DISCUSSION
cancer
CANCER
Nudges delivered through the EHR are a well-established way to affect clinical behaviors and can have a substantial effect on patient and implementation outcomes.The impact of patient-directed nudges is less well established, and depends on the style of the nudge and the nature of the target problem.When nudges are introduced to clinician workflows, they are particularly effective for increasing TUT penetration when APPs are handling clinical encounters. This may be due to training or perspective, with APPs engaging in this element of clinical care more readily than their physician counterparts. It is also likely that the details of cancer care workflow confound this association; physicians may be more likely to perform initial evaluations while APPs are more likely to perform follow-up care. If so, the over-representation of TUT among APPs may be a function of pragmatic care planning concerns.There are key strengths and limitations of this work. We used a pragmatic design and engaged both patients and clinicians—a key strength.Overall, this well-powered, rigorous pragmatic study demonstrates that implementation strategies, informed by behavioral economics within the EHR to counter biases that reduce health behavior engagement, can significantly increase the penetration of TUT in oncology care and do so without exacerbating health inequities in care delivery. Future work is needed to test the ability to generalize these findings to other health systems and to optimize the patient-directed nudge. Such work can continue to demonstrate the impact of implementation science and behavioral economics for enhancing the quality of cancer care to promote the best possible clinical outcomes for patients.