Nudges, Not Information, For Engagement And Adoption

You have a groundbreaking medical device or digital health app and data to show improved health outcomes or lower costs. You go to market with all the compelling facts, yet adoption rates are lower than forecast. Does this sound familiar? If so, you are not alone.

We as humans have biases

As humans, we like to think that we approach situations rationally and that facts and information will drive preferred behaviors. However, decades of behavioral science research has confirmed that humans are irrational— even when it comes to high-stakes health and healthcare.

For example, we have a bias toward the present (it’s why we eat the chocolate cake), we have an aversion to loss and regret (it’s why we hold onto losing stocks) and we overweight low-probability events while underweighting high-probability ones (it’s why we play the lottery).

Harnessing behavioral science 

Rather than fighting these innate psychological tendencies and assuming more information will overcome them, successful healthcare innovators harness behavioral science to achieve adoption and behavior change. The three main pillars for applying behavioral science in healthcare are:

1. Choice architecture
2. Behavioral framing
3. Principled incentives

Choice architecture: Designing decisions 

Choice architecture refers to the thoughtful design of how options are presented, organized, and structured to guide decision-makers toward preferred outcomes without restricting freedom of choice.

• Defaults in an EHR: Default settings dramatically impact physician behavior. When Penn Medicine changed the prescription default to “generic” for common medications, generic prescribing rates increased from a range of 25%-90% to 98.4%, overnight. By making generics the default choice rather than requiring extra clicks, the system made it easy for a physician to do what was in the best interest for the patient and the system.
• Opt-out for a remote management program: Making the right path the easy path increases engagement. A provider practice introduced a remote monitoring program by sending letters to their patients. In one set of letters, patients were asked to call in to schedule an appointment to pick up the devices, and 13% complied. In the other group, patients were told that they were already scheduled for a date/time to come pick up the devices, and 38% complied. Eliminating a step tripled patient participation rate.

Behavioral framing: Incorporating behavioral science into health communications

How information is framed matters more than what is being said.    

• Loss framing:  We weigh pros and cons differently. When physicians were told that in a situation “95% of patients were not hospitalized”, they rated acceptance of a drug as a 6.5 out of 10. However, if they were told the inverse, “5% of patients were hospitalized”, the rating decreased to 4.7 out of 10. The same information presented in a different way has varying effects on acceptance. 
• Anchoring:  We are influenced by reference points. When patients were asked to start a once-monthly injection, willingness was low, 2.0 out of 10. However, if they were first asked to start a once-daily injection, and then asked to start once-monthly injection, willingness increased to 7.5 out of 10. The initial greater ask increases patients’ acceptance of a new therapy. 
• Social norms:  Physicians are influenced by those around them. In one instance, inappropriate prescribing of antibiotics decreased by 16.3% after a physician received an email that compared their prescribing rates  to their peers. Using local, social comparison drives behavior change

Principled incentives: Presentation of financial components

The design of financial elements is more important than their size. 

• Loss framing and endowment:  People don’t like to lose what we already have. In an employer walking program, one group of participants could earn rewards of $1.40 a day, up to $42 if they met their step goals. The other group was rewarded $42 up front, but would have to give back $1.40 a day if they did not meet their step goal. Participants achieved their daily walking goal 29% more often when they were given $42 at the start. An economist would say the $1.40 a day is the same, but behavioral economics shows otherwise.  
• Value perception:  Higher cost, full-priced treatments are perceived to be more effective.  When patients are given a “$0.10 discounted” placebo drug, 61% had pain reduction. For those patients given a “full priced $2.50” placebo drug, 85% of them experienced pain reduction. Both were placebos, yet an item perceived to be of higher value can yield better patient reported outcomes.  

Summary 

Adoption of new devices and digital health tools often don’t meet strategic targets not because of too little information or weak evidence, but because human decision-making is irrational. To overcome these biases, innovators use behavioral science. Choice architecture leverages defaults and opt-out designs to make the preferred option the easiest path. Behavioral framing optimizes communications through techniques like loss framing, anchoring, and social norms. Finally, Principled Incentives should incorporate endowment and value perception. Together, these approaches build off natural human tendencies, and help an organization achieve adoption and behavior change.

Photo: StockFinland, Getty Images

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