Using nudges with electronic health records systems to improve advance care planning: a systematic review

Background: Researchers are increasingly studying nudges as a theoretical approach to promote behavior change. With the advancement of technology, nudges with electronic health records (EHR) systems become a new way to encourage healthcare professionals to perform advance care planning (ACP). This review aims to summarize nudges with EHR interventions and assess their effects on ACP outcomes. Methods: A comprehensive search was conducted in Scopus, CINAHL, Web of Science, PubMed, and Embase for randomized controlled trials (RCTs) published up to December 2024. Studies were included if they employed nudges developed within the EHR environment in healthcare setting and reported at least one objective measure of ACP. Two reviewers screened the titles, abstracts, and full texts and extracted data. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2.0. A narrative synthesis was conducted for the data. Results: Ten reports (nine studies), including 27,556 participants, met all of the inclusion criteria. Nudge interventions included both EHR-delivered nudges and non-EHR nudges. Using the MINDSPACE framework, the EHR-delivered nudges were categorized as priming (n = 10), salience/affect (n = 1), and default (n = 1). The non-EHR nudges were classified as priming (n = 5), salience/affect (n = 2), and norms and messenger (n = 1). Narrative synthesis showed consistently positive effects on ACP documentation, serious illness conversations documentation, prognosis communication, advance directive completion, and goals-of-care documentation. Most studies reported statistically significant improvements. In contrast, the effects of interventions on end-of-life outcomes were inconsistent and largely non-significant. Conclusion: Overall, findings suggest that EHR-integrated nudge strategies may improve documentation and communication practices related to ACP in patients with serious illness. However, their impact on downstream clinical outcomes remains uncertain. Due to the limited number of studies and high heterogeneity, further research is needed to validate these findings.