maintenance (wellness screening) | McDowell et al,64 1989; Frank et al,37 2004; O’Connor et al,61 2011; Kharbanda et al,65 2018 | Measuring blood pressure | McDowell et al: 30.7% vs 21.1%, P < .001; Frank et al: HR = 1.02 (95% CI, 0.90-1.16); O’Connor et al: 0.8% difference, P = .28 (patients with diabetes); Kharbanda et al: 14.3% vs 10.6%, P = .07 (within 30 d of index visit); 26.0% vs 23.4%, P = .46 (within 90 d of index visit) |
| Patient-centeredness | |||
| Other (weight issues) | Schriefer et al,55 2009 | Diet counseling for patients with obesity | 14.0% vs 7.3%, P = .002 |
| Other (weight issues) | Schriefer et al,55 2009 | Exercise counseling for patients with obesity | 12.1% vs 7.1%, P = .02 |
| Hypertension | Kressin et al,67 2016 | Blood pressure counseling | β = 1.10, P = .01 |
| Timeliness | |||
| NA | None | NA | NA |
| Efficiency | |||
| Upper respiratory infections, urinary tract infections | Flottorp et al,26 2002 | Ordering labs for viral infections | Urinary tract infections: −5.1% difference, P = .05; pharyngitis: −0.5% difference, P = .64 |
| Other (lab monitoring) | Lo et al,69 2009 | Appropriate ordering of labs | OR = 1.05 (95% CI, 0.75-1.46) |
| Other (chest pain) | Sequist et al,48 2012 | Cardiac stress testing | 10% vs 9%, P = .40 |
| Other (musculoskeletal pain) | Zafar et al,68 2019 | Lumbar spine MRI | Same-day orders: OR = 0.92 (95% CI, 0.68-1.25); orders within 30 d of visit: OR = 0.94 (95% CI, 0.70-1.25) |
| Descriptive | |||
| Routine health maintenance (wellness screening) | Frank et al,37 2004 | Documenting allergies | RR = 1.81 (95% CI, 1.63-2.02) |
| Routine health maintenance (wellness screening) | Frank et al,37 2004 | Documenting weight | RR = 1.28 (95% CI, 1.13-1.44) |
| Routine health maintenance (wellness screening) | Frank et al,37 2004 | Documenting smoking status | RR = 1.12 (95% CI, 0.90-1.39) |
| Other (weight issues) | Schriefer et al,55 2009; Tang et al,70 2012 | Diagnosis of obesity | Schriefer et al: 16.6% vs 10.7%, P = .02; Tang et al: OR = 4.1 (95% CI, 1.3-12.7) |
| Other (ADHD) | Co et al,44 2010 | Documenting ADHD symptoms | 100% vs 61.3%, P < .001 |
| Other (ADHD) | Co et al,44 2010 | Documenting ADHD treatment effectiveness | 96.6% vs 54.8%, P < .001 |
| Other (ADHD) | Co et al,44 2010 | Documenting ADHD adverse events | 96.6 vs 40.3%, P < .001 |
| Other (GERD) | Player et al,50 2010 | Diagnosis of GERD | OR = 1.33 (95% CI, 1.13-1.56) |
| Other (asthma) | Bell et al,45 2010 | Filing up-to-date asthma care plan | Urban practices: 1% difference, P > .05; suburban practices: 25% difference, P = .03 |
| Other (asthma) | Bell et al,45 2010 | Documenting spirometry | Urban practices: 3% difference, P = .04; suburban practices: 13% difference, P = .003 |
| Other (kidney disease) | Abdel-Kader et al,25 2011 | CKD documentation | OR = 1.23 (95% CI, 0.60-2.51) |
| Other (domestic violence screening) | Feder et al,49 2011 | Documenting domestic violence | IRR = 3.1 (95% CI, 2.2-4.3) |
| Other (weight issues) | Tang et al,70 2012 | Documenting results of weight counseling | OR = 2.1 (95% CI, 1.1-4.1) |
| Other (ADHD) | Wright et al,71 2012 | ADHD problem list | OR = 2.23 (P < .0001) |
| Other (asthma) | Wright et al,71 2012 | Asthma/COPD problem list | OR = 2.98 (P < .0001) |
