Design propositions for nudging in healthcare: Adoption of national electronic health record systems

Abstract

Objectives Electronic health records (EHRs) are considered important for improving efficiency and reducing costs of a healthcare system. However, the adoption of EHR systems differs among countries and so does the way the decision to participate in EHRs is presented. Nudging is a concept that deals with influencing human behaviour within the research stream of behavioural economics. In this paper, we focus on the effects of the choice architecture on the decision for the adoption of national EHRs. Our study aims to link influences on human behaviour through nudging with the adoption of EHRs to investigate how choice architects can facilitate the adoption of national information systems. Methods We employ a qualitative explorative research design, namely the case study method. Using theoretical sampling, we selected four cases (i.e., countries) for our study: Estonia, Austria, the Netherlands, and Germany. We collected and analyzed data from various primary and secondary sources: ethnographic observation, interviews, scientific papers, homepages, press releases, newspaper articles, technical specifications, publications from governmental bodies, and formal studies. Results The findings from our European case studies show that designing for EHR adoption should encompass choice architecture elements (i.e., defaults), technical elements (i.e., choice granularity and access transparency), and institutional elements (i.e., regulations for data protection, information campaigns, and financial incentives) in combination. Conclusions Our findings provide insights on the design of the adoption environments of large-scale, national EHR systems. Future research could estimate the magnitude of effects of the determinants.

How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France

“…Unlike some nudging interventions, EHR adoption is not solely reliant on individual behavior but involves complex interactions between patients, healthcare providers, and policy frameworks. Understanding the differences and similarities between nudging approaches in various domains and EHR adoption can provide valuable insights into the effectiveness of different behavioral interventions and their implications for public initiatives [ 75 ].…”

Citizen Views on an Opt-Out Approach to National Electronic Health Records in Germany: A Small-Scale Qualitative Study

“…One reason is the phenomenon of loss aversion, where the potential of a loss weighs more on decision making than on the potential to gain; as when one deviates from the current standard, the feeling of losing out on what others are gaining can significantly impact public behavior. This phenomenon promotes adherence to common practice, and is also reinforced through the lens of a status quo bias [ 8 , 30 , 31 ]. In addition to loss aversion, people often postpone decision-making when it requires an active response, as an active response usually requires time or may include aspects of uncertainty.…”

“…In addition to loss aversion, people often postpone decision-making when it requires an active response, as an active response usually requires time or may include aspects of uncertainty. A final reason for opt-out’s effectiveness is that people also often tend to choose whatever constitutes as the “default option,” as it is assumed that this option was chosen as default for a specific reason; representing an implicit recommendation for the action that coaxes people into a feeling of security and trust [ 8 , 30 ].…”

“…However, Germany is struggling with the uptake of nationwide ePAs, and participation in ePAs within Germany remains low [ 3 , 6 , 7 ]. As of 2023, less than 1% of German health insurance policy holders have signed up for an ePA [ 3 , 8 ].…”

“…But the switch to opt-out is contested. While adopting an opt-out approach to the use of ePAs will increase public participation in an ePA system, there has been criticism that such an approach will be unpopular amongst the public [ 8 , 15 , 16 ].…”