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Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care
  1. Valerie M Vaughn1,2,3,
  2. Jeffrey A Linder4
  1. 1 Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
  2. 2 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  3. 3 Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  4. 4 Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  1. Correspondence to Dr Valerie M Vaughn, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; valmv{at}

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In his book on the psychology of persuasion, Robert Cialdini noted: “as the stimuli saturating our lives continue to grow more intricate and variable, we will have to depend increasingly on our shortcuts to handle them all”.1 Such cognitive shortcuts, or heuristics, are responsible for much of human success in complex environments. Heuristics allow us to skip steps and save mental energy. Similarly, emotions provide a shorthand for remembering and reacting to complex situations and sociability allows us to function well in groups.

Medicine is the art of managing complexity. Physicians’ success similarly depends on effective use of these heuristics, emotion and sociability. When admitting a patient to the hospital, a physician must diagnose the presenting symptoms, reconcile and start medications, order diagnostic testing, communicate with consultants and participate in shared-decision making. In ambulatory visits, the time pressure and tasks are slightly different, but comparably complex. In both scenarios, triaging and simultaneously managing all of the complex processes require incredible mental energy, made even more difficult by frequent interruptions.2 If every decision had to be made in an ordered, fully informed manner, we would never complete even a single patient encounter. It is no wonder we lean on heuristics and emotional and social influences in our decision-making. They often serve us well.

Despite their utility, heuristics, emotion and social influences can lead to predictably poor choices. Richard Thaler won the 2017 Nobel Prize in Economics, largely for recognising this fact.3 Thaler also described a process, termed ‘nudging’, by which environments are re-designed to take advantage of heuristics to encourage better choices.4 Thaler’s work focuses on public policy and public health, but the same concepts of environment influencing behaviour is seen in the interaction between physician decision-making and the design of the electronic health record (EHR).

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