| Other (cancer) | Wright et al,71 2012 | Breast cancer problem list | OR = 1.78 (P < .001) |
| Other (CAD) | Wright et al,71 2012 | CAD problem list | OR = 4.66 (P < .0001) |
| Other (coagulopathy) | Wright et al,71 2012 | Congenital coagulopathy problem list | OR = 2.06, P = .04, finding not significant due to a Bonferroni correction |
| Other (CHF) | Wright et al,71 2012 | CHF problem list | OR = 7.56, P < .0001 |
| Diabetes | Wright et al,71 2012 | Diabetes mellitus problem list | OR = 1.97, P < .0001 |
| Other (glaucoma) | Wright et al,71 2012 | Glaucoma problem list | OR = 3.78, P < .0001 |
| Hypertension | Wright et al,71 2012 | Hypertension problem list | OR = 4.12, P < .0001 |
| Other (thyroid issues) | Wright et al,71 2012 | Hyperthyroidism problem list | OR = 1.30, P = .29 |
| Other (thyroid issues) | Wright et al,71 2012 | Hypothyroidism problem list | OR = 3.99, P < .0001 |
| Other (autoimmune issues) | Wright et al,71 2012 | Myasthenia gravis problem list | OR = 2.10, P = .11 |
| Other (osteoporosis) | Wright et al,71 2012 | Osteoporosis/Osteopenia problem list | OR = 3.40, P < .0001 |
| Other (autoimmune issues) | Wright et al,71 2012 | Rheumatoid arthritis problem list | OR = 3.97, P < .0001 |
| Other (kidney issues) | Wright et al,71 2012 | Renal failure/insufficiency problem list | OR = 8.22, P < .0001 |
| Other (sickle cell disease) | Wright et al,71 2012 | Sickle cell disease problem list | OR = 1.66, P = .29 |
| Other (stroke) | Wright et al,71 2012 | Stroke problem list | OR = 2.35, P = .0002 |
| Other (social determinants of health screening) | Weiner et al,73 2022 | Contextual factors integrated into care plan | OR = 2.67 (95% CI, 1.32-5.41) |
| Other (gun storage screening) | Sigel et al,72 2023 | Documenting gun storage counseling | 51.2% vs 20.0%, P = .04 |
| Other (substance use) | Lee et al,54 2023 | Alcohol intervention documented | 57% vs 11%, P < .001 |
| Routine health maintenance (wellness screening) | Lee et al,54 2023 | Alcohol screening documented | 83.2% vs 20.8%, P < .001 |
| Other (substance use) | Lee et al,54 2023 | Alcohol diagnoses | 33.8% vs 28.8%, P = .003 |
| Other (designating a proxy) | Loo et al,38 2011 | Designation of health care proxy | OR = 1.55 (95% CI, 1.00-2.41) |
| Other (social determinants of health screening) | Weiner et al,63 2022 | Improving or resolving “red flags” | OR = 0.96 (95% CI, 0.57-1.63) |
| Other (social determinants of health screening) | Weiner et al,63 2022 | Probing “red flags” | OR = 2.12 (95% CI, 1.14-3.93) |
Abbreviations: ACE, angiotensin-converting enzyme inhibitors; ADHD, attention-deficit/hyperactivity disorder; ARB, angiotensin receptor blockers; CAD, coronary artery disease; CHF, coronary heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DiD, difference-in-differences; eGFR, estimated glomerular filtration rate; EHR, electronic health records system; GERD, gastroesophageal reflux disease; HPV, human papillomavirus; HR, hazard ratio; IRR, incidence risk ratio; MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-inflammatory drugs; OR, odds ratio.
a
All findings are reported with the EHR nudge first before the usual care. For studies reporting ratios, the comparator is usual care.