Increasing Screening for Cancer Using EHR-Nudges

In this study, personalized nudges to clinicians and patients will be evaluated to help increase breast cancer screening rates in accordance with USPSTF guidelines among women with a primary care visit, with a particular emphasis on those at high risk for non-completion of cancer screening. In partnership with Penn Medicine (Penn) and Case Western Reserve University-University Hospitals (UH), two complementary, concurrent, 6-month, cluster-randomized, pragmatic trials will be conducted. Those assigned to the intervention arm will receive the following clinician and patient level nudge interventions: clinicians will receive a default pended order for a mammogram in the visit encounter in the EHR (Penn and UH), and patients will receive post-visit text message reminders to encourage them to schedule their mammogram (Penn). Patients identified as high risk for noncompletion will be individually randomized to receive an additional bidirectional text message nudge or the standard text messaging (Penn).

Inclusion Criteria: All patients must meet the following criteria to be eligible: 1. Women between 40 and 74 years of age 2. A scheduled new or return (non-urgent/sick) primary care visit at one of the study practices (Penn Trial) or with one of the study primary care providers (UH Trial) 3. Are overdue and eligible for a mammogram per Health Maintenance 4. Does not have a future scheduled mammogram appointment For the Penn Trial patient intensification nudge, at least one of the following criteria must be met to be considered high risk and randomized to receive the intensification nudge: 1. Medicare Insurance 2. Medicaid Insurance 3. No EHR patient portal account 4. Zero log-ins to EHR patient portal in the previous year Exclusion Criteria: Patients will be excluded from the study if: 1. History of bilateral mastectomy 2. Have a mammogram exclusion modifier in Health Maintenance 3. Have no phone number (home or mobile) listed in their chart (Penn Trial only)