By Manjula Julka, MD, MBA and Albert Karam, MS
Every year, people throw away millions of dollars when they decide to fill up their car tanks with more expensive premium gas when regular unleaded will do just fine for their cars.
There are several reasons for that kind of sub-optimal behavior. Nobel Laureate and University of Chicago professor Richard Thaler calls it — “misbehavior”. Thaler, in his book “Misbehaving” says that the optimization problems that ordinary people confront are often too hard for them to solve, or even come close to solving. Thaler’s two friends and mentors, Amos Tversky and Daniel Kahneman (himself a Noble Laureate) have illuminated several pathways on how we make decisions. Kahneman’s book “Thinking Fast and Slow” articulates some of them and one of their decision theories may have applicability here. They say that when people make decisions, they do not seek to maximize utility. They seek to minimize regret. So, in this case, among other things, perhaps people are thinking that “better not regret causing any damage to the car for a few pennies”, not realizing that those pennies add up and that there’s no damage being caused.
Regardless of the root cause though, one of the ways to minimize these behaviors is to use data to educate and frame choices (the famous “nudge”) to make the optimal decision the easier one to make (through appropriate defaults etc.). And we see these kinds of suboptimal behaviors play out in every walk of our lives and healthcare is no exception.
At PCCI, we recently had an opportunity to work with a group of passionate clinicians at Parkland Health and Hospital System regarding a very similar issue. Magnesium is a key mineral for body functionality especially for heart, nerve, muscle and protein synthesis. Monitored in most hospitalized patients, it is often replenished to maintain normal levels. With very few exceptions, oral Magnesium is as effective as intravenous (IV) Magnesium medication with the added value of being significantly less expensive and more comfortable for patient (think premier gas versus regular unleaded). However, for a variety of reasons, the primary route of ordering Mg was through IV. To understand the magnitude of the problem at hand (and potential savings), we used Parkland’s EHR system (Epic) to identify instances where oral Mg could be as effective as IV Mg and realized that simply by changing the route for appropriate patients, the system could save hundreds of thousands of dollars. This analysis led to system-wide effort to provide informational messages to clinicians at point of care in the ordering process via the EHR so that they could make a more informed choice.
This initiative is a great example of how innovation, changes in behavior and optimal choices happen at the intersection of analytics, data and human behavior and psychology. Every care team member wants to provide the best care for patients, but sometimes the cumulative impact of individual decisions is lost. The conversion of one single IV order at a time to oral magnesium multiplied across many clinicians is now saving thousands of dollars to the hospital system while improving evidence-based care.
For additional technical details, please see https://www.ahajournals.org/doi/abs/10.1161/hcq.12.suppl_1.12.